Mental Health Programme in India: Has the tide really turned?

Mental disorders in India form a major public health concern and the efforts to tackle these dates back to four decades, by way of the National Mental Health Programme (NMHP) and its operational arm, the District Mental Health Programme (DMHP). Although the progress of NMHP (and DMHP) was relatively slower till recently, the last 4-5 years have seen rapid strides with several initiatives, including (i) expansion of DMHPs to 90 per cent of the total districts of the country, (ii) the National Mental Health Policy and (iii) strengthening the Mental Health Legislation by way of providing explicit provisions for rights of persons with mental illnesses. Among others, factors responsible for this accelerated growth include the easily accessible digital technology as well as judicial activism. Federal and State cooperation is another notable feature of this expansion. In this review, the authors summarize the available information on the evolution of implementation and research aspects related to India's NMHP over the years and provide a case for the positive turn of events witnessed in the recent years. However, the authors caution that these are still baby steps and much more remains to be done.

Chhattisgarh community mental healthcare tele-mentoring program (CHaMP): Digitally driven initiative to reach the unreached.

OBJECTIVE: Harnessing technology is one accepted method to leapfrog the barrier of inadequate trained human resources for mental health. The Chhattisgarh Community Mental Healthcare Tele-Mentoring Program (CHaMP) is a collaborative digitally driven initiative of the Government of Chhattisgarh (GOC) and the National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru the aim of which is to train the Primary Care Doctors (PCDs) and Rural Medical Assistants (RMA) to identify, screen and treat/refer cases of mental health disorders presenting to the primary care settings (n = 2150). The objective of this article is to give a brief overview of the initiative. METHODS: CHaMP consists of the following modules: (a) a brief on-site training (b) eLearning and Skill Development (eLSD) and (c) Collaborative Video Consultation (CVC). The latter two are andragogic training methods delivered digitally. RESULTS AND CONCLUSION: From August 2019 to May 2020, 501 PCDs and RMAs have been covered. During this time, they have cared 15,000 patients suffering from mental illness, which hitherto was not the case. Technology that is easily available and usable has the potential to overcome the big hurdle of inadequate mental health human resources in India.

Impact Evaluation of Technology Driven Mental Health Capacity Building in Bihar, India.

Task-shifting is an important means to address the barrier of inadequate specialist human resources for mental health in countries such as India. This paper aims to report the impact of one such task-shifting initiative. Twenty-two non-specialist Medical Officers of Bihar, an eastern Indian state were engaged in a ten-month long hybrid (a 15-days onsite orientation to psychiatry and periodic online mentoring in primary care psychiatry) training program to enable them to identify commonly presenting psychiatric disorders in their respective clinics. 20 online sessions (hub and spoke ECHO model) occurred over the next 10 months. Apart from didactic topics, 75 cases covering severe mental disorders, common mental disorders and substance use disorders were discussed (case presentations by the primary care doctors (PCDs)) and moderated by a specialist psychiatrist and clinical psychologist). 12 successive self-reported monthly reports (comprising of the number and nature of psychiatric cases seen by the trainee PCDs) were analyzed. The mean (SD) number of sessions attended was 9 (8.0) and median was 13 (Range: 0-20). Mean number of cases (per PCD) discussed was 3.4 (3.4) (Median: 4; Range: 0-10). Total 20,909 patients were cared for in the 12 months after initiation of the training program. Increasingly, a greater number of patients were cared for as the training progressed. This pattern was mainly driven by more identifications of severe mental disorders (SMDs), common mental disorders (CMDs), dementias and substance use disorders. Mean (SD) number of patients seen per month before and after training was 1340.33 (86.73) and 1876.44 (236.51) (t = - 3.5, p < 0.05) respectively. A hybrid model of training PCDs is feasible and can be effective in identification of persons with psychiatric disorders in the community. Prospective, well designed studies are essential to demonstrate the effectiveness of this model.

Capacity Building in Mental Health for Bihar: Overview of the 1-Year Blended Training Program for Nonspecialist Medical Officers.

Objective The aim of this study is to give an experiential overview of a 1-year blended training program for nonspecialist medical officers (primary care doctors; PCDs) of Bihar State of India. The training program was aimed to enable PCDs identify, diagnose, and treat commonly presenting psychiatric disorders in primary care Methods PCDs had a brief onsite orientation program to psychiatric practice at National Institute of Mental Health and Neuro-Sciences (NIMHANS), followed by 10 months of online blended training. The online program followed the NIMHANS Virtual Knowledge- Extension for Community Healthcare Outcomes (ECHO) model, that is, a hub and spokes model of training Results Twenty-two PCDs participated in this program. Eleven of them got accredited at the end. The onsite orientation consisted of exposure to various psychiatry facilities at NIMHANS, in addition to learning psychiatric history taking and mental status examination. The ECHO model of online learning consisted of fortnightly sessions, lasting 2 hours each. There were 20 such sessions. Each session consisted of a didactic lecture by the psychiatrist followed by a case discussion. The cases were presented by PCDs, moderated by the hub specialists (NIMHANS). At the end of the training, participants rated an average of 4.5/5 on the mode, content and relevance of training and increase in knowledge due to the training. Around 23,000 patients were cared for during the said 1 year by the trained PCDs. Conclusion Training PCDs in a manner that enables retaining the learnt skills is feasible. However, rigorous evaluation protocols are needed in order to test this in a systematic fashion.

Disulfiram-Induced De Novo Convulsions without Alcohol Challenge: Case Series and Review of Literature.

Seizure induction by disulfiram (DSF) an adverse effect of therapeutic dosages of DSF is less understood. In our prospective case series of eight subjects with alcohol dependence a temporal, dose-dependent, and reversible epileptogenic potential due to DSF was noted. Mean duration of onset of first seizure was 2.13 ± 1.13 weeks after initiation of DSF therapy (125-500 mg/day) with no other detectable causes of seizures. Presence of alcohol withdrawal seizures (50%), DSF-induced hypertension (HTN) (37.5%), psychosis (12.5%) were noted, that may suggest common neurobiological underpinnings like dopamine-beta-hydroxylase inhibition. Various types of DSF-induced generalized seizures (tonic-clonic, 62.5%; myoclonic and tonic-clonic, 25%; myoclonic, 12.5%) were effectively managed by halving initial DSF dose (37.5%) even after cessation of antiepileptics, or stopping DSF (37.5%). Presence of alcohol withdrawal seizures, DSF-induced HTN/psychosis during DSF therapy may be early risk factors for dose-dependent and reversible adverse effect of DSF therapy - seizure induction, emphasizing caution.

Disulfiram-induced reversible hypertension: a prospective case series and review of the literature.

Disulfiram (DSF) is one of the recommended aids in the management of selected patients with alcohol dependence. Hypertension (HTN) as an adverse effect of DSF therapy is less understood. In our prospective case series of 7 subjects with co-morbid alcohol and nicotine dependence, a temporal, dose-dependent, and reversible grade 1-3 HTN within 1-6 weeks of initiation of DSF therapy (125-500 mg/day) with no other detectable causes of HTN was noted. Challenges and strategies surrounding diagnosis and treatment along with mean change and percentage rise in blood pressure are described. Literature review and clinical description of case series may suggest neurobiological role in its causation. HTN may be a clinically significant, dose-dependent, and reversible adverse effect of DSF therapy, especially in co-morbid alcohol and nicotine-dependent patients. Awareness amongst clinicians may render better health care delivery to subjects with alcohol dependence.

Disulfiram-induced combined irreversible anterior ischemic optic neuropathy and reversible peripheral neuropathy: a prospective case report and review of the literature.

Disulfiram is an alcohol-deterring agent with few rare serious adverse effects, usually dose-related, reversible, and more frequent with comorbid alcohol and nicotine dependence. We report a prospective follow-up of such a case with reversible peripheral neuropathy and irreversible optic neuropathy.

Disulfiram induced reversible hypertension: a prospective case study and brief review.

Disulfiram (DSF) is one of the recommended aids in the management of alcohol dependence. Hypertension may be a clinically significant, dose-dependent, and usually reversible adverse event of DSF therapy. We report 6 month prospective study of normotensive case of comorbid alcohol and tobacco dependence that developed reversible stage-II hypertension within 2-4 weeks of DSF therapy. We suggest that regular monitoring of blood pressure at least fortnightly for 1(st) 3 months, followed by monthly for next 3 months, and later once in 3 months, may possibly detect "silent" adverse event of DSF - hypertension.