An audit of initial six years of 5885 telepsychiatric direct video consultations: Findings from "benefits of savings" analysis and the effect of COVID-19 pandemic.

Background: Telepsychiatric direct video consultations (DVCs) meant for continuity of care began in 2017 and continued during the coronavirus disease 2019 (COVID-19) pandemic. Telemedicine-based consultation gained its long-due importance during the COVID-19 travel restriction, despite its existence for a long. The authors intend to share the utility and growth of the initial six years of live telepsychiatric DVCs from an academic hospital in India and also plan to understand the effects of the COVID-19 pandemic on its growth and report findings from an innovative "benefits of savings" (BOS) analysis from these clinics. Methods: A first six years of medical audit of the files and registers of telepsychiatric DVCs from two kinds of continuity of care clinics during 2017-2022 is performed. An analysis of 4991 (84.8%) live DVCs is successfully conducted for 1570 patients from the 5885 scheduled appointments. Year-on-year (YOY) growth and BOS analysis of successful DVCs from these clinics were performed. Results and Discussion: The growth suggests a gradual increase in DVCs yearly. The BOS analysis suggests its increased acceptability, feasibility at both user and provider ends, and possible cost-effectiveness of these video clinics. YOY analysis suggests a natural growth of these clinics than from the effect of the COVID-19 pandemic, except for an initial surge in 2020 and 2021 and observing stabilization effect by 2022. Conclusion: In the authors' understanding, this is the largest study of providing DVCs from India, irrespective of any medical/surgical specialty. The video/remote clinics could be an alternative model for regular follow-ups in ensuring the continuity of care among patients with psychiatric disorders. These clinics also saved significant travel time, travel distance, and travel costs for the patients that could have occurred for their in-person consultations.

Multivariate associations between cognition and neighborhood geospatial characteristics in schizophrenia.

Cognitive impairment contributes to functional impairment in schizophrenia. Yet, little is known about how environmental characteristics are related to cognition in schizophrenia. By examining how cognition and the environment are intertwined, it may be possible to identify modifiable risk and protective factors that can improve cognitive outcomes in schizophrenia. We aimed to identify multivariate associations between cognition and three geospatial characteristics (built-space density, habitable green spaces, and public spaces for social interaction) within one's immediate neighborhood among individuals with schizophrenia. We recruited participants with schizophrenia from three sites - an urban metropolitan and two towns in southern India. We administered standard cognitive assessments and performed a principal axis factoring to identify episodic memory, cognitive control, and social inference-making factors for use in further analyses. We estimated geospatial characteristics of an individual's neighborhood, i.e., up to 1 km2 around the residence, by sourcing data from Google Earth. We performed unconditional and conditional (to examine the effect of clinical covariates) canonical correlation analyses to understand the multivariate relationship between cognition and geospatial characteristics. We analyzed data from 208 participants; the first canonical cognitive variate (higher social inference-making and poorer cognitive control) shared 24% of the variance (r = 0.49; P < 0.001) with the first geospatial variate (lower built density and poorer access to public spaces). Years of education, age at onset, and place of residence significantly modulated this relationship. We observe differential associations of the built environment with social and non-social cognition in schizophrenia, and highlight the clinical and demographic characteristics that shape these associations.

Impact of incentivizing ASHAs on the outcome of persons with severe mental illness in a rural South Indian community amidst the COVID-19 pandemic.

BACKGROUND & OBJECTIVES: Task shifting has been recommended as a strategy to reach out to persons with mental illness and bridge the treatment gap. There is a need to explore task-shifting using existing health staff like Accredited Social Health Activists (ASHAs). We examined the impact of incentivizing ASHAs on the outcome of persons with severe mental illness (SMI) amidst the pandemic. METHODS: One hundred eighty-four adults with SMI from Jagaluru taluk were enrolled and followed up for a year. They were assessed for disability, work performance, internalized stigma, and illness severity at baseline, six months, and 12 months follow-up. ASHA workers were incentivized to ensure follow-up consultations, address concerns regarding illness/ medication side effects and monitor medication adherence. RESULTS: Out of the 184 recruited patients, 7 died (non-COVID-19 causes), 22 stopped treatment and did not report for follow-up consultations, 11 shifted to treatment from other centers, and in 1 case, there was a change in diagnosis. 143 (78%) patients with SMI completed the study amidst the COVID-19 pandemic. At one year follow-up, there was a significant reduction in disability, illness severity, self-stigma, and improved work performance. CONCLUSION: Incentivization of ASHAs helped ensure continuity of care to persons with SMI despite lockdowns and COVID-19 exigencies. It is feasible to involve ASHAs in the treatment of persons with SMI.

The Legality and Ethical Issues of Certifying Laypersons as Mental Health Counselors in India.

Background: The burden of mental health conditions and consequent disability impacts are felt most in low- and middle-income settings. These settings are constrained by the limited availability of resources to provide even essential aspects of mental health care (MHC). Task shifting and sharing interventions have shown promise in delivering community-based MHC across such low-resource settings. Some counseling tasks such as friendship bench interventions have been successfully shifted to laypersons. However, ethical and legal concerns regarding laypersons' incorporation in MHC delivery systems have not been examined. Purpose: To examine the ethical and legal concerns surrounding the certification of laypersons as community-based mental health counselors. Method: We undertook an academic review of various legislations pertinent to MHC service delivery and the certification of allied health care professionals to inform on acceptable and tenable strategies toward incorporating such a task-shifted intervention. Conclusion: Scaling up the training of human resources to address access problems can be the first step in addressing the MHC access and treatment gaps. The certification of laypersons as community-based mental health counselors, although legally tenuous, can be pioneered by tertiary-level MHC institutions. This certification has sound ethical justification and is a progressive step toward realizing universal mental health coverage.

Dual Clinical Collaborator: A Pragmatic Role of nurses from developing countries

Collaboration is crucial in Professional nursing practice. Nurses act as a liaison between physicians and patients and their family members. Thus, it is vital to define the collaborative role of nurses in developing countries. The authors discuss pragmatic nurses' role by adopting the Dual Clinical Collaborator model to ensure offering the quality of care to their clients. Nursing is a healthcare profession that focuses on the care of individuals and their families to help them recover from illness and maintain optimal health and quality of life.(1) Health Care Professionals (HCPs) work together to provide quality health care and accomplish common goals. As healthcare delivery is becoming more complex, collaboration among healthcare workers and the patient can be a path to improve the quality of healthcare services. According to Walker and Avant's method, the conceptual definition of collaboration in nursing is an intra professional or interprofessional process by which nurses come together and form a team to solve patient care or healthcare system problem with members of the team respectfully sharing knowledge and resources.(2) Thus, collaboration is crucial in everyday professional nursing practice and should be considered a core value of nursing.(3)

Care at Doorsteps for Persons with Severe Mental Illnesses as a Part of District Mental Health Program (DMHP): A Qualitative Needs Assessment and Psychosocial Framework.

Care at Doorstep (CAD) is a home care service that includes medical and social care by skilled professionals. The purpose of this paper is to explore the need for CAD among users of the district mental health programme (DMHP) in Ramanagaram, Karnataka, India who have severe mental illness. The design of this study was descriptive where a qualitative inductive methodology was adopted. Data was collected from interviews of 20 caregivers and 7 mental health service providers linked to the DMHP. Socio demographic information was collected from participants and a semi-structured interview guides were used to explore needs and challenges in delivering care at home by the professionals. The themes that emerged from the manually transcribed and coded data were categorized as needs and challenges and used for developing a CAD model.

A report on successful introduction of tele mental health training for primary care doctors during the COVID 19 pandemic.

Treatment gaps of 60-70%, reflecting, amongst many other factors, Human Resources shortfalls means that 150 million India never accessed mental healthcare. In Punjab, mental health training is required in primary health centers. A short-term synchronous training was conceptualized by the National Institute of Mental Health and Neurosciences. A total of 114 primary care doctors participated for the training. Substantial positive changes in knowledge, attitudes and practices were noted. Task sharing and capacity building initiatives can be undertaken during the pandemic to meet the demand for mental healthcare service delivery.

Criminal Responsibility in Geropsychiatry: Competence, Culpability, and Care.

Elderly persons can get involved in the criminal justice system as victims or as perpetrators. The interaction of elderly persons with mental illness at various cross-sections of the judicial process needs thoughtful consideration. Through this review, the authors approach this less studied aspect of forensic psychiatry. Concerning the evaluation of a prisoner, three scenarios need focused consideration: evaluation for fitness to stand trial before a competent court, evaluations for an insanity defense, and fitness for sentencing. At the same time, incarcerated elderly who developed dementia or a severe mental illness at any point of time during the trial or in prison need specific approaches. In this article, the authors discuss the acts and case laws relevant to navigating these legal scenarios. We discuss existing mental health care provisions for protecting the health interests of elderly care in prison.

Free legal aid for persons with mental illness and other marginalized group of population.

The marginalized and vulnerable population like those with mental illnesses and other disabilities, senior citizens, disaster victims and women are at risk of facing violation of their rights. To preserve the rights of the above-mentioned vulnerable groups, Government of India has passed a legislation named Legal Services Authority Act, 1987. In this article authors discuss the interconnection between mental illness and rights violation, how Legal Services Authority Act, 1987 is relevant in preserving rights of persons with mental illness and other vulnerable groups, different programs under the above legislation, the provisions under those programs and how to obtain them.

Dissimilar social cognition signatures in remitted schizophrenia and bipolar disorder.

In the light of shared genetic underpinnings of schizophrenia and bipolar disorder, their comparative profile of social cognition (SC) performance - an intermittent phenotype and determinant of functional outcome - is poorly understood. Using data from 160 individuals, we identify unique patterns of composite and domain-specific SC-abilities between these groups after controlling for their neurocognition. Individuals with schizophrenia and not bipolar disorder demonstrated deficits in composite SC-measures, which were not associated with their functional status. While patients with bipolar disorder had significantly lower scores on emotion recognition, they outperformed the healthy and schizophrenia groups on the second-order theory of mind.

Collaborative Video Consultations from Tertiary Care Based Telepsychiatrist to a Remote Primary Care Doctor to Manage Opioid Substitution Therapy Clinic.

Opioid use is a major problem in India and has high morbidity and mortality with a prevalence of 2.06%. There is a huge treatment gap for opioid use disorders (OUDs). Due to limited mental health resources and limited psychiatric training of medical practitioners in OUDs, a significant proportion of patients do not receive appropriate medical intervention. This article demonstrates how a primary care doctor working in a remote opioid substitution therapy (OST) clinic received assistance from the optional opioid module of clinical schedule for primary care psychiatry (CSP) and collaborative video consultation (CVC) module to address specific difficulties of patients already on Buprenorphine OST and improve the quality of care, thereby reducing chances of relapses. CVC module is a part of one-year digitally driven primary care psychiatry program designed by National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru. The opioid module was designed by NIMHANS, Bengaluru in collaboration with the All India Institute of Medical Sciences (AIIMS), New Delhi These observations warrant replication of this approach across diverse settings and at a larger scale to explore and evaluate its impact and effectiveness.

Supported employment programme for persons with severe mental disorders in India: A feasibility study.

BACKGROUND: A number of persons with severe mental illnesses are unable to prepare for, find or keep a job due to factors linked to their illness as well as psychosocial issues. AIM: To test the feasibility of a supported employment programme to help persons with severe mental disorders obtain and sustain employment. METHODS: A supported employment programme was developed for persons with severe mental disorders with components of (a) assessment of vocational potential, (b) vocational counselling, (c) networking and liaison with prospective employers, (d) job-related training and placement and (e) continued support for 6 months. Job placement status, social occupational functioning and disability (quantitative data) and benefits of enrolling in the employment programme (qualitative data) were assessed. RESULTS: A total of 40 employers were liaised with for providing job placement and reasonable accommodation. Out of 63 participants recruited into the study, 32 (50.8%) participants were placed in competitive jobs, placement was actively attempted for 17 (27.0%) participants, 7 (11.1%) were referred for skill training and 7 (11.1%) dropped out from the study. The disability score significantly reduced and socio-occupational functioning significantly improved in those who were placed over a period of 6 months. CONCLUSION: The supported employment programme was found to be feasible as it showed good placement rates and improvement in socio-occupational functioning and disability scores.

Community-Based Rehabilitation for Persons with Severe Mental Illness in a Rural Community of Karnataka: Methodology of a Randomized Controlled Study.

BACKGROUND: Task shifting has been recommended as a strategy to reach out to persons with mental illness and bridge the treatment gap. There is a need to explore task-shifting using existing health staff like Accredited Social Health Activists (ASHAs). AIM AND CONTEXT: ASHAs are involved in ongoing community-based rehabilitation (CBR) program run with a public-private partnership over the last 5 years at Jagaluru Taluk (an administrative block) in Davanagere district (Karnataka, India). This article aims to summarize a randomized controlled trial (RCT) to examine whether CBR delivered by ASHAs is more effective than treatment as usual (TAU) control group in reducing disability associated with severe mental illness (SMI). METHOD: A group of proactive ASHAs is already working with us for a follow-up of persons with SMI. For the study, we would allocate areas that are currently not being covered proactively by ASHAs randomly in a 1:1 ratio via computer-generated randomization list to receive either ASHAs delivered CBR arm or TAU control group. A sample size of about 100 in each arm is enough to identify an effect size of 0.5 in total IDEAS score between the intervention and control arms with a power of 90% and an alpha of 0.05. We use the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) statement to describe the methods of the trial. RESULT: The study has been approved by the institute ethics committee and registered with CTRI (CTRI/2019/08/020585 dated 6th August 2019). The recruitment of subjects is ongoing. The patients will be followed up for 1 year and assessed. The trial is funded by the Indian Council of Medical Research, Government of India. DISCUSSION: The results of the study will be helpful from a public health perspective in delivering cost-effective and replicable CBR for persons with SMI through ASHAs. If the model turns successful, this could be expanded throughout the state/country. This would go a long way in bridging the huge treatment gap.

A Report on a Series of workshops on "Mental Health Leadership" for Maharashtra State.

The article is a report on a series of workshops conducted by the National Institute of Mental Health And Neurosciences (NIMHANS), Bengaluru, India in collaboration with the Government of Maharashtra for the local leaders responsible for leading, organizing and delivering public mental health services throughout the state of Maharashtra. The overarching aim of these workshops was to sensitize and orient the participants on the mental health services offered/provided by NIMHANS, the collaborative activities between NIMHANS and Govt. of Karnataka to further the cause of public mental health and also to showcase the scope of DMHP (District Mental Health Program) activities in Karnataka. The professionals were divided into 5 batches as per their specialty or role i.e. Psychiatrists, Psychologists and Social Work besides the health administrators (Civil Surgeons and District Health Officers). Each batch underwent the training 2-3 days. Major areas covered included: Farmers' suicide, programs, policies and laws for the elderly, orientation to the new Mental Health Care Act 2017 and a fully functioning District Mental Health Program (DMHP).

Tele-psychiatric after care clinic for the continuity of care: A pilot study from an academic hospital.

BACKGROUND: There is a need of continuity of care research in psychiatric disorders to deal two important issues such as accessibility of psychiatrists, and travel. AIMS: This pilot was designed to evaluate the acceptability, feasibility, possible clinical effectiveness and cost benefit of video based tele-psychiatric aftercare (TAC) clinic from an academic hospital. METHODS: Fifty selected patients were recruited to provide direct video-consultations (DVC). RESULTS: This study shows higher score on acceptability, satisfaction and respect to privacy on these TAC. DISCUSSION AND CONCLUSIONS: This is first pilot study as one of the patient friendly and less expensive continuity of care.

Health insurance and mental illness.

One of the important provisions of the Mental Healthcare Act, 2017, in section 21 (4), is the inclusion of "mental illnesses" for health insurance coverage. This is a progressive step toward considering mental illness at par with physical illness, which will, in turn, ensure better access to mental health care. In this context, the article summarizes the concept of "health insurance" and then goes on to talk about various provisions for persons with mental illnesses in India. We also discuss some of the relevant concerns that may arise in this context. Whereas insurance for mental illness is a welcome step toward achieving universal health coverage, there is a need to deliberate on various issues before we can achieve that.

Mortality in schizophrenia: A study of verbal autopsy from cohorts of two rural communities of South India.

BACKGROUND: Schizophrenia is a life-shortening disease. Although the rate of mortality of persons with schizophrenia in India is established to be more compared to that in the general population, there is a little exploration of the causes for the same. AIM: The aim of this study is to explore the causes of death in two rural cohorts of schizophrenia. MATERIALS AND METHODS: In-person interviews of primary caregivers of 53 deceased persons with schizophrenia were conducted using the World Health Organization's verbal autopsy 2014 instrument. Physician-based method was used to determine the causes of death. RESULTS: Average age of 53 deceased schizophrenia patients was 50.45 ± 13.65 years with almost equal gender ratio. Just more than two-thirds of patients were married, just more than one-third are educated up to primary school and also had no formal education each. Noncommunicable diseases (NCDs) were the most common causes of death (30, 56.6%) in this sample, followed by communicable disease (7, 13.2%), and then unnatural deaths (suicide - 8, 15%, and road traffic accidents - 3, 5.6%). CONCLUSIONS: It is the first study in India to explore the causes of death in schizophrenia. NCDs being the most common cause of death in schizophrenia suggests to the need of integration of schizophrenia care into general health care.