A bird's eye view of the mental health systems in India.

Background: A staggering 85% of the global population resides in low- and middle-income countries (LAMICs). India stands as an exemplary pioneer in the realm of mental health initiatives among LAMICs, having launched its National Mental Health Program in 1982. It is imperative to effectively evaluate mental health systems periodically to cultivate a dynamic learning model sustained through continuous feedback from mental healthcare structures and processes. Materials and Methods: The National Mental Health Survey (NMHS) embarked on the Mental Health Systems Assessment (MHSA) in 12 representative Indian states, following a pilot program that contextually adapted the World Health Organization's Assessment Instrument for Mental Health Systems. The methodology involved data collection from various sources and interviews with key stakeholders, yielding a set of 15 quantitative, 5 morbidity, and 10 qualitative indicators, which were employed to encapsulate the functional status of mental health systems within the surveyed states by using a scorecard framework. Results: The NMHS MHSA for the year 2015-16 unveiled an array of indices, and the resultant scorecard succinctly encapsulated the outcomes of the systems' evaluation across the 12 surveyed states in India. Significantly, the findings revealed considerable interstate disparities, with some states such as Gujarat and Kerala emerging as frontrunners in the evaluation among the surveyed states. Nevertheless, notable gaps were identified in several domains within the assessed mental health systems. Conclusion: MHSA, as conducted within the framework of NMHS, emerges as a dependable, valid, and holistic mechanism for documenting mental health systems in India. However, this process necessitates periodic iterations to serve as critical indicators guiding the national mental health agenda, including policies, programs, and their impact evaluation.

Stake holder perspectives on the role of accredited social health activists (ASHAs) in Indian public mental healthcare space: A qualitative study.

Background: Community health workers such as Accredited Social Health Activists (ASHAs) are existing resources who can facilitate the bridging of the mental health treatment gap. Knowing about the perspectives of ASHAs in delivering mental health care and other professionals with experience working in the area of community mental health is imperative. Method: As part of an implementation research project aimed at comparing the effectiveness of two training methods for community health workers (ASHAs), we conducted five focussed group discussions including four with ASHAs (n = 34) and one with other stakeholders (n = 10). Focussed Group Discussion (FGD) was conducted under the following themes: acceptance and feasibility of provision of mental health services from ASHA's point of view and understanding the supply and demand side opportunities and challenges. The discussion began with open-ended questions, allowing for new themes to emerge until saturation was reached. Results: ASHAs were willing to incorporate mental health identification (and referral) in their regular activities without additional perceived burden. ASHAs were easily able to identify severe mental disorders (SMDs). For substance use disorders (SUDs), due to factors such as normalization of substance consumption and stigma, there was a felt difficulty in the recognition by ASHAs. ASHAs' difficulty in identifying the CMDs was because of poor awareness in both those with mental illness and ASHAs. Incentivizing the work of ASHAs was thought to yield more returns. Conclusions: ASHAs have the potential to be excellent resources for easy screening, identification, and follow-up of those with mental health concerns in the community. Policies to involve them need to evolve.

Economic Perspectives on Setting up and Running Telepsychiatry Services in India.

BACKGROUND: Telemedicine Practice Guidelines, 2020 and Telepsychiatry Operational Guidelines, 2020 can be potential game changers in the practice of medicine in India. They provide legal grounds for the practice of telemedicine. The economics of setting up and running telepsychiatry services vis-à-vis in-person services in India is discussed in this paper to aid the practitioners in understanding the costs involved in each of these modalities. METHODS: Costs for various hardware, software, real estate, and human resources are collated from various sources. Telepsychiatry vs. in-person setup is compared for the costs involved. RESULTS: Telepsychiatry consultation will cost much lesser to that of in-person consultation. CONCLUSIONS: Telepsychiatry is an economically viable option. There are many benefits and hurdles in telepsychiatry practice. It is a step towards providing psychiatric services at the doorstep in compliance with the Mental Healthcare Act 2017, upholding the rights of persons with mental illness. It will benefit the practitioner, the patient, and the society.

Sociodemographic, Legal, and Clinical Profiles of Female Forensic Inpatients in Karnataka: A Retrospective Study.

BACKGROUND: Forensic patients are often admitted to psychiatric hospitals without any details of illness or treatment. They pose a unique challenge for clinical services in the context of diagnosis, management, and particularly legal issues. MATERIALS AND METHODS: We conducted a retrospective chart review using a structured data-extraction tool. A total of 23 female forensic inpatients were admitted under the Department of Psychiatry from January 2006 to June 2016. Data were analyzed by descriptive statistics. RESULTS: The mean age of the patients was 31.3 ± 7.9 years. In total, 82.6% of them were married, 87% were from a nuclear family, and 78.3% were from an urban background. Totally, 73.9% were referred from prison and 26.1% from the court. However, 73.9% were referred for the purpose of diagnosis and treatment and 21.7% for assessment of fitness to stand trial. Moreover, 47.8% had an alleged charge of murder (of killing close family members). A total of 30.4% had schizophrenia and other psychotic disorders, and 47.8% had a mood disorder. The mean duration of inpatient care was 6.2 ± 7.4 weeks, and 87% had shown considerable clinical improvement at the time of discharge. CONCLUSIONS: The majority of female forensic patients were young adults from nuclear families. They had mood disorders, schizophrenia, and other psychotic disorders. They were referred primarily for treatment purposes. Prospective studies are required for a better characterization of the relationship between crime and psychiatric disorders.

Caregiver burden is associated with disability in schizophrenia: results of a study from a rural setting of south India.

BACKGROUND: Taking care of patients with schizophrenia is a major source of burden to the family. Research on burden experienced by family members of patients living in rural communities is sparse. METHODS: Data were obtained from a community intervention program for psychoses in a rural community of south India, where persons with severe mental disorders were identified, treated and followed up. As part of the program, caregivers of 245 schizophrenia patients were interviewed using the Burden Assessment Schedule. Psychopathology (Positive and Negative Syndrome Scale; PANSS), treatment status and disability (Indian Disability Evaluation and Assessment Scale; IDEAS) experienced by the patients were also assessed. Univariate and multivariate analyses were used to study the influence of different factors on the caregiver burden. RESULTS: Level of burden had a significant direct correlation with disability (Pearson's r = .35; p < .01) and severity of psychopathology (r = .21; p < .01). Duration of treatment had an inverse correlation with burden (Pearson's r = -.16; p < .01). Multivariate analysis revealed that total IDEAS score (Beta = .28; t = 4.37; p ≤ .01), duration of treatment (Beta = -.17; t = -2.58; p = .01), age of the family caregiver (Beta = .15; t = 2.4; p = .02) and gender of the patient (Beta = -.13; t = -2.1; p = .04) were significant predictors of burden. The model including total IDEAS score explained 14% of variance (adjusted R (2) = .139; p < .01). CONCLUSION: Burden experienced by family caregivers of schizophrenia patients depends on the level of disability experienced by the patient, age of the family caregivers and gender of the patient. Interventions to reduce disability of the patients may reduce the caregiver burden.

Seizure duration decreases over a course of bifrontal and not bitemporal electroconvulsive therapy.

CONTEXT: Mechanism of action of electroconvulsive therapy (ECT) is unclear. Anticonvulsant action of ECT has also been one among the hypothesized mechanisms. Anticonvulsant effect may manifest during ECT in at least two ways (a) increased seizure threshold (b) decrease in seizure duration. In depression, increased seizure threshold has been shown to be associated with better antidepressant response. However, relationship between seizure duration and antidepressant activity has been inconsistent. These issues are not investigated in conditions other than depression. AIMS: We examined seizure duration over the course of ECT in schizophrenia patients. SETTINGS AND DESIGN: Material for this analysis was obtained from a clinical trial examining the differential efficacy of bifrontal ECT (BFECT) versus bitemporal ECT (BTECT) in schizophrenia patients. As a part of study 122 schizophrenia patients who were prescribed ECT were randomized to receive either BFECT or BTECT. SUBJECTS AND METHODS: Final analysis was conducted on data from 70 patients, as the rest of the data either had artifact or there was a significant change in medication status. Electroencephalogram seizure duration was noted in each session for these patients. RESULTS: Seizure duration declined significantly from second ECT to 6(th) ECT (repeated measures analysis of variance F = 4.255; P = 0.006). When separate analysis was conducted for BTECT and BFECT patients the decline in seizure duration from 2(nd) to 6(th) ECT was significant only with BFECT (F = 3.94; P = 0.014) and not with BTECT (F = 0.966; P = 0.424). CONCLUSIONS: Better anticonvulsant effects with BFECT may explain the better therapeutic observed with BFECT in schizophrenia as well as mania in our earlier studies.