Relational Solidarity and Conflicting Ethics in Dementia Care in Urban India.

OBJECTIVES: Using the concept of relational solidarity, we examine how autonomy, equality, dignity, and personhood are practiced in the care of people living with dementia at home in urban India. METHODS: Video interviews with 19 family carers and 25 health providers conducted in English, Hindi, and Kannada in Bengaluru between March and July 2022. Data were translated into English and thematically analyzed. RESULTS: Family carers and providers unanimously agreed that people with dementia should be respected and cared for. Concurrently, they perceived people with dementia as being "like a kid" and used the analogy of a parent-child relationship to understand their care responsibilities. This analogy informed how ethical principles such as personhood and equality were reframed in the relationships between family carers and people with dementia, as well as how carers and providers maintained the safety but undermined the autonomy of people with dementia through restricting their movements inside and outside the home. DISCUSSION: There can be relational solidarity in dementia care at home in urban India but also contradictions in the interpretations and applications of the ethical principles of autonomy, equality, dignity, and personhood. As such, a more organic, grassroots model of ethical practice is needed to frame care and provide material support to families in India.

Prevalence of DSM-5 mild and major neurocognitive disorder in India: Results from the LASI-DAD.

INTRODUCTION: India, with its rapidly aging population, faces an alarming burden of dementia. We implemented DSM-5 criteria in large-scale, nationally representative survey data in India to characterize the prevalence of mild and major Neurocognitive disorder. METHODS: The Harmonized Diagnostic Assessment of Dementia for the Longitudinal Aging Study in India (LASI-DAD) (N = 4,096) is a nationally representative cohort study in India using multistage area probability sampling methods. Using neuropsychological testing and informant reports, we defined DSM-5 mild and major neurocognitive disorder, reported its prevalence, and evaluated criterion and construct validity of the algorithm using clinician-adjudicated Clinical Dementia Ratings (CDR)®. RESULTS: The prevalence of mild and major neurocognitive disorder, weighted to the population, is 17.6% and 7.2%. Demographic gradients with respect to age and education conform to hypothesized patterns. Among N = 2,390 participants with a clinician-adjudicated CDR, CDR ratings and DSM-5 classification agreed for N = 2,139 (89.5%) participants. DISCUSSION: The prevalence of dementia in India is higher than previously recognized. These findings, coupled with a growing number of older adults in the coming decades in India, have important implications for society, public health, and families. We are aware of no previous Indian population-representative estimates of mild cognitive impairment, a group which will be increasingly important in coming years to identify for potential therapeutic treatment.

Effectiveness of road safety interventions: An evidence and gap map.

Background: Road Traffic injuries (RTI) are among the top ten leading causes of death in the world resulting in 1.35 million deaths every year, about 93% of which occur in low- and middle-income countries (LMICs). Despite several global resolutions to reduce traffic injuries, they have continued to grow in many countries. Many high-income countries have successfully reduced RTI by using a public health approach and implementing evidence-based interventions. As many LMICs develop their highway infrastructure, adopting a similar scientific approach towards road safety is crucial. The evidence also needs to be evaluated to assess external validity because measures that have worked in high-income countries may not translate equally well to other contexts. An evidence gap map for RTI is the first step towards understanding what evidence is available, from where, and the key gaps in knowledge. Objectives: The objective of this evidence gap map (EGM) is to identify existing evidence from all effectiveness studies and systematic reviews related to road safety interventions. In addition, the EGM identifies gaps in evidence where new primary studies and systematic reviews could add value. This will help direct future research and discussions based on systematic evidence towards the approaches and interventions which are most effective in the road safety sector. This could enable the generation of evidence for informing policy at global, regional or national levels. Search Methods: The EGM includes systematic reviews and impact evaluations assessing the effect of interventions for RTI reported in academic databases, organization websites, and grey literature sources. The studies were searched up to December 2019. Selection Criteria: The interventions were divided into five broad categories: (a) human factors (e.g., enforcement or road user education), (b) road design, infrastructure and traffic control, (c) legal and institutional framework, (d) post-crash pre-hospital care, and (e) vehicle factors (except car design for occupant protection) and protective devices. Included studies reported two primary outcomes: fatal crashes and non-fatal injury crashes; and four intermediate outcomes: change in use of seat belts, change in use of helmets, change in speed, and change in alcohol/drug use. Studies were excluded if they did not report injury or fatality as one of the outcomes. Data Collection and Analysis: The EGM is presented in the form of a matrix with two primary dimensions: interventions (rows) and outcomes (columns). Additional dimensions are country income groups, region, quality level for systematic reviews, type of study design used (e.g., case-control), type of road user studied (e.g., pedestrian, cyclists), age groups, and road type. The EGM is available online where the matrix of interventions and outcomes can be filtered by one or more dimensions. The webpage includes a bibliography of the selected studies and titles and abstracts available for preview. Quality appraisal for systematic reviews was conducted using a critical appraisal tool for systematic reviews, AMSTAR 2. Main Results: The EGM identified 1859 studies of which 322 were systematic reviews, 7 were protocol studies and 1530 were impact evaluations. Some studies included more than one intervention, outcome, study method, or study region. The studies were distributed among intervention categories as: human factors (n = 771), road design, infrastructure and traffic control (n = 661), legal and institutional framework (n = 424), post-crash pre-hospital care (n = 118) and vehicle factors and protective devices (n = 111). Fatal crashes as outcomes were reported in 1414 records and non-fatal injury crashes in 1252 records. Among the four intermediate outcomes, speed was most commonly reported (n = 298) followed by alcohol (n = 206), use of seatbelts (n = 167), and use of helmets (n = 66). Ninety-six percent of the studies were reported from high-income countries (HIC), 4.5% from upper-middle-income countries, and only 1.4% from lower-middle and low-income countries. There were 25 systematic reviews of high quality, 4 of moderate quality, and 293 of low quality. Authors' Conclusions: The EGM shows that the distribution of available road safety evidence is skewed across the world. A vast majority of the literature is from HICs. In contrast, only a small fraction of the literature reports on the many LMICs that are fast expanding their road infrastructure, experiencing rapid changes in traffic patterns, and witnessing growth in road injuries. This bias in literature explains why many interventions that are of high importance in the context of LMICs remain poorly studied. Besides, many interventions that have been tested only in HICs may not work equally effectively in LMICs. Another important finding was that a large majority of systematic reviews are of low quality. The scarcity of evidence on many important interventions and lack of good quality evidence-synthesis have significant implications for future road safety research and practice in LMICs. The EGM presented here will help identify priority areas for researchers, while directing practitioners and policy makers towards proven interventions.

Defining anthropometric thresholds (mid-arm circumference and calf circumference) in older adults residing in the community: a cross-sectional analysis using data from the population representative Longitudinal Aging Study in India (LASI DAD).

OBJECTIVES: To identify factors associated with malnutrition (undernutrition and overnutrition) and determine appropriate cut-off values for mid-arm circumference (MAC) and calf circumference (CC) among community-dwelling Indian older adults. DESIGN: Data from the first wave of harmonised diagnostic assessment of dementia for Longitudinal Ageing Study in India (LASI-DAD) were used. Various sociodemographic factors, comorbidities, geriatric syndromes, childhood financial and health status were included. Anthropometric measurements included body mass index (BMI), MAC and CC. SETTING: Nationally representative cohort study including 36 Indian states and union territories. PARTICIPANTS: 4096 older adults aged >60 years from LASI DAD. OUTCOME MEASURES: The outcome variable was BMI, categorised as low (<18.5 kg/m2), normal (18.5-22.9 kg/m2) and high (>23 kg/m2). The cut-off values of MAC and CC were derived using ROC curve with BMI as the gold standard. RESULTS: 902 (weighted percentage 20.55%) had low BMI, 1742 (44.25%) had high BMI. Undernutrition was associated with age, wealth-quintile and impaired cognition, while overnutrition was associated with higher education, urban living and comorbidities such as hypertension, diabetes and chronic heart disease. For CC, the optimal lower and upper cut-offs for males were 28.1 cm and >31.5 cm, respectively, while for females, the corresponding values were 26 cm and >29 cm. Similarly, the optimal lower and upper cut-offs for MAC in males were 23.9 cm and >26.9 cm, and for females, they were 22.5 cm and >25 cm. CONCLUSION: Our study identifies a high BMI prevalence, especially among females, individuals with higher education, urban residents and those with comorbidities. We establish gender-specific MAC and CC cut-off values with significant implications for healthcare, policy and research. Tailored interventions can address undernutrition and overnutrition in older adults, enhancing standardised nutritional assessment and well-being.

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.

Attitudes to long-term care in India: a secondary mixed-methods analysis.

BACKGROUND: India is the world's most populous country, and overseas Indians the world's largest diaspora. Many of the more than 1·4 million UK-based Indians will be providing care at a distance for parents living in India. Globalisation has contributed to a shift in India from traditional joint family systems to more nuclear structures. We investigated how commonly Indian parents consider and use long-term care facilities and attitudes to their use. METHODS: We did a secondary mixed-methods statistical analysis of the LASI (Longitudinal Ageing Study in India), a national, cross-sectional household survey administered in 2017-18 to 73 396 randomly selected adults aged 45 years and older in all Indian states and Union Territories (42 261 [58%] women, 31 135 [42%] men). We report the proportion and sociodemographic predictors of respondents' parent(s) living in a care home. We also did a secondary thematic analysis of the qualitative interviews from the Moving Pictures India Study, exploring attitudes to long-term care in 2022. These interviews included 19 carers (nine [47%] women; age range 31-79 years) for people with dementia and 25 professionals (19 [76%] women; age range 24-56 years) purposively selected for diversity from networks of the team based at a Bangalore hospital, India. FINDINGS: 24 LASI participants reported that their parent was living in a long-term care facility (father [n=8], mother [n=15], both parents [n=1]). Although rare overall, use and consideration of use of long-term care were more frequently reported in urban areas (n=14, 58%), by people in middle-income quintiles (n=17, 71%) with higher levels of education (n=7, 29%), who rated their health as good or very good (n=15, 63%). The themes identified in qualitative interviews were the use of long-term care facilities as a last resort, social expectations, and limited availability of long-term care facilities. INTERPRETATION: Although interviews were only conducted in Bangalore and respondents could misrepresent living arrangements due to ongoing societal stigma, the data show that very few people reside in old age homes across India, with strong preference towards intergenerational and community care. With the UK home to a growing diaspora of nuclear Indian families, our findings illustrate the contexts in which they provide care at a distance, navigating cross-cultural attitudes and social norms around long-term care. FUNDING: Alzheimer's Association US.

Improving the lives of ethnically diverse family carers and people living with dementia using digital media resources - Protocol for the Draw-Care randomised controlled trial.

Objectives: Ethnically diverse family carers of people living with dementia (hereafter carers and people with dementia) experience more psychological distress than other carers. To reduce this inequality, culturally adapted, multilingual, evidence-based practical assistance is needed. This paper details the Draw-Care study protocol including a randomised control trial (RCT) to test the effectiveness of a digital intervention comprising a multilingual website, virtual assistant, animated films, and information, on the lives of carers and people with dementia in Australia. Methods: The Draw-Care intervention will be evaluated in a 12-week active waitlist parallel design RCT with 194 carers from Arabic, Cantonese, Greek, Hindi, Italian, Mandarin, Spanish, Tamil, and Vietnamese-speaking language groups. Our intervention was based on the World Health Organization's (WHO) iSupport Lite online carer support messages and was co-designed with carers, people with dementia, service providers, and clinicians. Culturally adapted multilingual digital resources were created in nine languages and English. Results: In Phase I (2022), six co-design workshops with stakeholders and interviews with people with dementia informed the development of the intervention which will be trialled and evaluated in Phases II and III (2023 and 2024). Conclusions: Digital media content is a novel approach to providing cost-effective access to health care information. This study protocol details the three study phases including the RCT of a co-designed, culturally adapted, multilingual, digital intervention for carers and people with dementia to advance the evidence in dementia and digital healthcare research and help meet the needs of carers and people with dementia in Australia and globally.

'It's Too nice': Adapting iSupport Lite for Ethnically Diverse Family Carers of a Person with Dementia.

OBJECTIVES: Resources to support dementia carers from ethnically diverse families are limited. We explored carers' and service providers' views on adapting the World Health Organization's iSupport Lite messages to meet their needs. METHODS: Six online workshops were conducted with ethnically diverse family carers and service providers (n = 21) from nine linguistic groups across Australia. Recruitment was via convenience and snowball sampling from existing networks. Data were analyzed using thematic analysis. RESULTS: Participants reported that iSupport Lite over-emphasized support from family and friends and made help-seeking sound "too easy". They wanted messages to dispel notions of carers as "superheroes", demonstrate that caring and help-seeking is stressful and time-consuming, and that poor decision-making and relationship breakdown does occur. Feedback was incorporated to co-produce a revised suite of resources. CONCLUSIONS: Beyond language translation, cultural adaptation using co-design provided participants the opportunity to develop more culturally relevant care resources that meet their needs. These resources will be evaluated for clinical and cost-effectiveness in future research. CLINICAL IMPLICATIONS: By design, multilingual resources for carers must incorporate cultural needs to communicate support messages. If this intervention is effective, it could help to reduce dementia care disparities in ethnically diverse populations in Australia and globally.

Association Between Cognitive Performance and Nutritional Status: Analysis From LASI-DAD.

Malnutrition in low- and middle-income countries causes cognitive decline and other health problems. Harmonized Diagnostic Assessment of Dementia for Longitudinal Aging Study in India (LASI DAD) is an extensive study on late-life cognition and dementia. This study examines the link between nutrition and cognitive abilities in older adults using data from the LASI DAD. We conducted descriptive statistics on nutritional parameters (body-mass index, waist-hip ratio, and Mini-Nutritional Assessment), cognitive functions, and socio-demographic variables in 2,892 adults aged ≥60 years. Cognitive domains assessed included delayed recall, orientation, language, executive function, abstract reasoning, and attention. Cognitive impairment was defined as impaired performance in two or more domains. Mean age was 69.3 ± 7.1 years, 52.9% were female, and 57.5% were illiterate. Low body-mass index (adjusted OR: 1.88, p < .001), at risk of malnutrition (adjusted OR: 1.89, p < .001) and malnourished (adjusted OR: 2.86, p < .001) on Mini-Nutritional Assessment were associated with the presence of cognitive impairment. Better cognitive performance was associated with increased body mass index (adjusted OR: 0.74, p-.03), hemoglobin (adjusted OR: 0.91, p-.006), and serum albumin (adjusted OR: 0.38, p < .001). This study shows that nutritional status assessed by anthropometric measures and blood markers is strongly linked to cognitive performance in older adults.

Indian Psychiatric Society multicentre study: Diagnostic patterns, comorbidity and prescription practices for patients with Dementia.

Background: There are more than 5 million people with dementia in India. Multicentre studies looking at details of treatment for people with dementia In India are lacking. Clinical audit is a quality improvement process which aims to systematically assess, evaluate, and improve patient care. Evaluating current practice is the key to a clinical audit cycle. Aim: This study aimed to assess the diagnostic patterns and prescribing practices of psychiatrists for patients with dementia in India. Method: A retrospective case file study was conducted across several centers in India. Results: Information from the case records of 586 patients with dementia was obtained. Mean age of the patients was 71.14 years (standard deviation = 9.42). Three hundred twenty one (54.8%) were men. Alzheimer's disease (349; 59.6%) was the most frequent diagnosis followed by vascular dementia (117; 20%). Three hundred fifty five (60.6%) patients had medical disorders and 47.4% patients were taking medications for their medical conditions. Eighty one (69.2%) patients with vascular dementia had cardiovascular problems. Majority of the patients (524; 89.4%) were on medications for dementia. Most frequently prescribed treatment was Donepezil (230; 39.2%) followed by Donepezil-Memantine combination (225; 38.4%). Overall, 380 (64.8%) patients were on antipsychotics. Quetiapine (213, 36.3%) was the most frequently used antipsychotic. Overall, 113 (19.3%) patients were on antidepressants, 80 (13.7%) patients were on sedatives/hypnotics, and 16 (2.7%) patients were on mood stabilizers. Three hundred nineteen (55.4%) patients and caregivers of 374 (65%) patients were receiving psychosocial interventions. Conclusions: Diagnostic and prescription patterns in dementia which emerged from this study are comparable to other studies both nationally and internationally. Comparing current practices at individual and national levels against accepted guidelines, obtaining feedback, identifying gaps and instituting remedial measures help to improve the standard of care provided.

Prevalence of dementia in India: National and state estimates from a nationwide study.

INTRODUCTION: Prior estimates of dementia prevalence in India were based on samples from selected communities, inadequately representing the national and state populations. METHODS: From the Longitudinal Aging Study in India (LASI) we recruited a sample of adults ages 60+ and administered a rich battery of neuropsychological tests and an informant interview in 2018 through 2020. We obtained a clinical consensus rating of dementia status for a subsample (N = 2528), fitted a logistic model for dementia status on this subsample, and then imputed dementia status for all other LASI respondents aged 60+ (N = 28,949). RESULTS: The estimated dementia prevalence for adults ages 60+ in India is 7.4%, with significant age and education gradients, sex and urban/rural differences, and cross-state variation. DISCUSSION: An estimated 8.8 million Indians older than 60 years have dementia. The burden of dementia cases is unevenly distributed across states and subpopulations and may therefore require different levels of local planning and support. HIGHLIGHTS: The estimated dementia prevalence for adults ages 60+ in India is 7.4%. About 8.8 million Indians older than 60 years live with dementia. Dementia is more prevalent among females than males and in rural than urban areas. Significant cross-state variation exists in dementia prevalence.

Deep phenotyping and genomic data from a nationally representative study on dementia in India.

The Harmonized Diagnostic Assessment of Dementia for the Longitudinal Aging Study in India (LASI-DAD) is a nationally representative in-depth study of cognitive aging and dementia. We present a publicly available dataset of harmonized cognitive measures of 4,096 adults 60 years of age and older in India, collected across 18 states and union territories. Blood samples were obtained to carry out whole blood and serum-based assays. Results are included in a venous blood specimen datafile that can be linked to the Harmonized LASI-DAD dataset. A global screening array of 960 LASI-DAD respondents is also publicly available for download, in addition to neuroimaging data on 137 LASI-DAD participants. Altogether, these datasets provide comprehensive information on older adults in India that allow researchers to further understand risk factors associated with cognitive impairment and dementia.

Risk clustering and psychopathology from a multi-center cohort of Indian children, adolescents, and young adults.

Developmental adversities early in life are associated with later psychopathology. Clustering may be a useful approach to group multiple diverse risks together and study their relation with psychopathology. To generate risk clusters of children, adolescents, and young adults, based on adverse environmental exposure and developmental characteristics, and to examine the association of risk clusters with manifest psychopathology. Participants (n = 8300) between 6 and 23 years were recruited from seven sites in India. We administered questionnaires to elicit history of previous exposure to adverse childhood environments, family history of psychiatric disorders in first-degree relatives, and a range of antenatal and postnatal adversities. We used these variables to generate risk clusters. Mini-International Neuropsychiatric Interview-5 was administered to evaluate manifest psychopathology. Two-step cluster analysis revealed two clusters designated as high-risk cluster (HRC) and low-risk cluster (LRC), comprising 4197 (50.5%) and 4103 (49.5%) participants, respectively. HRC had higher frequencies of family history of mental illness, antenatal and neonatal risk factors, developmental delays, history of migration, and exposure to adverse childhood experiences than LRC. There were significantly higher risks of any psychiatric disorder [Relative Risk (RR) = 2.0, 95% CI 1.8-2.3], externalizing (RR = 4.8, 95% CI 3.6-6.4) and internalizing disorders (RR = 2.6, 95% CI 2.2-2.9), and suicidality (2.3, 95% CI 1.8-2.8) in HRC. Social-environmental and developmental factors could classify Indian children, adolescents and young adults into homogeneous clusters at high or low risk of psychopathology. These biopsychosocial determinants of mental health may have practice, policy and research implications for people in low- and middle-income countries.

Health and socioeconomic resource provision for older people in South Asian countries: Bangladesh, India, Nepal, Pakistan and Sri Lanka evidence from NEESAMA.

BACKGROUND: The global population is ageing rapidly, with low- and middle-income countries (LMICs) undergoing a fast demographic transition. As the number of older adults in LMICs increases, services able to effectively address their physical and mental health needs will be increasingly important. OBJECTIVE: We review the health and socioeconomic resources currently available for older people in South Asian countries, Bangladesh, India, Nepal, Pakistan and Sri Lanka, to identify gaps in available resources and assess areas for improvement. METHODS: We conducted a search of grey and published literature via Google Search, Compendex, EBSCO, JSTOR, Medline, Ovid, ProQuest databases, Scopus and Web of Science. Data on population demographics, human resources, health funding and social protection for older people were extracted. Local informants were consulted to supplement and verify the data. RESULTS: In the study countries, the number of health professionals with expertise in elderly care was largely unknown, with minimal postgraduate training programmes available in elderly medicine or psychiatry. Older adults are therefore cared for by general physicians, nurses and community health workers, all of whom are present in insufficient numbers per capita. Total average healthcare expenditure was 2.5-5.5% of GDP, with 48.1-72.0% of healthcare costs covered by out-of-pocket payments. Pakistan did not have a social pension; only India and Nepal offered financial assistance to people with dementia; and all countries had disproportionately low numbers of care elderly homes. CONCLUSIONS: Inadequate healthcare funding, a shortage of healthcare professionals and insufficient government pension and social security schemes are significant barriers to achieving universal health coverage in LMICs. Governing bodies must expand training programmes for healthcare providers for older adults, alongside increasing social protection to improve access to those in need and to prevent catastrophic health expenditure.

Prevalence of Psychiatric Disorders in Chhattisgarh: Findings from National Mental Health Survey.

Background: Psychiatric disorders are among the leading contributors to disability in India and worldwide. The pattern, prevalence, and distribution of psychiatric disorders in the country and its regions need to be assessed to facilitate early diagnosis and treatment. No study on the epidemiology of psychiatric disorders has been conducted in the Chhattisgarh state. This paper, as part of the National Mental Health Survey (NMHS), discusses the prevalence and pattern of psychiatric disorders in Chhattisgarh state. Methods: A stratified random cluster sampling technique and random selection based on probability proportional to size (PPS) at each stage were adopted. Participants were from three selected districts of Chhattisgarh, such as Janjgir-Champa, Kabirdham, and Raipur. Adults (aged ≥18 years) residing in selected households were interviewed using Mini International Neuropsychiatric Interview (version 6.0), the Fagerstrom test for nicotine dependence, the WHO-SEARO screening questionnaire for generalized tonic-clonic seizures, and screening tools for intellectual disability and autism spectrum disorders. Results: A total of 2841 individuals were interviewed. The state's lifetime and current prevalence of psychiatric disorders for adults were 14.06% [95% confidence interval (CI) = 13.83-14.29] and 11.66% (95% CI = 11.45-11.87), respectively. Prevalence of substance use disorders, tobacco use disorders, schizophrenia and related disorders, and mood disorders was 32.4% (95% CI = 32.09-32.71), 29.86% (95% CI = 29.56-30.16), 0.8% (95% CI = 0.75-0.86), and 4.44% (95% CI = 4.31-4.58), respectively. High risk for suicide was detected in 0.28% (95% CI = 0.25-0.31). Psychiatric disorders were twice more common in males than in females. Conclusions: The study gives authentic data on the prevalence of psychiatric disorders in Chhattisgarh. This shall pave the way for policymakers and planners to design state-specific plans for dealing with mental disorders and related issues.

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.

District-level differences in the distribution of mental and substance use disorders in Assam.

Background: The lifetime prevalence of mental morbidity in Assam is estimated at 8% (NMHS 2015-16). Understanding the distribution patterns of different types of mental disorders among persons with mental morbidity in different districts would facilitate evidence-driven district mental health programming in Assam. Given the varied socio-geopolitical situation across districts in Assam, significant variations in the distribution of mental disorders are expected. Aims: To assess interdistrict differentials in common mental disorders (CMDs), severe mental disorders (SMDs), socioeconomic impact, healthcare utilization, and mental disability across three districts sampled in NMHS in Assam. Materials and Methods: This cross-sectional study used stratified random cluster sampling to identify and study eligible adult participants in Dibrugarh, Barpeta, and Cachar districts. Standardized scales and validated questionnaires were used to assess mental morbidity, disability, socioeconomic impact, and healthcare utilization. The distribution of different mental disorders among persons with mental disorders and their interdistrict differentials were tested using the Chi-square test of significance. Results: Among persons with mental morbidity, the most common disorder was CMDs (79%). The proportional distribution of CMDs among persons with mental morbidity was significantly higher in the Dibrugarh district (79%), whereas the distribution of SMDs was higher in the Cachar district (55%). The distribution of alcohol use disorder was the highest in the Dibrugarh district (71.6%). Significant differences in disability and healthcare utilization were observed between the districts. Conclusions: NMHS 2015-16 Assam indicates significant differentials in the distribution of CMDs and SMDs, healthcare utilization, and associated disability between the three districts. The differentials necessitate further research to understand socio-ethnocultural, religious, geopolitical, and other factors influencing the distribution. These differences need to be accounted for during the implementation of mental health programs in the state.

Nationally representative epidemiological study of social anxiety disorder from India.

Background: Social anxiety disorder (SAD), also termed as social phobia, is a disabling psychiatric condition with limited epidemiological research on it in India. This study, using data from the National Mental Health Survey (NMHS), 2016, is the first to explore its current prevalence and associated factors in India. Materials and Methods: The NMHS in India used a comprehensive population-based study with subjects selected through a multistage stratified random cluster sampling technique across 12 states. The study included 34,802 adults interviewed with the Mini-International Psychiatric Interview 6.0.0. Firth penalized logistic regression (FPLR) was used to estimate covariate odds ratios (ORs), and the treatment gap for SAD and disability measured using Sheehan's disability scale was calculated. Results: The study found a 0.47% prevalence of SAD, with an average age of 35.68 years (standard deviation (SD) = 15.23) among those affected. Factors, such as male gender, unemployment, and living in urban areas, were associated with higher odds of SAD, while the elderly had lower odds. A significant proportion of individuals with SAD experienced disability in work (63%), social life (77%), and family life (68%). They spent a median of ₹ 2500 per month on treatment and had a high rate of comorbid psychiatric disorders (58%). The treatment gap was substantial at 82%. Conclusions: A considerable portion of India's population (approximately >65 lakhs) is affected by SAD. Surprisingly, the NMHS 2016 report indicates a higher risk of SAD among males compared with females, a trend that warrants further investigation. SAD in India is linked to significant disability and a considerable treatment gap, emphasizing the need for innovative approaches to address this large, affected population, especially in light of the scarcity of mental health professionals.

Bipolar affective disorder in India: A multi-site population-based cross-sectional study.

Introduction: Bipolar Affective Disorder (BPAD) merits careful consideration within the medical and healthcare communities, researchers, and policymakers. This is due to its substantial disability burden, elevated prevalence of co-morbidities, heightened lifetime risk of suicidality, and a significant treatment gap. This article focuses on the lifetime and current prevalence, correlates, co-morbidities, associated disabilities, socio-economic impact, and treatment gap for BPAD in the adult population of the National Mental Health Survey (NMHS) 2016. Materials and Methods: The NMHS 2016 was a nationally representative study conducted across 12 Indian states between 2014 and 2016. A multi-stage, stratified, random cluster sampling technique based on probability proportionate to size at each stage was used. The diagnosis of BPAD was based on Mini-International Neuropsychiatric Interview 6.0.0. Sheehan's Disability Scale was used to assess the disability. Results: A total of 34,802 adults were interviewed. The overall weighted prevalence of BPAD was 0.3% [95% confidence interval (CI): 0.29-0.31] for current and 0.5% (95% CI: 0.49-0.51) for lifetime diagnosis. Male gender [odds ratio (OR) 1.56] and residence in urban metropolitans (OR 2.43) had a significantly higher risk of a lifetime diagnosis of BPAD. Substantial cross-sectional co-morbidities were noted as per MINI 6.0.0 with the diagnosis of current BPAD such as tobacco use disorder (33.3%), other substance use disorders (14.6%), and anxiety disorders (10.4%). Two-thirds of persons with current BPAD reported disability of varying severity at work (63%), social (59.3%), and family life (63%). The treatment gap for current BPAD was 70.4%. Conclusion: Most individuals with current BPAD reported moderate-severe disability. There were substantial co-morbidities and a large treatment gap. These warrant concentrated efforts from policymakers in devising effective strategies.

Mental health morbidities in Kerala, India: Insights from National Mental Health Survey, 2015-2016.

Background: The National Mental Health Survey was borne out of the felt need for a comprehensive epidemiological survey on mental health to understand the magnitude of psychiatric morbidities in India to aid in mental health policymaking, service planning, and delivery. Kerala was one of the 12 surveyed states, representing southern India. Aims: To estimate the prevalence and pattern of various mental illnesses and substance use disorders in a representative sample from Kerala state. Settings and Design: A household survey using a multi-stage, stratified, random cluster sampling technique, with selection based on probability proportionate to size at each stage. Materials and Methods: The community-based survey was carried out by trained field staff on individuals from systematically selected households from three randomly selected districts of Kerala. The instruments used in the survey included M.I.N.I adult version 6.0, a modified version of the Fagerström Nicotine Dependence Scale and questionnaires to screen for epilepsy, intellectual disability, and autism spectrum disorders. Results: A total of 2479 respondents aged >18 years were interviewed. The lifetime and current prevalence of mental morbidity (excluding tobacco use disorders) was 14.14% and 11.36%, respectively. Neurotic/stress-related disorders and depressive disorders were 5.43% and 2.49%, respectively, while severe mental disorders were prevalent in 0.44% of the sample. The prevalence of high risk for suicide was 2.23%. Conclusions: The survey revealed high rates of common mental illnesses and suicide risk in the state when compared to national estimates.