Telemedicine Guidelines of India, 2020 promises to pave a road map for regularization and diversification of teleconsultation services across the country. This guideline is the need of the hour, especially during the current coronavirus disease pandemic. All modes of communications (text, audio, video, etc.) between the service provider and user are included in the broad rubric of the guidelines. Scope, inclusions, exclusions, and restrictions are clearly specified in the guideline. Medications are grouped and listed for the specific type of consultation, and restricted drugs are notified. This guideline especially helps mitigate the gaps in legislation and reduces the uncertainty while providing a practical, safe, and cost-effective framework to improve healthcare service delivery in this article; the authors discuss the implications of this new guideline and the challenges during the implementation of teleconsultation services across the country.
Background: The positive association between adverse life events and somatoform disorders is a consistent observation. But no systematic studies have evaluated the relationship between health-related life events (HLEs) in patients with somatic symptom disorder (SSD)/somatoform disorders. Aim: To examine the nature and relationship of HLE in patients with SSD and to assess the correlates of HLE. Methods: A total of 50 adult patients with SSD and 50 matched healthy controls from a Neuropsychiatric hospital were recruited. Sociodemographic interview, scale for assessment of somatic symptoms (SASS), Patient Health Questionnaire-15 (PHQ-15) and a semi-structured interview schedule to gather information on HLE were used. Results: Patients in the SSD group had a significantly higher number of total HLE in general (4.72 ± 2.63, 3.36 ± 1.92; p = .004), major HLE (1.48 ± 1.45, 0.68 ± 0.94; p = .006), during their lifetime in comparison to controls. Infections, trauma, non-communicable diseases and reproductive system–related diseases were the more common types of HLE in SSD group. Conclusion: Our findings may implicate a role of major HLE of patients and HLE of their family members in the pathophysiology of SSD.
Background: A substantial proportion of persons with psychosis (PWP) remain untreated in the community across the world. Factors that preclude them from accessing psychiatric treatment are poorly studied. In this study, we explored the factors that prevented persons with schizophrenia and their caregivers from accessing psychiatric treatment using an interview schedule specifically developed for this purpose. Methods: We identified individuals with schizophrenia and related disorders who had never accessed psychiatric treatment. We interviewed 67 such individuals and their family members using a validated tool, the Schedule of Factors Influencing Access to Treatment (SOFIAc) and analysed the data using descriptive statistics. Results: The M ( SD) number of factors reported to preclude individuals with psychosis and families from seeking psychiatric treatment was 10 (3.32). No PWP/family reported any single factor as the sole reason for not accessing treatment. Distance to the nearest psychiatric centre (97%), PWP's/family members' knowledge and attitude towards symptoms of psychosis and treatment (92.5%), financial problems (91%), lack of insight and active resistance to efforts towards treatment (86.6%), lack of support from the family (83.6%) and family issues and dynamics (79.1%) were reported to be the commonest factors that precluded them from accessing psychiatric treatment. Conclusions: The reason for individuals with psychosis and their family members not accessing psychiatric treatment was invariably multifactorial, involving, on average, 10 factors. Programmes that target the reduction of the treatment gap should be cognizant of the multifactorial nature of the challenge of reaching psychiatric treatment for persons with psychoses.
As telemedicine gained both importance and momentum following COVID -19 pandemic, Telemedicine Practise Guidelines (TPG) March 2020 was notified by the Central Government of India. Following the above, the Indian Psychiatrists Society, Telemedicine Society of India (TSI) and National Institute of Mental Health and Neurosciences (INI), Bangalore came together to address the specific needs of Psychiatrists practicing tele consultations, there by releasing Telepsychiatry Operational Guidelines 2020. This article discusses the guidelines outlines in the above documents with respect to prescribing psychotropics. We have discussed the thought process behind formulation of Telepsychiatry Operational guidelines, the challenges that may arise while following the above guidelines with possible solutions.
India signed the United Nations Convention on the Rights of Person with Disabilities (UNCRPD) and subsequently ratified the same on October 1, 2007. The UNCRPD proclaims that disability results from an interaction of impairments with attitudinal and environmental barriers which hinders full and active participation in society on an equal basis. Further, the convention also mandates the signatories to change their national laws, to identify and eliminate obstacles and barriers, and to comply with the terms of the UNCRPD. In this regard, the Government of India initially undertook the amendment of laws such as Persons with Disability Act, 1995 (PWD Act 1995). The Rights of PWD Act, 2016 (RPWD Act 2016) replaced the PWD Act 1995 to comply with the UNCRPD. The new act was fine-tuned considering the socio-cultural and local needs of the society, and the available resources. Persons with Mental Illness (PMI) are often stigmatized and discriminated, which hinders their full and active participation in society. This is a much larger issue, especially in women, gender minorities, backward communities, and the poor and the migrated populations. Adding to the complexities, PMIs are often not aware of their illness, refuse the much-needed treatment and often are not in a place to exercise their rights. There is an urgent need to address this issue of attitudinal barrier so that the rights of PMI are upheld. Hence, this article discusses challenges and opportunities in the RPWD Act 2016 from the perspective of PMI.
INTRODUCTION: Lifetime prevalence of psychiatric disorders in India is about 14%, and the treatment gap is huge necessitating large-scale public health efforts. Manochaitanya programme (MCP), one such innovative program, was launched by the Government of Karnataka in October 2014. MCP entails provision of outpatient psychiatric care in subdistrict (Taluk) hospitals and primary health centers under a public–private (Indian Psychiatric Society-Karnataka chapter) partnership model, at least one Tuesday of every month. AIM: The aim was to do a secondary care level performance audit of MCP of initial 2½ years at all Taluka general hospitals of Karnataka. METHODOLOGY: Data on MCP were collected and tabulated from all 31 districts using a specially designed semistructured pro forma. This includes the number of self-reported psychiatric consultations in each Tuesday's clinic, number of psychiatrists, and their visit details. Prospective data were obtained from monthly reports. RESULTS: The district coverage was 100% during initial 2½ years over this period, i.e., MCPs were successfully covered in at least one Taluka hospital in all 31 districts. A total number of estimated consultations under this initiative were 73,663 with an average of 24.1 patients per psychiatrist consultation. One hundred and eleven psychiatrists participated in a total of 3,056 visits across the state. Patient footfall increased consistently over this time period. CONCLUSIONS: Psychiatrist-based Manochaitanya programme at secondary care level at Taluk hospitals has noticed substantial benefits to patient care. There is a need for psychiatrist-based secondary care at Talukas (subdistrict) level across the country.
There is no health without mental health. Recently conducted National Mental Health Survey quoted a prevalence of 13.7% lifetime and 10.6% current mental morbidity. To address this mammoth problem, an aspirational law was enacted titled "Mental Healthcare Act, 2017" (MHCA 2017). The act is progressive and rights based in nature. The whole dedicated Chapter 5 on "Rights of the person with mental illness" is the heart and soul of this legislation. However, the act mainly focuses on the rights of the persons with mental illness (PMI), only during treatment in hospital but is not equally emphatic about continuity of treatment in the community. The act fails to acknowledge and foster the role and contribution of family members in providing care to PMI. Although there are many positive aspects to the MHCA 2017, it may impact adversely on the mental health care in India. This article focuses on the shortcomings and challenges of the act and also makes attempts to offer alternatives considering the available resources and ground reality. Concepts such as "Advance directives" and "Nominated representatives" appear to be very attractive, idealistic, and aspirational, but not evidenced based in the Indian context considering the resources. The act fails to make an impact even after 22 months to attain the goal, and will require pervasive efforts to fulfil a purpose that directs its development. This law needs to be amended as per the local resources and requirements of the society.
The Mental Healthcare Act, 2017 (MHCA) was a step that was essential, once the Government of India ratified the United Nations Convention on the Rights of Persons with Disabilities in 2007. The MHCA looks to protect, promote, and fulfill the rights of persons with mental illness (PMI) as stated in the preamble of the Act. Further, there is an onus on the state to provide affordable mental health care to its citizens. In India, mental health has always been a lesser priority for lawmakers and citizens alike. The rights-based MHCA looks to overhaul the existing system by giving prominence to autonomy, protecting the rights of the mentally ill individuals, and making the State responsible for the care. The decision to make all this happen is commendable. The annual health expenditure of India is 1.15% of the gross domestic product, and the mental health budget is <1% of India's total health budget. This article systematically analyses and describes the cost estimation of the implementation of MHCA 2017, and it is not an estimation of mental health economics. The conservative annual estimated cost on the government to implement MHCA, 2017 would be 94,073 crore rupees. The present study estimation depicts that investing in the implementation of MHCA, 2017 by the government will yield 6.5 times the return on investment analysis benefit. If the State is not proactive in taking measures to implement the MHCA, the rights promised under this legislation will remain aspirational.
Objectives: A significant number of homeless mentally ill (HMI) patients without any personal, family or other identification details represent a unique problem in the psychiatric services of developing countries like India in the context of legal, humanitarian and treatment issues. These patients pose challenge to the mental health professional in diagnosis and management. Aims: To study the sociodemographic and clinical profiles of HMI patients admitted under psychiatry. Methods: We performed a retrospective chart review of 'HMI' patients from 1 January 2002 to 31 December 2015, who were admitted to the Department of Psychiatry at National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India. Sociodemographic and clinical profiles of the patients were analyzed by descriptive statistics. Results: Mean age of the sample was 34.6 years (±12.21 years), 42 (53.8%) were females, 74 (94.9%) were registered as Medico Legal Case and 53 (80.8%) were admitted under reception order issued by a magistrate. HMI patients brought by police were 32 (41.0%), by the public were 32 (41.0%) and 14 (18.0%) by nongovernmental organization /ambulance/social worker. In total, 51 (65.4%) of them had schizophrenia and other psychotic disorders, 24 (30.8%) had mental retardation and 23 (29.5%) had a comorbid substance use disorder. The mean Clinical Global Impression severity at admission was 5.07 (±1.7), and the mean duration of inpatient care was 15 weeks. Anemia and malnutrition were found in 34 (43.6%) and 25 (32.1%) patients, respectively. Conclusion: This study shows that schizophrenia, comorbid mental retardation and substance use disorder are common causes of admission of HMI patients in psychiatry. It is an emerging problem, which needs urgent interventions, and there is a need for an efficient system, guidelines and collaboration with government and nongovernmental agencies.
Background: Non-adherence to medication leading to a break in continuity of care poses significant challenges in severe mental illness (SMI), leading to poor outcomes. In India, proxy consultation, wherein caregivers consult on behalf of patients, is a commonly adopted but insufficiently researched area to address these challenges. Aims: To explore the extent of proxy consultation in outpatient care of persons with SMI and investigate its sociodemographic and clinical correlates. Methodology: In a tertiary care psychiatry outpatient setting, we conducted a cross-sectional study involving 374 caregivers of persons with SMI (Schizophrenia, Bipolar and related disorders). Descriptive statistics and univariate logistic regression were performed to examine correlates' relationships with proxy consultation. Results: Proxy consultation prevalence was 43% in the past 1 year. Compared with 18 to 30 years, middle-aged patients aged 31 to 40, 41 to 50 and 51 to 60 years had twofold, threefold and sixfold increased chances of proxy consultation, respectively. Being illiterate had six times higher odds than graduates, three times and two times if they studied till primary and secondary education. Early age of onset was associated with three times higher chances of proxy consultation compared to the onset of illness in adulthood. On the contrary, male gender and upper and middle socioeconomic status decreased the chances of proxy consultation by 40%. Financial difficulties ( n = 72, 45%) and patients' unwillingness to visit outpatients ( n = 44, 27.5%) were the most commonly cited reasons for proxy consultation. Conclusion: Proxy consultations are relatively common, driven by many social, economic, patient-related, pragmatic and practical factors. In formulating community care policies for persons with SMI, the primary imperative should be to conduct additional research, deepening our understanding of proxy consultations. Additionally, it is essential to be mindful of the diverse issues associated with proxy consultations during the formulation process.
Telepsychiatry is a cost-effective alternative to in-person psychiatric consultations. The COVID-19 pandemic brought about a sharp spike in the utilization of telepsychiatry due to ongoing restrictions on gatherings and traveling. In recognition of the importance of telemedicine in general, and telepsychiatry specifically, telemedicine practice guidelines and telepsychiatry operational guidelines have been released. Due to the rising trend in telemedicine, the Insurance Regulatory and Development Authority of India (IRDIA) incorporated teleconsultation health insurance coverage at a level on par with regular in-person consultations. In contrast, in the United States of America, private insurance coverage for telepsychiatry has been in vogue for some time. In this paper we draw comparisons between India and the United States on telepsychiatry and health insurance. We compare the evolving regulatory policies of these two countries in relation to existing insurances plans that are available, the challenges in implementation of new regulations and the possible ways to overcome the challenges to make telepsychiatry affordable to all.
The COVID pandemic has affected the world in a drastic manner taking a toll of not only human lives but also the economy and lifestyle. Of all the population suffering, the underprivileged and vulnerable groups have faced the maximum economic burden. Within India, an ample quota of people migrates annually for elementary occupations in service, sales, building and domestic industries. Generally, they are exposed to discrimination, work-rights exploitation and job insecurity. The onset of COVID 19 has accentuated these issues in unprecedented ways. The Apex Court of the country took note of this plight and gave directions to the governments to take care of the immediate needs of the migrant workers. This article attempts to reflect the mental health concerns of the migrant workers who were temporarily sheltered at relief camps across Bengaluru city in the state of Karnataka, during the ongoing COVID pandemic. The article ends with giving recommendations
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.
This article highlights the platform and framework for the new public mental health initiative, the Taluk Mental Health Program (TMHP), rolled out by the Government of India, as part of the expansion of the District Mental Health Program. In this initial phase, TMHP has been approved for ten taluks of Karnataka state. In the authors' collective opinion, few of the initiatives in the country could be considered as foundations for conceptualizing the TMHP (a) research programs and projects in the community, (b) community intervention programs running in two taluks of Karnataka since the past one and a half decade (Thirthahalli and Turuvekere taluks of Karnataka), and the (c) Primary Care Psychiatry Program of National Institute of Mental Health and Neurosciences. The article briefly describes the above initiatives and ends with further suggestions to scale up TMHP.
BACKGROUND: A burgeoning rise in the elderly subpopulation is being noted in India. This rise has already earned the designation as a shining nation by the United Nations/World Health Organization. This growth will take the elderly subpopulation to 324 million persons above 60 years by 2050. The mental health needs of this subpopulation are varied and nuanced compared to that of the general population. The risk and prevalence of mental health morbidity are also greater. There is an urgent need to gear up the health care systems. CONSIDERATIONS: Various aspects of the ongoing demographic transitions are considered alongside available health information. Legislative mandates and laws are also reviewed to provide context to qualify the action points and recommendations. Recommendations, India must act urgently to strengthen health care delivery systems in a concurrent multipronged approach. These efforts should focus on developing trained Human Resources and adequate infrastructural resources. Review mechanisms to inform on required updates on best practices and evidence-based medicine must also be incorporated and developed to perform periodically.
