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Rickli C, Stoll J, Westermair AL, Trachsel M. Comparing attitudes towards compulsory interventions in severe and persistent mental illness among psychiatrists in India and Switzerland. BMC Psychiatry 2024; 24:295. [PMID: 38637747 PMCID: PMC11025243 DOI: 10.1186/s12888-024-05710-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 03/24/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Psychiatrists face a major ethical challenge when deciding whether to make use of coercive measures in the treatment process of patients suffering from severe and persistent mental illness (SPMI). As India and Switzerland show major cultural, political and financial differences, it is hypothesized that attitudes towards coercive measures among Indian and Swiss psychiatrists will vary too. Exploring differences in attitudes between cultures strengthens the critical reflection on one's own stances and in consequence, on our way of action. Especially when it comes to situations involving power imbalances between patients and health practitioners, self-reflection is essential to prevent ethically inappropriate behavior. METHODS An online survey on aspects of care for patients with SPMI was sent to 3'056 members of the Indian Psychiatric Society between April and June 2020 and to 1'311 members of the Swiss Society for Psychiatry and Psychotherapy between February and March 2016. The respondents' answers were compared. This article deals with the questionnaire's items on autonomous decision making and the implementation of coercive measures in clinical practice. More precisely, participating psychiatrists were asked to rate the importance of patient's autonomy in general and their willingness to apply coercive measures regarding two specific case vignettes depicting a patient with schizophrenia and one with depression. The statistical analysis, namely descriptive data analysis and calculation of arithmetic means, Shapiro Wilks tests and Mann-Whitney U tests, was carried out using IBM SPSS Statistics version 27. RESULTS Answers were received from 206 psychiatrists in India and 457 psychiatrists in Switzerland. Indian participants tended to value autonomous decision making as slightly less important than Swiss participants (62.2% vs. 91%, p =.01). Regarding a case of severe and persistent depression, psychiatrists in the Indian group were on average more in favor of acting against the wishes of the patient (55% vs. 34.1%, p <.0001) as well as of accepting a temporary decrease in quality of life due to coercion (40% vs. 23%, p =.008). Answers concerning a case of schizophrenia revealed that Indian participants were more in favor of acting against the patient's wishes than Swiss participants (39% vs. 37%, p =.007), whereas the comparison whether to accept a temporary decrease in quality of life regarding this case showed no significant difference (p =.328). CONCLUSIONS The significant difference in attitudes towards coercive measures among Indian compared to Swiss psychiatrists found in this study might arise from a predominantly more collectivist society in India compared to Switzerland. Moreover, differences in financial resources, the organization of the health care system, and the historical background might have an influence. Continuous and critical reflection on one's own views and behavior is essential, especially if ethical principles and individual rights could be violated through a power imbalance, as in the case of coercive measures.
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Affiliation(s)
- Christina Rickli
- Institute of Biomedical Ethics and History of Medicine, University of Zurich (UZH), Zurich, Switzerland
| | - Julia Stoll
- Institute of Biomedical Ethics and History of Medicine, University of Zurich (UZH), Zurich, Switzerland
| | - Anna Lisa Westermair
- Institute of Biomedical Ethics and History of Medicine, University of Zurich (UZH), Zurich, Switzerland
- Clinical Ethics Unit, University Hospital Basel (USB) and University Psychiatric Clinics (UPK) Basel, Basel, Switzerland
| | - Manuel Trachsel
- Clinical Ethics Unit, University Hospital Basel (USB) and University Psychiatric Clinics (UPK) Basel, Basel, Switzerland.
- Faculty of Medicine, University of Basel, Basel, Switzerland.
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Vanagundi R, Pokle S, Walwaikar R, Waikar S. Exploring Psychiatrists' Experiences During Transition from Mental Health Act, 1987 to Mental Healthcare Act, 2017 in Goa, India. Indian J Psychol Med 2024; 46:32-38. [PMID: 38524960 PMCID: PMC10958085 DOI: 10.1177/02537176231198404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/26/2024] Open
Abstract
Background Mental Healthcare Act 2017 (MHCA) came into force on 29 May 2018. Goa State Mental Health Authority (GSMHA) notified the Mental Health Review Board on 8 February 2022, completing the important process of implementation of the act. The transition comes with challenges. Methods A qualitative study was conducted with 18 practicing psychiatrists who had worked under Mental Health Act 1987 as well as MHCA 2017 through purposive sampling across Goa. Data was collected through individual interviews; analysis was done by Braune and Clarke's framework of Thematic Analysis. Results Eighteen psychiatrists participated: 4 private, 3 secondary and 11 from tertiary levels. The themes extracted were work during MHA 1987, transition, and after the implementation of MHCA 2017. Some participants reported difficulties, felt an increase in workload, and had negative emotions, while a few were neutral, indicating mixed perceptions. Conclusion This study highlights the administrative struggles and moral dilemmas faced by psychiatrists in handling the new legislation. It's imperative that the implementation of new act should be carried out with sufficient resource allocation and monitoring mechanisms.
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Affiliation(s)
- Rohan Vanagundi
- Dept. of Psychiatry, Institute of Psychiatry and Human Behavior, Goa, India
| | - Sneha Pokle
- Dept. of Psychiatry, Institute of Psychiatry and Human Behavior, Goa, India
| | - Rohit Walwaikar
- Dept. of Psychiatry, Institute of Psychiatry and Human Behavior, Goa, India
| | - Shilpa Waikar
- Dept. of Psychiatry, Institute of Psychiatry and Human Behavior, Goa, India
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Lava-Parmele S, Lava C, Parmele JB. The Historical Struggles of Modified Electroconvulsive Therapy: How Anesthesia Came to the Rescue. J Anesth Hist 2021; 7:17-25. [PMID: 34175108 DOI: 10.1016/j.janh.2021.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 03/14/2021] [Indexed: 10/21/2022]
Abstract
The complicated history of modified electroconvulsive therapy (ECT) started back before anesthesia was incorporated when unmodified electroconvulsive therapy was not considered humane. When anesthesiologists started working with psychiatrists, ECT gradually regained acceptance by decreasing the obstacles inherent to this therapy despite the complexities of the anesthetics. However, the sociopolitical and medicolegal factors negatively impacted the use of modified ECT leading to a period of time when it was banned from use in the United States. Fortunately, as advances in anesthesia and technology continued to develop, anesthesiologists helped ECT regain widespread usage improving the safety profile, cost effectiveness, quicker onset of seizures, and ease of control despite its stained past. This allowed more accessibility, especially for high-risk medical patients, to a relatively safe and effective treatment for psychiatric diseases.
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Affiliation(s)
- Susan Lava-Parmele
- Metropolitan Anesthesia Consultants, 4737 County Road 101, #305, Minnetonka, MN 55345, USA.
| | | | - James B Parmele
- Interventional Spine and Pain Physicians, 9645 Grove Circle, North Suite 200, Maple Grove, MN 55369, USA
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Ponnudurai R. A journey through psychiatry - A personal perspective. Indian J Psychiatry 2021; 63:215-221. [PMID: 34211212 PMCID: PMC8221215 DOI: 10.4103/indianjpsychiatry.indianjpsychiatry_448_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/14/2020] [Accepted: 05/31/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- R Ponnudurai
- Department of Psychiatry, A.C.S. Medical College, Chennai, Tamil Nadu, India.,Department of Psychiatry, Madras Medical College, Chennai, Tamil Nadu, India
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McDevitt D. Psychiatric advance directives: Navigating the regulatory landscape. Nurse Pract 2020; 45:10-13. [PMID: 32205667 DOI: 10.1097/01.npr.0000657304.67256.e5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Affiliation(s)
- Diane McDevitt
- Diane McDevitt is an associate professor at Kingsborough Community College in Brooklyn, NY, and assistant director of nursing at Richmond University Medical Center in Staten Island, NY
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Makkar N, Jain K, Siddharth V, Sarkar S. Patient Involvement in Decision-Making: An Important Parameter for Better Patient Experience-An Observational Study (STROBE Compliant). J Patient Exp 2019; 6:231-237. [PMID: 31535012 PMCID: PMC6739683 DOI: 10.1177/2374373518790043] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background and Aim: Preferences of service users is an important consideration for developing health-care services. This study aimed to assess the experiences of the patients with substance use disorders who were admitted to a tertiary health-care facility in India. Method: This cross-sectional sectional study recruited adult inpatients who stayed for a period of 7 days or more. The Picker Patient Experience questionnaire (PPE-15) was used to gather information about the views of the patients about the care received at the center. Results: Responses were available from 113 inpatients. Majority of the participants were males and were dependent on opioids. The experience was generally positive about being treated with respect and dignity and access to information. The participants were most satisfied with opportunity being given to discuss anxiety and fear about the condition or treatment (91.2% positive response) and least satisfied with differences in responses from doctors and nurses (43.4% positive response). Further attention seemed desired about communication with the staff and patients’ involvement in their own treatment-related decision-making. Conclusion: Efforts need to be made to involve patients in their own treatment-related decision-making and to improve communication with the treatment team. This might lead to better involvement in treatment process, which could enhance the treatment outcomes in this vulnerable population.
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Affiliation(s)
- Namrata Makkar
- Department of Hospital Administration, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Kanika Jain
- Department of Hospital Administration, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Vijaydeep Siddharth
- Department of Hospital Administration, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
| | - Siddharth Sarkar
- Department of Psychiatry, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
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Affiliation(s)
- Avinash De Sousa
- Department of Psychiatry, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
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Philip S, Chandran D, Stezin A, Viswanathaiah GC, Gowda GS, Moirangthem S, Kumar CN, Math SB. EAT-PAD: Educating about psychiatric advance directives in India. Int J Soc Psychiatry 2019; 65:207-216. [PMID: 30945582 DOI: 10.1177/0020764019834591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND With India enacting the Mental Health Care Act (MHCA; No. 10 of 2017a), Psychiatric Advance Directives (PADs) have been legalised and have become binding orders for psychiatrists treating patients. There is a paucity of research into acceptability of PADs in Indian mental health care, likely due to a lack of awareness. There are no educational measures about PADs provided for in this Act. Facilitators and facilitation methods have not been elaborated upon as well. AIM The aim of this study is (a) to develop/evaluate the effectiveness of a structured Education-cum-Assessment Tool (EAT) in providing information regarding PADs and (b) to evaluate modes of facilitation required by patients to complete PADs. METHODS A tool was developed as per provisions regarding PADs in the Mental Health Care Bill of 2013. This tool was administered to patients ( n = 100), purposively sampled from the adult psychiatry review out-patient department (OPD). Patients were evaluated on retention of information, completion of PADs, modes of facilitation and time taken to write one. RESULTS Mean years of education was 8.28 (±5.74) years and mean duration of illness was 8.30 (±7.04) years. In all, 65% had Below-Poverty Line (BPL) status. All participants completed valid PADs in an average of 15 minutes. About 93% required facilitation via assistance in writing and reminding. The mean EAT scores implied above 70% retention but did not relate to types of facilitation. CONCLUSIONS EAT scores can be used as an approximate measure of the patient's ability to understand and retain information which is a part of decisional capacity. Types of facilitation can help in understanding patient's ability to communicate their choices. Service providers may find EAT a time-effective tool for uniformly educating service users regarding PADs and indirectly assessing competence.
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Affiliation(s)
- Sharad Philip
- 1 Department of Psychiatry, National Institute of Mental Health And Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Dhanya Chandran
- 2 Neuropsychology Unit, Department of Clinical Psychology, National Institute of Mental Health And Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Albert Stezin
- 3 Department of Clinical Neurosciences, National Institute of Mental Health And Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Geetha C Viswanathaiah
- 4 Center for Addiction Medicine, Department of Psychiatry, National Institute of Mental Health And Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Guru S Gowda
- 1 Department of Psychiatry, National Institute of Mental Health And Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Sydney Moirangthem
- 1 Department of Psychiatry, National Institute of Mental Health And Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Channaveerachari Naveen Kumar
- 1 Department of Psychiatry, National Institute of Mental Health And Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Suresh Bada Math
- 1 Department of Psychiatry, National Institute of Mental Health And Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
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Philip S, Rangarajan SK, Moirangthem S, Kumar CN, Gowda MR, Gowda GS, Math SB. Advance directives and nominated representatives: A critique. Indian J Psychiatry 2019; 61:S680-S685. [PMID: 31040457 PMCID: PMC6482704 DOI: 10.4103/psychiatry.indianjpsychiatry_95_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
With the ratification of the landmark United Nations Convention on Rights of Persons with Disabilities by India, it was imperative to revamp the mental health-care legislation, among other changes. Most notably, a presumption of mental capacity has been introduced, which means a paradigm shift in the client and provider relationship. The Mental Healthcare Act, 2017 empowers all persons to make advance directives (AD) and nominate representatives for shared decision-making. Psychiatric ADs (PADs) also seem to improve the information exchange between the care provider and the service user. PADs may also be used as a vehicle of consent to future treatments. While drafting the PAD, the drafter must also plan how such directed care would be financed. Insurance companies have not been mandated to comply with ADs. In the eventuality that the drafter's family refuse support for treatment specified in the PAD, the drafter would be left holding an unimplementable PAD. The AD saw its origins in the care of the terminally ill and decades later came to be utilized in mental health care. After nearly three decades of use in developed countries, evidence at best remains mixed or inconclusive. This review focuses on the AD from the Indian perspective.
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Affiliation(s)
- Sharad Philip
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Subhashini K Rangarajan
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Sydney Moirangthem
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Channaveerachari Naveen Kumar
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Mahesh R Gowda
- Department of Psychiatry, Spandana Health Care, Bengaluru, Karnataka, India
| | - Guru S Gowda
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
| | - Suresh Bada Math
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, Karnataka, India
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Prashanth NR, Abraham SE, Hongally C, Madhusudan S. Dealing with statutory bodies under the Mental Healthcare Act 2017. Indian J Psychiatry 2019; 61:S717-S723. [PMID: 31040463 PMCID: PMC6482699 DOI: 10.4103/psychiatry.indianjpsychiatry_152_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
India has an enormous burden of mental illness. In spite of the recognition of this population of people living with mental illness, the treatment gap continues to be about 83%. In order to meet this vast unmet need and in the view of aligning the mental health legislation with the international standards and the UN-Convention on the Rights of Persons with Disabilities, the Mental Healthcare Act 2017 was passed and enforced recently. The provisions in the act have been controversial from its conception. Now after the enforcement of the act, all mental health professionals (MHPs) have a legal binding to follow the provisions in the law. The MHPs are accountable to the statutory bodies - the Central Mental Health Authority, State Mental Health Authority (SMHA), Mental Health Review Board, and finally, the High Court or the Supreme Court. The Mental Healthcare Act (MHCA) and relevant articles/documents obtained pertaining to MHCA and their evaluation were reviewed, the major focus being on the role of statutory/regulatory bodies. Furthermore, an attempt was made to summarize the previous experiences in inspection of mental health establishments by SMHA of Karnataka. We concluded that the MHCA will have both positive and negative aspects. Many of the provisions in the law may appear unclear and unrealistic by many practitioners. However, it becomes precautionary for the MHPs to be well equipped with the MHCA and be acquainted with the requirements of the statutory bodies for ensuring a safe practice. The outcome of the implementation of the act will become evident only with time.
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Affiliation(s)
- N R Prashanth
- Department of Psychiatry, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
| | - Shalu Elizabeth Abraham
- Department of Psychiatry, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
| | - Chandrashekar Hongally
- Department of Psychiatry, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
| | - S Madhusudan
- Department of Psychiatry, Bangalore Medical College and Research Institute, Bengaluru, Karnataka, India
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Math SB, Basavaraju V, Harihara SN, Gowda GS, Manjunatha N, Kumar CN, Gowda M. Mental Healthcare Act 2017 - Aspiration to action. Indian J Psychiatry 2019; 61:S660-S666. [PMID: 31040454 PMCID: PMC6482691 DOI: 10.4103/psychiatry.indianjpsychiatry_91_19] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Suresh Bada Math
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - Vinay Basavaraju
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | | | - Guru S. Gowda
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - Narayana Manjunatha
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - Channaveerachari Naveen Kumar
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India
| | - Mahesh Gowda
- Department of Psychiatry, Spandana Health Care, Bengaluru, Karnataka, India
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Sinclair DJM, Zhao S, Qi F, Nyakyoma K, Kwong JSW, Adams CE. Electroconvulsive therapy for treatment-resistant schizophrenia. Cochrane Database Syst Rev 2019; 3:CD011847. [PMID: 30888709 PMCID: PMC6424225 DOI: 10.1002/14651858.cd011847.pub2] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Electroconvulsive therapy (ECT) involves the induction of a seizure by the administration of an electrical stimulus via electrodes usually placed bilaterally on the scalp and was introduced as a treatment for schizophrenia in 1938. However, ECT is a controversial treatment with concerns about long-term side effects such a memory loss. Therefore, it is important to determine its clinical efficacy and safety for people with schizophrenia who are not responding to their treatment. OBJECTIVES Our primary objective was to assess the effects (benefits and harms) of ECT for people with treatment-resistant schizophrenia.Our secondary objectives were to determine whether ECT produces a differential response in people: who are treated with unilateral compared to bilateral ECT; who have had a long (more than 12 sessions) or a short course of ECT; who are given continuation or maintenance ECT; who are diagnosed with well-defined treatment-resistant schizophrenia as opposed to less rigorously defined treatment-resistant schizophrenia (who would be expected to have a greater affective component to their illness). SEARCH METHODS We searched the Cochrane Schizophrenia Group's Study-Based Register of Trials including clinical trial registries on 9 September 2015 and 4 August 2017. There were no limitations on language, date, document type, or publication status for the inclusion of records in the register. We also inspected references of all the included records to identify further relevant studies. SELECTION CRITERIA Randomised controlled trials investigating the effects of ECT in people with treatment-resistant schizophrenia. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data. For binary outcomes, we calculated the risk ratio (RR) and its 95% confidence intervals (CIs), on an intention-to-treat basis. For continuous data, we estimated the mean difference (MD) between the groups and its 95% CIs. We employed the fixed-effect model for all analyses. We assessed risk of bias for the included studies and created 'Summary of findings' tables using the GRADE framework. MAIN RESULTS We included 15 studies involving 1285 participants (1264 completers with an average age of 18 to 46 years) with treatment-resistant schizophrenia. We rated most studies (14/15, 93.3%) as at high risk of bias due to issues related to the blinding of participants and personnel. Our main outcomes of interest were: (i) clinically important response to treatment; (ii) clinically important change in cognitive functioning; (iii) leaving the study early; (iv) clinically important change in general mental state; (v) clinically important change in general functioning; (vi) number hospitalised; and (vii) death. No trial reported data on death.The included trials reported useable data for four comparisons: ECT plus standard care compared with sham-ECT added to standard care; ECT plus standard care compared with antipsychotic added to standard care; ECT plus standard care compared with standard care; and ECT alone compared with antipsychotic alone.For the comparison ECT plus standard care versus sham-ECT plus standard care, only average endpoint BPRS (Brief Psychiatric Rating Scale) scores from one study were available for mental state; no clear difference between groups was observed (short term; MD 3.60, 95% CI -3.69 to 10.89; participants = 25; studies = 1; very low-quality evidence). One study reported data for service use, measured as number readmitted; there was a clear difference favouring the ECT group (short term; RR 0.29, 95% CI 0.10 to 0.85; participants = 25; studies = 1; low-quality evidence).When ECT plus standard care was compared with antipsychotics (clozapine) plus standard care, data from one study showed no clear difference for clinically important response to treatment (medium term; RR 1.23, 95% CI 0.95 to 1.58; participants = 162; studies = 1; low-quality evidence). Clinically important change in mental state data were not available, but average endpoint BPRS scores were reported. A positive effect for the ECT group was found (short-term BPRS; MD -5.20, 95% CI -7.93 to -2.47; participants = 162; studies = 1; very low-quality evidence).When ECT plus standard care was compared with standard care, more participants in the ECT group had a clinically important response (medium term; RR 2.06, 95% CI 1.75 to 2.42; participants = 819; studies = 9; moderate-quality evidence). Data on clinically important change in cognitive functioning were not available, but data for memory deterioration were reported. Results showed that adding ECT to standard care may increase the risk of memory deterioration (short term; RR 27.00, 95% CI 1.67 to 437.68; participants = 72; studies = 1; very low-quality evidence). There were no clear differences between groups in satisfaction and acceptability of treatment, measured as leaving the study early (medium term; RR 1.18, 95% CI 0.38 to 3.63; participants = 354; studies = 3; very low-quality evidence). Only average endpoint scale scores were available for mental state (BPRS) and general functioning (Global Assessment of Functioning). There were clear differences in scores, favouring ECT group for mental state (medium term; MD -11.18, 95% CI -12.61 to -9.76; participants = 345; studies = 2; low-quality evidence) and general functioning (medium term; MD 10.66, 95% CI 6.98 to 14.34; participants = 97; studies = 2; very low-quality evidence).For the comparison ECT alone versus antipsychotics (flupenthixol) alone, only average endpoint scale scores were available for mental state and general functioning. Mental state scores were similar between groups (medium-term BPRS; MD -0.93, 95% CI -6.95 to 5.09; participants = 30; studies = 1; very low-quality evidence); general functioning scores were also similar between groups (medium-term Global Assessment of Functioning; MD -0.66, 95% CI -3.60 to 2.28; participants = 30; studies = 1; very low-quality evidence). AUTHORS' CONCLUSIONS Moderate-quality evidence indicates that relative to standard care, ECT has a positive effect on medium-term clinical response for people with treatment-resistant schizophrenia. However, there is no clear and convincing advantage or disadvantage for adding ECT to standard care for other outcomes. The available evidence was also too weak to indicate whether adding ECT to standard care is superior or inferior to adding sham-ECT or other antipsychotics to standard care, and there was insufficient evidence to support or refute the use of ECT alone. More good-quality evidence is needed before firm conclusions can be made.
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Affiliation(s)
- Diarmid JM Sinclair
- Nottinghamshire Healthcare NHS TrustGeneral Adult PsychiatryBassetlaw HospitalWorksopSouth YorkshireUKS81 0BD
| | - Sai Zhao
- The Ingenuity Centre, The University of NottinghamSystematic Review Solutions LtdTriumph RoadNottinghamUKNG7 2TU
| | - Fang Qi
- The Ingenuity Centre, The University of NottinghamSystematic Review Solutions LtdTriumph RoadNottinghamUKNG7 2TU
| | - Kazare Nyakyoma
- Derbyshire Healthcare Foundation NHS TrustDerby City Acute Mental HealthSt. Andrew's House201 London RoadDerby DE1 2QYUKDE1 2SQ
| | - Joey SW Kwong
- National Center for Child Health and DevelopmentDepartment of Health Policy and Department of Clinical Epidemiology2‐10‐1 OkuraSetagaya‐kuTokyoJapan
| | - Clive E Adams
- The University of NottinghamCochrane Schizophrenia GroupInstitute of Mental HealthInnovation Park, Triumph Road,NottinghamUKNG7 2TU
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Rao R, Varshney M, Singh S, Agrawal A, Ambekar A. Mental Healthcare Act, 2017, and addiction treatment: Potential pitfalls and trepidations. Indian J Psychiatry 2019; 61:208-212. [PMID: 30992618 PMCID: PMC6425793 DOI: 10.4103/psychiatry.indianjpsychiatry_463_18] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The Mental Healthcare Act (MHCA), 2017, is enacted with an aim to promote and protect the rights of and improve the care and treatment for people affected by mental illness in India. The Act purportedly includes substance use disorder (SUD) specifically in the definition of mental illness itself. However, some of the phrases used in the definition such as "abuse" are not clear, as the current classificatory systems of mental illnesses do not have any diagnostic category termed "abuse." Another important issue is the lack of clarity on which categories of SUD would be covered under MHCA. Simple reading of the text of the Act seems to suggest that SUD is a single entity for the purpose of this law. In such case, many provisions of the act such as supported admission that are meant for the treatment of people with severe mental illnesses with gross impairment may become applicable to all types of SUD. This can create potential problems for addiction treatment providers. On the other hand, certain other provisions of the Act are good news for patients suffering from SUD. The Act lays down various rights that include, among others, protection from cruel, inhuman, or degrading treatment in any mental health establishment. This is very important from the perspective of treatment of SUD in the context of India, where human rights violations in the name of addiction treatment are often reported. The inclusion of SUD in MHCA, 2017, slots SUD as a health issue, rather than a law-and-order issue alone. This displays the intent of policymakers toward SUD, which, in itself, is laudable. There are certain ways in which the potential pitfalls mentioned earlier can be addressed, which is discussed in the article.
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Affiliation(s)
- Ravindra Rao
- Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Mohit Varshney
- Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Shalini Singh
- Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Alok Agrawal
- Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Atul Ambekar
- Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, New Delhi, India
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Tekkalaki B, Patil VY, Patil S, Chate SS, Dhabale R, Patil NM. How do Our Patients Respond to the Concept of Psychiatric Advance Directives? An Exploratory Study From India. Indian J Psychol Med 2018; 40:305-309. [PMID: 30093739 PMCID: PMC6065124 DOI: 10.4103/ijpsym.ijpsym_10_18] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Psychiatric advance directives have been incorporated in the Mental Health Care Act 2017 despite strong concerns about their feasibility and utility in the Indian patient population. Data on its utility in India is very scarce. AIMS To determine the possible treatment options our clients make as a part of psychiatric advance directives. MATERIALS AND METHODS Fifty consecutive individuals with severe mental illness were interviewed using a self-designed semi-structured tool to find out the possible choices they make as part of advance directives and the factors affecting their choices. RESULTS About 10% of the participants failed to understand the concept of advance directives. Of those who understood, 89% were willing to make advance directives, 15% refused future hospitalizations, 47% refused future electroconvulsive therapies (ECTs), and 62% refused physical restraints in future. CONCLUSION The majority of the participants agreed to make advance directives. The majority of those who agreed to make advance directives refused to undergo ECTs and physical restraints in future episodes of illness. Approximately 10% of the patients could not understand the concept of advance directives.
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Affiliation(s)
- Bheemsain Tekkalaki
- Department of Psychiatry, K.L.E. Academy of Higher Education, J.N. Medical College, Belagavi, Karnataka, India
| | - Veerappa Y Patil
- Consultant Psychiatrist, District Mental Health Program, Bagalkot, Karnataka, India
| | - Sandeep Patil
- Department of Psychiatry, K.L.E. Academy of Higher Education, J.N. Medical College, Belagavi, Karnataka, India
| | - Sameeran S Chate
- Department of Psychiatry, K.L.E. Academy of Higher Education, J.N. Medical College, Belagavi, Karnataka, India
| | | | - Nanasaheb M Patil
- Department of Psychiatry, K.L.E. Academy of Higher Education, J.N. Medical College, Belagavi, Karnataka, India
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Abstract
Although mental health legislation has existed in India since the mid-19th century, it has gone through various changes over the years and the Mental Health Care Bill 2013 has generated a lot of debate and criticism. Despite its shortcomings, the general expectation is that this bill will usher in a new era of proper care and allow people with mental disorders to lead a dignified life.
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Duffy RM, Kelly BD. Concordance of the Indian Mental Healthcare Act 2017 with the World Health Organization's Checklist on Mental Health Legislation. Int J Ment Health Syst 2017; 11:48. [PMID: 28828037 PMCID: PMC5563026 DOI: 10.1186/s13033-017-0155-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 08/12/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND India is revising its mental health legislation with the Indian Mental Healthcare Act 2017 (IMHA). When implemented, this legislation will apply to over 1.25 billion people. In 2005, the World Health Organization (WHO) published a Resource Book (WHO-RB) on mental health, human rights and legislation, including a checklist of 175 specific items to be addressed in mental health legislation or policy in individual countries. Even following the publication of the United Nations Convention on the Rights of Persons with Disabilities (CRPD) (2006), the WHO-RB remains the most comprehensive checklist for mental health legislation available, rooted in UN and WHO documents and providing the most systematic, detailed framework for human rights analysis of mental health legislation. We sought to determine the extent to which the IMHA will bring Indian legislation in line with the WHO-RB. METHODS The IMHA and other relevant pieces of Indian legislation are compared to each of the items in the WHO-RB. We classify each item in a binary manner, as either concordant or not, and provide more nuanced detail in the text. RESULTS The IMHA addresses 96/175 (55.4%) of the WHO-RB standards examined. When other relevant Indian legislation is taken into account, 118/175 (68.0%) of the standards are addressed in Indian law. Important areas of low concordance include the rights of families and carers, competence and guardianship, non-protesting patients and involuntary community treatment. The important legal constructs of advance directives, supported decision-making and nominated representatives are articulated in the Indian legislation and explored in this paper. CONCLUSIONS In theory, the IMHA is a highly progressive piece of legislation, especially when compared to legislation in other jurisdictions subject to similar analysis. Along with the Indian Rights of Persons with Disabilities Act 2016, it will bring Indian law closely in line with the WHO-RB. Vague, opaque language is however, used in certain contentious areas; this may represent arrangement-focused rather than realisation-focused legislation, and lead to inadvertent limitation of certain rights. Finally, the WHO-RB checklist is an extremely useful tool for this kind of analysis; we recommend it is updated to reflect the CRPD and other relevant developments.
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Affiliation(s)
- Richard M. Duffy
- Department of Psychiatry, Trinity College Dublin, Trinity Centre for Health Science, Tallaght Hospital, Dublin, D24 NR0A Ireland
| | - Brendan D. Kelly
- Department of Psychiatry, Trinity College Dublin, Trinity Centre for Health Science, Tallaght Hospital, Dublin, D24 NR0A Ireland
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Narayan CL, John T. The Rights of Persons with Disabilities Act, 2016: Does it address the needs of the persons with mental illness and their families. Indian J Psychiatry 2017; 59:17-20. [PMID: 28529356 PMCID: PMC5419007 DOI: 10.4103/psychiatry.indianjpsychiatry_75_17] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Affiliation(s)
| | - Thomas John
- Consultant Psychiatrist and Retd Deputy Director (Health Services), Dr. Thomas' Clinic, Kochi, Kerala, India
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Rao GP, Math SB, Raju MSVK, Saha G, Jagiwala M, Sagar R, Sathyanarayana Rao TS. Mental Health Care Bill, 2016: A boon or bane? Indian J Psychiatry 2016; 58:244-249. [PMID: 28065999 PMCID: PMC5100113 DOI: 10.4103/0019-5545.192015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Gundugurti Prasad Rao
- Division of Schizophrenia and Psychopharmacology, Asha Hospital, Hyderabad, Telangana, India
| | - Suresh Bada Math
- Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, (Institute of National Importance), Bengaluru, India
| | - M S V K Raju
- Hon. Adjunct Professor, IRSHA, Pune - 411043 and Hon. Consultant, Shanti Nursing Home, Aurangabad, Maharashtra, India
| | - Gautam Saha
- Clinic Brain, 19/C, Pioneer Park, P. O. Barasat North 24 Parganas, Kolkata, West Bengal, India
| | - Mukesh Jagiwala
- Brain Psycho Clinic and De-Addiction Centre, Chowk Bazar, Surat, Gujarat, India
| | - Rajesh Sagar
- Department of Psychiatry, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, India
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Affiliation(s)
- James T Antony
- Department of Psychiatry, Jubilee Mission Medical College and Research Institute, Thrissur, Kerala, India
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Sinclair DJM, Ellison JMA, Adams CE. Electroconvulsive therapy for treatment-resistant schizophrenia. Hippokratia 2015. [DOI: 10.1002/14651858.cd011847] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Diarmid JM Sinclair
- Nottinghamshire Healthcare NHS Trust; General Adult Psychiatry; Bassetlaw Hospital Worksop South Yorkshire UK S81 0BD
| | - James MA Ellison
- The University of Nottingham; Division of Psychiatry & Applied Psychology; Room B08, Institute of Mental Health, Triumph Road Nottingham UK NG7 2TU
| | - Clive E Adams
- The University of Nottingham; Cochrane Schizophrenia Group; Institute of Mental Health Innovation Park, Triumph Road, Nottingham UK NG7 2TU
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Psychiatric Advance Directives in India: What will the future hold? Asian J Psychiatr 2015; 16:36-40. [PMID: 26168765 DOI: 10.1016/j.ajp.2015.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Revised: 06/14/2015] [Accepted: 06/20/2015] [Indexed: 01/14/2023]
Abstract
Psychiatric Advance Directives (PADs) have been incorporated into India's Mental Health Care Bill, 2013. This is the first time any form of Advance Directive stands to receive legal sanction in India. PADs have numerous theoretical and empirically tenable therapeutic and financial advantages. Western experiences have shown high acceptance for the concept among psychiatric patients, and illustrated that most stable patients with severe mental illness retain the capacity to frame PADs consistent with community practice standards. However active psychopathology does impair this capacity, and therein, current subjective assessments of competence performed by Physicians without objective instruments are often inaccurate. Though PADs champion patient autonomy, when applied and studied, they have shown little significant advantage-there is currently not enough data to support evidence-based universal recommendations for PADs. PADs as incorporated into the Mental Health Care Bill model on existing Western statutes, and though many of the strengths of earlier systems have been subsumed, so have several of the shortcomings. The risks, benefits and applicability of PADs in India are complicated by the social re-calibration of patient autonomy, mental-healthcare delivery system weaknesses, and the relatively peripheral role the Psychiatrist is mandated to play in the entire advance directive process. Treating patients within the framework of their pre-stated wishes will be a much more intricate and arduous task than most of modern Psychiatric practice in India, but the difficulties, obstacles and inevitable failures encountered will provide evidence of the delivery system's weaknesses and thereby contribute to its strength.
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What do service users want? A content analysis of what users may write in psychiatric advance directives in India. Asian J Psychiatr 2015; 14:52-6. [PMID: 25486868 DOI: 10.1016/j.ajp.2014.10.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 10/07/2014] [Accepted: 10/19/2014] [Indexed: 11/23/2022]
Abstract
Although psychiatric advance directives give service users control over their care, very few studies exist on the content of PADs. This paper aims to contribute to this evidence base by presenting the content of psychiatric advance directives in India. Participants were 75 clients seeking outpatient care at a mental health services organisation in Tamil Nadu, India, who agreed to draft a PAD. Most clients were comfortable with appointing a representative (usually a family member) to make decisions on their behalf during a period of decisional incapacity or relapse, were willing to accept admission to the hospital/clinic and take medication if required, wanted to have a trusted person to discuss their mental health problems. No client used the opportunity to outright refuse treatment. This study highlights an important first step in improving the quality of mental health care by documenting user preferences for care in India. More in-depth research is needed to elicit rich descriptions of experiences of care and user-centred understanding of rights.
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Abstract
The Mental Health Care Bill - 2013 has been introduced in Rajya Sabha and is now waiting for enactment. The Bill entails unprecedented measures to be undertaken by the Government ensuring everyone right to access mental health care and treatment from services run or funded by the Government. The Government is to meet the man-power requirement of mental health professionals according to international standard within a period of ten years. Various rights of persons with mental illness have been ensured. All the places where psychiatric patients are admitted and treated including the general hospital psychiatry units (GHPU) are to be registered as mental health establishments. Unmodified ECT has been banned and ECT to minors can be given only after approval from the Mental Health Review Board. This article advocates for exemption of GHPU from the purview of the Bill, taking into consideration impediment created in the treatment of vast majority of psychiatric patients who retain their insight into the illness and seldom require involuntary admissions. It is also advocated to reconsider ban on unmodified ECT and restriction placed on ECT to minor which are very effective treatment methods based on scientific evidence. In our country, family is an important asset in management of mental illness. But requirement of seeking approval from the Board in many of the mental health care decision may discourage the families to be proactive in taking care of their wards. The Board and Mental Health Authorities at the central and the state levels are authorized to take many crucial decisions, but these panels have very few experts in the field of mental health.
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Affiliation(s)
| | - Shivendra Shekhar
- Department of Psychiatry, Anugrah Narayan Magadh Medical College, Gaya, Bihar, India
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Kar SK, Tiwari R. Impact of Mental Health Care Bill on caregivers of mentally ill: Boon or bane. Asian J Psychiatr 2014; 12:3-6. [PMID: 25440558 DOI: 10.1016/j.ajp.2014.06.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2013] [Revised: 06/18/2014] [Accepted: 06/22/2014] [Indexed: 11/16/2022]
Abstract
BACKGROUND To improvise the shortcomings of existing of mental health legislation (The Mental Health Act, 1987) of India, amendments have been made which ultimately conceptualized, to form the Mental Health Care Bill. Mental Health Care Bill has brought a revolutionary change in the existing mental health legislation which is in its final phase of approval. METHOD Many of the changes brought by the Mental Health Care Bill has been appreciated at different level, at the same time it has received robust criticism for over-legalizing and complicating the delivery of mental health care. RESULT Caregivers play a pivotal role in the management of psychiatric illness in developing countries like India and they face a lot of challenges for providing support to the mentally ill patients. DISCUSSION The social, economical, physical as well as the psychological wellbeing of the caregivers are significantly affected while providing care to the mentally ill. The forthcoming Mental Health Care Bill is likely to have a noteworthy impact on the caregivers. It's high time to analyze, its projected impact on the caregivers of patients suffering from mental illness.
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Affiliation(s)
- Sujita Kumar Kar
- Department of Psychiatry, King George's Medical University, Chowk, Lucknow 226003, U.P., India.
| | - Rashmi Tiwari
- Department of Psychiatry, King George's Medical University, Chowk, Lucknow 226003, U.P., India
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Jacob P, Gogi PKV, Srinath S, Thirthalli J, Girimaji S, Seshadri S, Sagar JV. Review of electroconvulsive therapy practice from a tertiary Child and Adolescent Psychiatry Centre. Asian J Psychiatr 2014; 12:95-9. [PMID: 25440568 DOI: 10.1016/j.ajp.2014.06.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2013] [Revised: 06/25/2014] [Accepted: 06/26/2014] [Indexed: 11/15/2022]
Abstract
AIMS AND OBJECTIVES The use of electroconvulsive therapy (ECT) in children and adolescents is a controversial issue. This study was done to examine the pattern and practice as well as the outcome of electroconvulsive therapy administered to children and adolescents admitted to a tertiary care centre. METHODOLOGY A 10 year retrospective chart review of all children and adolescents (up to 16 years of age) admitted in the Child and Adolescent Psychiatry Centre, National Institute of Mental Health and Neurosciences (NIMHANS) who had received at least 1 session of ECT was done. Information regarding diagnosis, reasons for prescribing electroconvulsive therapy, details regarding the procedure and outcome variables was collected from the records. Clinical Global Impressions (CGI) scale rating of the severity of illness and improvement seen were done by 2 trained psychiatrists independently. RESULTS 22 children and adolescents received electroconvulsive therapy over 10 years. There were an equal number of boys and girls. All received modified ECT. Most patients who received electroconvulsive therapy were severely ill. Catatonic symptoms 54.5% (12) were the most common reason for prescribing electroconvulsive therapy. It was efficacious in 77.3% (17) of the patients. Electroconvulsive therapy was relatively safe, and most experienced no acute side effects. 68.2% (15) who were on follow up and did not experience any long term side effects due to the electroconvulsive therapy. CONCLUSIONS Electroconvulsive therapy has a place in the acute management of severe childhood psychiatric disorders. Further long term prospective studies are required.
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Affiliation(s)
- Preeti Jacob
- Department of Child and Adolescent Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), India.
| | | | - Shoba Srinath
- Department of Child and Adolescent Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), India
| | - Jagadisha Thirthalli
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), India
| | - Satish Girimaji
- Department of Child and Adolescent Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), India
| | - Shekhar Seshadri
- Department of Child and Adolescent Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), India
| | - John Vijay Sagar
- Department of Child and Adolescent Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), India
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Narayan CL, Shikha D, Narayan M. The Mental Health Care Bill 2013: A step leading to exclusion of psychiatry from the mainstream medicine? Indian J Psychiatry 2014; 56:321-4. [PMID: 25568470 PMCID: PMC4279287 DOI: 10.4103/0019-5545.146509] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
| | - Deep Shikha
- Department of Psychiatry, Katihar Medical College, Katihar, India
| | - Mridula Narayan
- Akanksha - An Institute of Mentally Retardates, Bodhgaya, Bihar, India
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Affiliation(s)
- T V Asokan
- President, Indian Journal of Psychiatry, Chennai, Tamil Nadu, India
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Affiliation(s)
- James T Antony
- Department of Psychiatry, Jubilee Mission Medical College and Research Institute, Kerala, India
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