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.

Models of Care of Schizophrenia in the Community-An International Perspective

PURPOSE OF REVIEW

We reviewed the existing and recent community models of care in schizophrenia. We examine characteristics, recent updates, evidence, cost-effectiveness, and patients' acceptance for existing and new community-based care models in high-income (HI) and low- and middle-income (LAMI) countries.

RECENT FINDINGS

Assertive Community Treatment (ACT), Intensive Case Management (ICM), and Crisis Intervention are cost-effective interventions for schizophrenia and time tested in the last few decades in HI countries. The growing evidence suggests that tailor-made ACTs and ICM can effectively reduce substance use, homelessness, and criminal activity in persons with schizophrenia who live in the community. Similarly, in LAMI Countries, a few community-based care models for schizophrenia have been developed and tested based on community-based rehabilitation principles. The modality of a community model of care and interventions for a person with schizophrenia should be chosen based on the person's co-existing psychosocial difficulties and challenges such as homelessness, criminal behaviour, and substance use.

A Survey among Teachers of Psychiatry to Improve the Quality of Undergraduate Training: Outcomes from Karnataka

BACKGROUND

In India, there is a large gap between the mental health morbidity in society and the availability of psychiatrists. However, the latest Indian undergraduate medical curriculum does not require any competency in psychiatry to be fulfilled for certification of medical graduates as doctors. Thus, the role of Indian psychiatry teachers is quite challenging. Interestingly, there has been hardly any effort to understand the felt needs of psychiatry teachers that may further improve the quality of undergraduate training.

METHODS

We used a survey questionnaire that was both qualitative and quantitative, with questions on topics such as years of psychiatry training and experience as a psychiatry teacher. Do they feel the need for training in undergraduate psychiatry teaching? Do they require training in teaching psychiatry theory or clinics or both? What are the specific areas where they want training? What more should be planned for psychiatry teachers? Based on an online survey further steps in the direction of psychiatry teachers felt needs were initiated.

RESULTS

Around 55 responses with a response rate of 37% were received. More than 50% were working in medical colleges for the last 5 years. About 80% felt the need for further training to teach medical students while 97% felt that additional training is required for handling theory as well as bedside clinic. More than 60% were keen to attend a 1-day workshop to upgrade their teaching skills. A majority wanted to have a forum to share their experiences and to learn from others. Based on the felt needs of psychiatry teachers from the survey, a 1-day workshop was carried out and a forum for psychiatry teachers was inaugurated.

CONCLUSION

Training of psychiatry teachers is an important felt need for the challenges that are unique to Indian medical education. The outcome from the Karnataka survey is a progressive step in addressing this challenge.

Chronology of alcohol dependence: implications in prevention

Background:

Study of the chronology of criteria of dependence in alcohol dependence syndrome (ADS) can enable us design strategies for the prevention for ADS, which aims at reducing the occurrence of ADS.

Objective:

To study the age-wise and order-wise chronologies of ICD-10 (DCR) dependence criteria in individuals with ADS.

Materials and Methods:

Consecutively admitted and consenting inpatients with ICD-10 (DCR) diagnosis of ADS were evaluated in a structured interview after detoxification using Semi-Structured Assessment for the Genetics of Alcoholism (SSAGA)-II.

Results:

The total sample size was 81. The mean ages at the first onset of alcohol use, development of the first criterion and International Statistical Classification of Diseases and Related Health Problems 10^th Revision (ICD-10) dependence was 18.72 years (SD, 6.84), 24.33 years (SD, 9.21) and 27.51 years (SD, 9.28), respectively. In age-wise chronology, tolerance, loss of control and craving were present in 97.53%, 80.24% and 79%, respectively, of our study sample. In order-wise chronology, either craving (16%) or tolerance (71.6%) was present as the first criterion and the presence of craving (16%), tolerance (21%) or loss of control (18.5%) was observed in the first criterion in 55.5% of the subjects.

Conclusions:

Knowledge of chronology, its frequencies and time duration between various milestones in the development of the dependence criteria may enable the selection of the target population at an early stage. The pattern of development of dependence may provide us with an opportunity for interventions to reduce the incidence of ADS, as a step toward primary prevention. Adequate training of the primary care personnel and early psychiatric referral may help in the reduction in the incidence of ADS.

Prevention of alcohol dependence: strategies for selective, indicated, and universal prevention

Study of the chronology of criteria of dependence in alcohol dependence syndrome (ADS) can enable us to design strategies for the prevention for ADS, which takes into account primary prevention (indicated, selective, and universal prevention) approaches and aims at reducing the occurrence of ADS. The objective of this work is to study the age-wise and order-wise chronologies of International Classification of Diseases Tenth Revision Diagnostic Criteria for Research (ICD-10 DCR) dependence criteria in individuals with ADS. Consecutively admitted and consenting inpatients with ICD-10 DCR diagnosis of ADS were evaluated in a structured interview after detoxification using Semi-Structured Assessment for the Genetics of Alcoholism (SSAGA)-II. The total sample size was 81. The mean ages at the first onset of alcohol use, development of the first criterion, and ICD-10 dependence was 18.72 years (SD: 6.84), 24.33 years (SD: 9.21), and 27.51 years (SD: 9.28), respectively. In age-wise chronology, tolerance, loss of control, and craving were present in 97.53%, 80.24%, and 79%, respectively, of our study sample. In order-wise chronology, either craving (16%) or tolerance (71.6%) was present as the first criterion and the presence of craving (16%), tolerance (21%), or loss of control (18.5%) was observed as the first criterion in 55.5% of the subjects. Indicated prevention may be attempted by enquiring about craving, tolerance, and loss of control and use of anticraving medications or behavioral strategies. Selective prevention by using naltrexone for those genetically inclined and universal prevention by use of "clinical" labeling on alcoholic beverages can also be attempted.

Knowledge, attitude and practices of Indian dental surgeons towards tobacco control: advances towards prevention

AIMS AND METHODS

We assessed the knowledge, attitude and practices of dental surgeons in the city of Bangalore, Karnataka, concerning use of tobacco in their patients. A self-administered questionnaire was administered to all dental surgeons prior to a sensitization program on nicotine dependence.

RESULTS

The dental surgeons who responded (n=100) reported a need for increasing sensitization on the issue of tobacco especially among health professionals. Only 33% knew that nicotine is the most addictive drug and knowledge was poor about pharmacological as well as non pharmacological methods of treatment of nicotine dependence. Only 52% asked all their patients about tobacco use. However, almost all dental surgeons agreed that there should be a ban on public use of tobacco.

IMPLICATIONS

The results of this study call for sensitizing health professionals on a larger scale on the issue of tobacco use and its treatment.

Somatization, somatosensory amplification, attribution styles and illness behaviour: a review

Somatic symptoms have been conceptualized in many different ways in literature. Current classifications mainly focus on the numbers of symptoms, with relative neglect of the underlying psychopathology. Researchers have emphasized the importance of a number of experiential, perceptual and cognitive-behavioural aspects of somatization. This review focuses on existing literature on the role of somatosensory amplification, attribution styles, and illness behaviour in somatization. Evidence suggests that somatosensory amplification is neither sensitive nor specific to somatizing states, and that other factors like anxiety, depression, neuroticism, alexithymia may also have an influence. Attribution research supports the existence of multiple causal attributions, which are related to the numbers of somatic symptoms. While somatizing patients have more organic attributions, depressed patients have more psychological attributions. A global somatic attribution style is associated with the number of obscure somatic symptoms, while a psychological attribution style is associated with both--psychological and somatic-- symptoms of depression and anxiety. There are conflicting findings with respect to the role of normalizing attributions in reducing physician recognition of anxiety and depression. Specific symptom attributions appear to explain physician recognition of psychological distress, but global attribution styles do not appear to explain any further variance in physician recognition beyond that explained by specific causal attributions. Illness behaviour has been studied in two distinct ways in literature. Research focusing on attendance rates as a form of illness behaviour suggests that somatization is associated with high levels of health care utilization. There is also some evidence that health care utilization, amplification and attributions styles may be interrelated among somatizing patients. More structured ways to assess illness behaviour have found high levels of abnormal illness behaviour in this population. Overall, research appears to suggest a complex (and as yet unclear) relationship between somatic symptoms and underlying cognitions/illness behaviours. While it is clear that somatization is closely related to a number of perceptual and cognitive-behavioural factors, the precise nature of these relationships are yet to be elucidated.

Risk factors for completed suicides: a case-control study from Bangalore, India

INTRODUCTION

Suicides are a hidden and unrecognized epidemic in the Indian region, affecting predominantly younger age groups. Information on causative risk factors and mechanisms is not available in the country, which is crucial for designing intervention programmes.

OBJECTIVES

To identify and quantify risk factors for completed suicides in the city of Bangalore.

METHODS

A case-control study was conducted with the families of 269 completed suicides and 269 living controls within the broader population of the city using psychological autopsy methods.

RESULTS

The study has shown that several factors in the areas of family, marriage, education, occupation, general health, mental health and absence of protective factors contribute significantly for suicides. The cumulative and repetitive interaction of several factors in a complex manner results in suicides. The significant factors were presence of previous suicidal attempt in self (odds ratio (OR) = 42.62), interpersonal conflicts and marital disharmony with spouse (OR = 27.98), alcoholism in self (OR = 23.38), presence of a mental illness (OR = 11.07), sudden economic bankruptcy (OR = 7.1), domestic violence (OR = 6.82) and unemployment (OR = 6.15). Individuals completing suicides did not have a positive outlook towards life, problem-solving approaches and coping skills.

CONCLUSION

The observed findings are at variance with suicidal causation in the West in some areas operating in a different sociocultural and economic environment. The intervention strategies should include prioritized macro and micro level efforts aimed at individual, family and society.

Delusion of test-tube pregnancy in a sexually abused girl

We report the case of a patient who presented with catatonic features and delusion of test-tube pregnancy in the background of previous sexual abuse. The reported case illustrates the importance of contemporary themes in the evolution of psychopathology.

Alexithymia in somatoform and depressive disorders

OBJECTIVE

Alexithymia and its association with attribution styles, amplification and illness attitudes was studied among subjects with somatoform disorders, depressive disorders and normal subjects.

METHODS

Two groups of 30 subjects each, bearing diagnoses of somatoform disorder and depressive disorder respectively (ICD-10 DCR), and one group of 30 normal controls were recruited. The study subjects were assessed using the Toronto Alexithymia Scale and scales for assessing attribution styles, amplification and illness attitudes.

RESULTS

Mean alexithymia scores in the somatoform (60.4) and depressive disorder groups (62.5) were higher than in normal subjects (54.2). In the somatoform disorder group, total alexithymia and 'difficulty describing feelings' scores positively correlated with psychological attribution (the latter correlation was also noted in the depressive disorder group), but not with the illness attitudes, amplification, somatic attribution scores or any of the sociodemographic variables. Compared with normal subjects, those with somatoform and depressive disorder had greater difficulty in identifying bodily sensations and feelings. Subjects with depressive disorder had more difficulty in expressing feelings compared to somatoform disorder subjects.

CONCLUSIONS

While total alexithymia scores do not differentiate somatoform from depressive disorders, the two diagnostic groups do differ in that depressed subjects have greater difficulty in expressing feelings. However, all three groups had mean scores within the non-alexithymic range. Alexithymia and difficulty in expressing feelings were associated with psychological attribution of innocuous bodily sensations in the somatoform disorder group suggesting that alexithymic subjects are more able to psychologize bodily symptoms than non-alexithymic subjects. Somatoform and depressive disorder subjects and normals differ from each other in certain alexithymic characteristics, which could have potential therapeutic implications.

Amplification and attribution styles in somatoform and depressive disorders--a study from Bangalore, India

OBJECTIVE

The present investigation aimed to study attribution styles and somatosensory amplification among patients suffering from somatoform and depressive disorders.

METHODS

Two groups of 30 patients with diagnoses of somatoform disorder and depressive disorder, respectively (ICD-10 DCR), and one group of 30 normal controls were recruited. The study patients were assessed using the symptom interpretation questionnaire, somatosensory amplification scale, and scales for assessing alexithymia and illness attitudes.

RESULTS

The somatoform and depressive disorder patients had greater recent symptom experience than the normal group. The somatoform disorder group had higher somatic attribution scores, the depressive disorder sample had higher psychological attribution scores, and the normal group had higher normalizing attribution scores than the two other groups. Somatoform disorder patients had higher mean amplification scores than depressed patients, who in turn had higher scores than normals. Correlation analyses showed somatic attribution and certain illness attitudes to be closely associated in all three groups. Recent symptom experience was associated with amplification in the somatoform disorder group alone. Recent symptom experience, a diagnosis of somatoform disorder and lower normalizing attribution scores predicted amplification.

DISCUSSION

These findings indicate that somatoform and depressive disorder patients and normals differ from each other in their attribution styles. There is a clustering of attributes among somatoform disorder patients that include greater symptom experience, which is somatically attributed, and is associated with excessive illness worry, concern and preoccupation with bodily symptoms, and a fear of having or developing a disease. On the other hand, depressed patients and normal subjects who do have a somatic attribution style (though, as a group, they have lower somatic attribution scores than the somatoform disorder group), also harbor hypochondriacal beliefs and related attitudes.

Life events and somatoform disorders

Presumptive Stressful Life Events Scale (PSLES) was administered to 69 physically ill, 23 patients with somatoform disorders and 45 patients with psychiatric disorders other than somatoform disorders who sought medical help in primary health care settings. The 137 patients were cluster analysed in orderto obtain the patterns of distribution of 39 life events. Five clusters emerged. All the patients in cluster Vhad somatoform disorders and life events had a significant occurrence and discrimination.

Effect of fluoxetine and bromocriptine on craving occurring during withdrawal from alcohol

Craving is an integral element in the understanding of alcohol dependence. Recent human and animal research implicates the serotonergic and dopaminergic systems in the mediation of excessive alcohol consumption. In this study, a cue-based approach was used to qualify and quantify craving occurring during acute withdrawal from alcohol. Fifty alcoholics were given either placebo, bromocriptine or fluoxetine in a randomised double-blind fashion and craving was sequentially measured over the next 15 days. Both fluoxetine and bromocriptine significantly attenuated total craving scores without similarly affecting withdrawal symptoms. The results suggest the importance of neurotransmitters in mediating craving. The significance of these data in the light of various behavioural and neurochemical models have been discussed.

The perception and experience of health personnel about the integration of mental health in general health services

The National Mental Health Program of India focuses on the integration of mental health in general health services. Using a structured questionnaire, 100 health personnel (40 Medical Officers and 60 Health Assistants) in the District Mental Health Program were interviewed regarding their perception and knowledge about the integration of mental health in general health services. Most personnel were found to be satisfied with their new role in carrying out mental health services and only a few felt that it was an extra burden. Suggestions were made by them about the free supply of drugs, short and long term training and active supervision and support by the higher authorities.

Evaluation of short term training in mental health for multipurpose workers

Training of multipurpose workers in mental health is an essential component in the implementation of the National Mental Health Program. This study examines the efficacy of a six day training program and the changes in knowledge, management skills and attitudes of multipurpose workers with regard to mental disorders.

Training of primary health care medical officers in mental health care. Errors in clinical judgment before and after training

This investigation examined the nature and frequency of errors in clinical judgment that were displayed by primary health care medical officers before and after short-term training in mental health care. Thirty-nine medical officers who underwent inservice training for 2 weeks were evaluated using standardized case vignettes. Before the training, doctors displayed a sizable percentage of major and minor errors, which dropped significantly following training. Errors were not unique to psychiatric presentations alone, but occurred with respect to vignettes representing physical disorders as well. The results on the whole demonstrate a satisfactory gain in clinical skills of medical officers following the training and highlight the need for continuation of a program of this nature.

Development of case vignettes to assess the mental health training of primary care medical officers

This article reports the development of case vignettes as a method of assessing the short-term in-service training of primary care medical officers in mental health care. A pool of 18 case vignettes representing common psychiatric problems and a standard response sheet were written first. This was mailed to 45 psychiatrists for their comments. Based on the comments received from 21 psychiatrists, 2 sets of questionnaires with 7 vignettes in each set were developed. When administered to a group of 32 medical officers, this method of assessment was found to be sensitive in detecting gain in knowledge and skills following training. Further, performance on case vignettes was found to correlate positively with clinical skills when actual cases were given for assessment.

Training primary care medical officers in mental health care: an evaluation using a multiple-choice questionnaire

This report aimed to evaluate the mental health knowledge of primary care medical officers following short-term training in mental health care using a multiple-choice questionnaire. Seventy-eight medical officers who underwent 2 weeks' training in mental health care were assessed using parallel forms of a standardized multiple-choice questionnaire administered before and soon after the training. Young doctors scored significantly higher in the pretraining assessment. The medical officers demonstrated a significant gain in knowledge, although the amount of gain varied. Doctors who had relatively lower pretraining scores showed a higher gain. Six doctors (8%) showed less than acceptable posttraining scores. These doctors were older than the rest of the group. The doctors' pretraining knowledge was best with respect to epilepsy and poorest with respect to manic-depressive psychosis. Items pertaining to epidemiology and aetiology elicited relatively less gain than other clinical dimensions.

The General Health Questionnaire (GHQ). Comparison of the English version and a translated Indian version

The English version of the General Health Questionnaire (GHQ) and a translated Indian version were administered to a sample of hundred bilingual college students. Both the versions of the GHQ showed adequate internal consistency and reliability. There was a high concordance between the two versions on high scorers and low scorers. These results were also applicable to GHQ-30 and GHQ-12. Item analysis revealed certain differences between the two versions attributable to semantic and technical problems. Validity of the GHQ in the Indian setting are discussed.

Standardisation of multiple-choice questionnaire for evaluating medical officers' training in psychiatry

This study reports the standardisation of a multiple choice questionnaire (MCQ) for evaluating the training of primary care physicians in psychiatry. An item pool of 104 multiple-choice questions of the 'single best response' type was written. This item pool along with an 'MCQ assessment sheet' was mailed to 90 psychiatrists with a request to evaluate the questionnaire. Twenty five psychiatrists responded to the enquiry, of which 22 gave their detailed comments regarding the MCQ. Based on the responses that were received, 14 items were discarded, 77 items were modified and 13 items accepted without any modification. The final pool of 90 items was split into two comparable sets, one for pre-training assessment and the other for post-training assessment. The questionnaire was administered to a group of 32 medical officers and was found to be sensitive in detecting gains in knowledge following training.

Training general practioners in psychiatry - an icmr multi-centre study

The specialist psychiatric services available in India is insufficient to meet the mental health needs of the country. Training of general practitioners in psychiatry through short courses is one of the remedial strategies. In 1982-83, an ICMR Multi-Centre Project of Training in Psychiatry for Non-Psychiatrist Primary Care Doctors was successfully completed at Bangalore, Hyderabad and Vellore using the training methods developed at NIMHANS. This paper describes the training programme and the results.

Clinical vignettes for assessment of training general practitioners in psychiatry

Training of non-psychiatrist medical professionals in psychiatry through short courses is an urgent need recognised by the National Mental Health Policy. In order to improve the training programmes over a time, a suitable method of evaluation of the effect of training is essential. Such a method of evaluation was developed at NIMHANS using clinical vignettes. These vignettes were successfully used in the I. C. M. R. Multi-centre Project of Training non-psychiatrist primary care doctors in 1982-83. This paper describes the effectiveness of the clinical vignettes as tools of evaluating short training programmes.

Extension of mental health service through psychiatric camps : a new approach

Psychiatric camps in the manner they are usually conducted serve no useful purpose in the long run, except to identify cases and to increase people's awareness about mental illnesses. The main drawback is poor follow up of the cases detected.To overcome these drawbacks and to make these camps more useful in delivering mental health services to the community, a new approach is being worked out. Screening and selection of the patients for the camp by the local doctors with the help of symptom check-list, a good propaganda well in advance incorporating the cardinal symptoms through mass media, training of the local doctors to gain basic skills and knowledge to manage cases during follow up, periodic visits by the psychiatrists to help these doctors in this job for some time, mental health exhibition during the camp were some of the strategies adopted in Kollegal Neuropsychiatric camp by community psychiatry unit of NIMHANS.It was a three days' camp. 312 cases were registered after screening. Only 6.7% cases were non-psychiatric. 30% epileptics, 30% neurotics, 12% Headache, 9% MR, 9% neurological cases, 5% psychoses. 25 doctors participated in training programme and camp patients were allotted to them for follow up. Monthly follow up is in progress. Findings and experiences are discussed.

Mental health delivery through rural primary care-development and evaluation of a training programme

There is a growing consensus of opinion (WHO 1975) that in developing countries, doctors and para-medical staff of the existing health care cadres should, after a short course of problem oriented training, deliver basic mental health care. This paper describes the development and evaluation of such a training programme.

A profile of the follow up of the rural mentally ill

108 Psychotic and 268 epileptic patients were followed up for 3½ years as a part of an ongoing rural mental health care programme. Some of the observed situations, possible limitations and reasons for the evolved follow up pattern in this endeavour of non-institutional, family centred and community oriented treatment programme, are reported. The strategies to improve the follow up rate among the rural patients are discussed.

A cost-effectiveness analysis of three different methods of psychiatric case finding in the general population

A study was carried out to compare the sensitivity as well as cost of three different methods of psychiatric case detection. It was found that the simplest method, which involved interviewing about 3% of the adult population, with a questionnaire taking only five minutes to complete, picked up as many adult epileptics and nearly as many psychotics as the inquiry with all the adults in the population using a sophisticated structured interview schedule. A method of medium complexity, in which the short five-minute questionnaire was given to one adult member of each family, detected in addition to all adult epileptics and psychotics, and many juvenile epileptics and mentally retarded. The cost of the simplest method was one-ninth and that of the method of medium complexity, one-fifth of the cost of the most sophisticated method. The method of medium complexity is recommended for use in the rural psychiatry programme of the developing countries.