General Hospital Psychiatry Unit Research Articles

Amend the Mental Health Care Act 2017: A Survey of Indian psychiatrists (Part 2)

Background: Information about the experience of practicing psychiatrists with the use of the Mental Health Care Act (MHCA), 2017, India, after 5 years of its promulgation has not been available. Aim: The present study was carried out to understand the experience of the practicing psychiatrists in using and complying with the MHCA 2017 and to bring out the problems and suggested reforms, if any, in various provisions of the MHCA 2017. Methods: An online survey by practicing psychiatrists of Indian Psychiatric Society on the various sections and provisions of the MHCA 17 was carried out through structured and open-ended responses. This paper presents the qualitative analysis of the open-ended responses. Results: There were 600 respondents, who gave a total of 1239 (range 116–154) responses to eight open-ended questions about various provisions of the MHCA. Qualitative analysis revealed that most respondents opined for keeping the General Hospital Psychiatry units exempted from inclusion as the mental health establishment, thus treating physical illness at par with the mental illness; a separate stand-alone law for mental illness perpetuates stigma, asked for a larger representation of psychiatrists in the State Mental Health Authority and Mental Health Review Boards. Most respondents opined that the provisions of capacity assessment, nominated representative, and advance directive are a hinderance in treatment and should be amended; treating psychiatrists and family/caregiver’s consent should suffice for supported admission, just like in other disciplines of medicine; and MHCA 2017 needs major amendments/repeal to make it convenient for patient care. Any unauthorized places/centers where persons with mental illness are kept should come under regulatory control of the state mental health authorities. Conclusion The survey has highlighted several deficiencies and operational difficulties in the current Act that hinder the delivery of mental health care to patients with mental illness in the country and need amendments.

An Overview of Different Clinical Rotation Styles and Organizational Strategies for Postgraduate Psychiatry Training Adopted in General Hospital Psychiatry Units—A Critical Viewpoint from India

An Overview of Different Clinical Rotation Styles and Organizational Strategies for Postgraduate Psychiatry Training Adopted in General Hospital Psychiatry Units—A Critical Viewpoint from India

What We Know, We See and Do: Formative Assessments Practices of Psychiatry: Postgraduate Residency from a General Hospital Psychiatry Unit in India

What We Know, We See and Do: Formative Assessments Practices of Psychiatry: Postgraduate Residency from a General Hospital Psychiatry Unit in India

Amend the Mental Health Care Act 2017: A Survey of Indian Psychiatrists (Paper 1).

This paper highlights the difficulties and lacunae in the Mental Health Care Act 2017 that hinder its implementation and use for the care and treatment of persons with mental illness in India. An online nationwide survey, involving structured questions as well as open-ended questions, to elicit the level of implementation, experience in complying with the provisions of the Act, and level of satisfaction, of practicing psychiatrists was carried out. Responses were analyzed using appropriate statistics. 600 respondents answered the online questionnaire. A majority of psychiatrists were senior practitioners with over 10 years of experience. 92.5% respondents were dissatisfied with the MHCA, wherein 73.3% wanted it amended, and 19.2% asked for repeal. Procedural issues were deterrent for 66.5% from taking medically necessary or helpful decisions for patients. Non-implementation of the Act was a major finding. Major dissatisfaction was expressed regarding judicial over reach in admission and discharge procedures, inclusion of general hospital psychiatry units in the definition of mental health establishment, non-applicability of provisions like advance directive and nominated representative in Indian setting, and that all treatment should be covered under insurance. The Act in its present form defies the spirit of its own objectives and is unimplementable. It needs major revisions.

Understanding Coping Among Spouses of Persons With Alcohol Use Disorder at a General Hospital Psychiatry Unit De-addiction Center: A Cross-Sectional Study.

Introduction Alcoholism is seen as a severe social and health issue. It usually refers to the excessive and unrestrained intake of alcoholic beverages to the point where it becomes harmful to the health, interpersonal connections, and general social functioning of the drinker. The study aims to comprehend coping strategies used by spouses of people suffering from alcoholism and to make significant contributions to the fields of addiction and mental health services. Methodology The study was conducted at a General Hospital Psychiatry Unit De-addiction Center from November 2020 to April 2021. Fifty spousesof people with alcohol use disorder (AUD)diagnoses took part in total. Structured questionnaires were used to gather sociodemographic data. The degree of AUD was measured with the Severity of Alcohol Dependence Questionnaire (SADQ), and coping mechanisms were examined with the Questionnaire of Coping Strategies Used by Spouses of Alcoholic Clients. Results Out of 120 screened patients, 50 spouses participated in the study. The mean age of the spouses was 33.66 years and 35.08 years for husbands. Sixty percent of the spouses mainly worked in unskilled labor, and the majority (80%) were between the ages of 26 and 35. Based on SADQ scores, about 50% of husbands exhibited severe alcohol dependence. Among the spouses, engaged coping techniques were more common than tolerant or withdrawal coping strategies. Conclusion The results highlight the need for specialized therapies and support services to help spouses of people with AUD better manage their stress and improve their general well-being. Comprehending coping mechanisms within this framework can enhance therapy practice and lead to better results for AUD sufferers and their families.

Perceptions regarding the Indian Mental Healthcare Act 2017 among psychiatrists: Review and critical appraisal in the light of CRPD guidelines.

Informed by the UN Convention on the Rights of Persons with Disabilities, the Indian government replaced the 1987 Mental Health Act with the transformative "Indian Mental Healthcare Act, 2017" (IMHCA 2017), which gained presidential approval on April 7, 2017. While the new act aligns with CRPD guidelines, emphasizing the promotion, protection and realization of complete and equitable human rights, legal capacity, equality and dignity for persons with mental illness, it has faced diverse criticism from various stakeholders, particularly psychiatrists. This study systematically explores the critiques and apprehensions expressed by psychiatrists regarding the IMHCA 2017 using available published resources and assesses these criticisms within the context of CRPD guidelines. We conducted a scoping review of the literature, using two search engines like PubMed and Scopus. The review covered academic publications, reports and documents from both national and international sources, authored by psychiatrists and psychiatric organizations, related to the IMHCA 2017. The primary search term "IMHCA 2017" was used without temporal restrictions. Publications authored by mental health professionals from India and around the world were included in the final analysis. Through qualitative analysis, key themes reflecting psychiatrists' viewpoints were identified. These themes, marked by substantial criticism, were then assessed in accordance with the guiding principles of the CRPD, including its optional protocol and general comments. The study analyzed 33 manuscripts discussing criticisms and concerns about IMHCA 2017. Manuscript types included opinion papers (60.6%), original research articles (21.21%), review articles (9.09%), editorials (6.06%) and comments (3.03%). All but one article were authored by psychiatrists, with five by non-Indian authors and the rest by Indian psychiatrists. Most articles were published in the Indian Journal of Psychiatry (75.76%), with some in other journals. About 54.55% critically scrutinized act provisions, while 45.45% highlighted positive aspects. The analysis identified seven prominent criticism themes: clinical apprehensions, lack of clarity and comprehensiveness, feasibility challenges, neglect of caregivers, mistrust toward psychiatrists, crises in general hospital psychiatry units and ideological reservations. Each theme was critically assessed in the context of CRPD guidelines, and corresponding recommendations were formulated.

Post-graduate Psychiatry Teaching and Training in India

In India, the history of psychiatry is approximately 80 years of post-graduate education. The first psychiatrist who received an MD degree from an Indian medical institution was Late Prof. L.P. Verma, who received his degree in 1941 from Patna Medical College, Bihar.1 In India, a post-graduate course in psychiatry is taught in two forms (MD in Psychiatry and DNB in Psychiatry). MBBS is the minimum educational requirement to be eligible for pursuing MD or DNB Psychiatry course. The duration of the post-graduate course in psychiatry is three years in India. A recent study revealed that the post-graduate degree courses in psychiatry are unequally distributed in the country, which might be responsible for the not-so-equitable distribution and generation of mental health manpower in the country.2 In India, general hospital psychiatry units (psychiatry units attached to medical colleges) play an instrumental role in training post-graduate students of psychiatry. Other than this, mental hospitals also provide teaching and training facilities for post-graduate psychiatry trainees.

Public-Private Partnership (PPP) Model of Psychiatry Day Care Center in India: Its Challenges and Opportunities-A 2-Year Experience.

Background Most patients admitted in day care center are suffering from schizophrenia who do not recover fully due to nagging negative symptoms and cognitive deficits which linger and persist making the patients unfit and unacceptable for employment. But regular employment can help in recovery. In this way, day care centers would help in recovery of patients and hence the need for these kinds of centers. In India, day care centers are in infancy stage and to a larger extent are inadequately used. There is no data available from psychiatry day care center run as public–private partnership (PPP) project in a tertiary care general hospital psychiatry unit (GHPU). This model is first of its kind in India. Here, we narrate experiences gained in last 2 years. Objectives This article narrates the challenges and opportunities in a psychiatry day care center in PPP model. Materials and Methodology It a cross-sectional study. Description of day care center: Day care center was started as PPP model called Manasadhara model in the state of Karnataka, first of its kind in India.Recruitment Patients currently asymptomatic are recruited into the center after initial interview/assessment of patients and family members from the in-charge psychiatrist after obtaining informed consent. Statistical Analysis Data are analyzed using mean and median mode. A p -value of < 0.05 was considered significant. Appropriate statistical methods were applied. Results Total number of patients recruited in the study were 33 ( n = 33). Mean age of the patients was 34.5 (7.4) years. Majority (51.52%) of patients were in the age group of between 26 and 35 years. Majority (51.52%) of patients' age of onset of illness fell between 21 and 30 years, and 63.64% of patients' duration of illness ranged between 11 and 15 years.Conclusion Running a day care center in PPP model that too in a GHPU set up is difficult. Skills in which patients need to be trained should be decided based on patients' profile and cultural basis of the place. Common problems faced were poor placements, transportation, financial difficulties, and poor funding.

The pattern of inpatient psychiatry admissions at a general hospital psychiatry unit in South India: A retrospective study.

Mental illnesses are becoming a major health issue across the world. The availability of inpatient facilities for mentally ill patients is very much limited in developing countries such as India. This study was aimed to explore the pattern of psychiatric admissions at a general hospital psychiatry unit (GHPU) in South India. The study was conducted at a multispecialty tertiary care hospital in South India. A retrospective, chart-based study design was adopted to achieve the objectives. All inpatient case records available from the department of psychiatry, the medical records department, and the electronic hospital information system of the institute were reviewed between April 2006 and March 2016. A total of 3082 patients were admitted as psychiatry inpatients during the 10-year study period, representing an average of 308.2 admissions per calendar year. The majority of inpatients were male (n = 1824; 59.2%). Concerning diagnostic categories, mood disorders were accounted for 33.6% of admissions, followed by psychotic disorders (26.4%) and substance use disorders (19.3%), respectively. The median length of hospital stay was 14 days (range 0-163 days). A statistically significant seasonality pattern was noticed for mood disorders (December to February) and anxiety and neurotic disorders (August to October). It is obvious that treatment-seeking attitude among individuals with mental illnesses is increasing and the awareness regarding treatment aspects is also increasing among the general public. Hence, there is a need to improve the existing resources to facilitate intensive management for better treatment outcomes and this, in turn, will enhance the quality of life of mentally ill individuals.

Symposium

BackgroundAbout 4% Alcohol dependence syndrome (ADS) suffer complicated withdrawal. Nearly all evidence based treatment for ADS originated as individual interventions, and most major treatment research studies have been limited to individual-based treatments e.g., COMBINE and Project MATCH studies. However this is a challenge to implement Individual therapy in our country where treatment gap is 70-90%. It has been found that group-based interventions have strong experimental support. Department of psychiatry KIMS hubli explored the utility of group therapy in general hospital psychiatry unit (GHPU) setting for patients with ADS.Aims1. Need of resource efficient psychosocial intervention in ADS in relapse prevention.2. Utility of group therapy in ADSMethods92 consenting individuals along with their primary care giver were enrolled in group therapy. A total of 6 sessions of structured group therapy, one session monthly for 6 months. There were 9 closed groups and each group consisted of less than males. Individuals were assessed for relapse and care givers knowledge attitude and practices (KAP) towards ADS were assessed at baseline, end of 6 sessions and after 6 months of follow-up. Under supervision of senior psychiatrist post graduates students in MD Psychiatry conducted the Group therapy sessions.Results and Conclusion18 individuals dropped out. Attrition rate of 19.5%. Relapse rate was 40%. Early identification and intervention of relapses. Most patients and their care givers were retained in the treatment loop. KAP were favourable in the caregivers. It is a challenge to provide Individual psychotherapy for ADS where mental health care services are scare. However group interventions are promising as they are effective and economical relapse prevention strategy. It is acceptable by the caregivers and feasible in GHPU. Prospective research and controlled trials to be considered in the future.

Ethics and Law.

Ethics and Law.

Auditory Hallucinations: A Phenomenological Study

Background: Auditory hallucinations are common feature in psychotic disorder and have also given diagnostic importance. These hallucinations can be rated on different dimensions both quantitatively and qualitatively, so here comes phenomenological aspect. Study of phenomenological aspects may lead to more understanding about them and further can help in management of distressing auditory hallucinations.&#x0D; Aims and Objectives: The aims and objectives of the current study was as follows- 1. To explore the phenomenology of auditory hallucination in schizophrenia spectrum disorder. 2. To find out clinical correlation of auditory hallucination with other psychotic symptoms. 3. To find out factor structure of PSYRATS (Psychotic Symptom Rating Scale) and their correlation with PANSS and its subscales.&#x0D; Materials and Methods: One hundred patients, who had schizophrenia spectrum diagnoses attending general hospital psychiatry unit in India having auditory verbal hallucination (AVH) in last seven days were studied. Phenomenology was assessed by using Psychotic Symptoms Rating Scale (PSYRATS) and Positive and Negative Syndrome Scale (PANSS). Pearson correlation for the psychotic symptoms, Dimensions of psychotic symptoms on PSYRATS were explored by principal component analysis.&#x0D; Results: In study 82% patients had schizophrenia. More than one third patients heard voices continuously, in more than two-third patients voices were coming from outside head only, had no control over them, and had same loudness as one’s own voice. One third patients had AVH (Auditory Verbal Hallucinations) with all negative content, 19% had AVH commanding nature. 79% had delusions, 96% had hallucinatory behavior. Bipolar index showed dominance of positive symptoms. 80% reported depression. On principal component analysis three factors found, all three factors were positively correlated with positive subscale and total PANSS score. None of three factors were correlated with negative subscale of PANSS.&#x0D; Conclusion: In this study of AVH phenomenology among schizophrenia spectrum disorders, most dimensions of AVH correlated well with one another. On principal component analysis three factor structure of PSYRATS was found.

Psychiatric rehabilitation in indian general hospital psychiatry unit settings

In India, General Hospital Psychiatry Units (GHPUs) are the backbone for mental health care. GHPUs have less stigma, facilitate inter-specialty collaboration, and provide integrated mental and physical healthcare. GHPUs offer a predominantly medical model of care and face multiple challenges in offering psychiatric rehabilitation, including a severe crunch of human resources. This article summarizes the basic concepts of psychiatric rehabilitation, possible rehabilitation interventions in resource-constrained settings, and interventions that can be delivered with the help of caregivers and frontline mental health workers. The article concludes with some of the pragmatic indigenous models of psychiatric rehabilitation at GHPUs.

Trends and issues in community mental health programs in India: The Ranchi Institute of Neuropsychiatry and Allied Sciences experience.

Psychiatric disorders are among the leading causes of disability the world over. With the World Health Organization, spearheading the crusade to incorporate the mental health component into primary health care, developing countries also have accepted the need for community care of patients with psychiatric disorders. Since independence various initiatives by the government has led to a significant change in the place of mental health care as part of the general health care. At the time of independence apart from mental hospitals, there was practically no organized mental health care. Since then General Hospital Psychiatry units and also Psychiatric Nursing homes have started. Currently, mental health issues are actively seen as part of the public agenda in the various forms. The overall effect has been the movement to recognize mental health as an important issue in the community and services to move beyond mental hospital care to care to the community. Majority of population in Jharkhand is residing in rural areas. Due to the lack of proper communications and infrastructure, Ranchi Institute of Neuropsychiatry and Allied Sciences (RINPAS) had started community outreach program way back in 1999. At present, these centers are running in four different areas of the state with great success. RINPAS experience shows that how even with resource constraints, quality services can be provided to unreached population.

Audit of requests for disability certification of adults received at a tertiary care general hospital psychiatry unit.

Background:Persons with disability (PwD) are entitled to certain benefits from the State on grounds of being disabled. With the recent enactment of the Rights of PwD Act, 2016, and increased efforts to provide assistance to persons with certifiable disabilities, data pertaining to disability requests can be useful to understand the way in which services are utilized.Materials and Methods:This study is an audit of the disability certificates issued to all subjects with age ≥18 years between 2016 and 2019 at a tertiary care general hospital psychiatry unit, and discusses the pattern and profile of the certificates.Results:A total of 356 patients were issued disability certificates (2016–2019). The mean age of the subjects was 32.8 (±11.2) years and about 30% of them were females. Intellectual disability (58.3%) was the most common diagnosis, followed by schizophrenia and related disorders (31%), while all other disorders constituted a smaller proportion (11%) of the sample. About 60% of the subjects had moderate disability, 37.4% had severe disability, and 1.7% had profound disability.Conclusion:A large majority of the certificates were issued to subjects with intellectual disability. Patients with severe mental illnesses are probably not accessing the disability benefits optimally. This audit also points to under-representation of women as well as an overall underutilization of services by individuals with mental disability.

Analysis of the prescription pattern of psychotropics in an outpatient department of a general hospital psychiatry unit

BackgroundWorld Health Organization has prescribed drug use indicators for evaluating rational prescribing. Very few studies have been conducted on rational prescriptions for psychotropic drugs; hence, this study was undertaken at a tertiary care center of North India. MethodsAfter obtaining approval of the Institutional Ethics Committee, all prescriptions deposited with the dispensary of the psychiatry department of the hospital between 01 October 2017 and 31 December 2017 were included in the study. The prescriptions were analyzed for drug use indicators, namely the average number of drugs per encounter, percentage of prescriptions with generic name, percentage of prescriptions from the essential drug list, percentage of prescriptions with antibiotics, and percentage of prescriptions with an injection. In addition, the prescriptions were analyzed for patterns of psychotropics prescribed. ResultsA total of 3770 prescriptions were analyzed. On an average, 2.35 medicines were prescribed per prescription. Injectable comprised 2.39% of prescriptions and fixed drug combinations were 0.16% of the total. Of all prescriptions, 91.3% were by generic name, while 55.02% of prescriptions were from the essential drug list. Polypharmacy constituted 4.53% of prescriptions. Risperidone, escitalopram, sodium valproate, and clonazepam were the most commonly prescribed drugs. ConclusionWhile we fared well with respect to the percentage of prescriptions with injections and those with an antibiotic, we have not been able to achieve the prescribed standards in prescription with generic names, number of drugs per prescription, and prescriptions from the essential drug list. The study emphasizes that there is scope for improvement.

Delaying clozapine: how long is too long?

BackgroundAlthough clozapine is the most effective drug for treatment-resistant schizophrenia, its use remains restricted in clinical practice in India. The delay in initiating treatment with clozapine and its impact on...

Profile of “Suspected Suicide Attempters” based on variations in intent

Background: Suicide and attempted suicide are on a rise in India. Suicide attempt is an area which is well researched. However, there is a dearth of studies that focus on any other/absence of suicidal intent in “suspected suicidal attempters” (SSA). The present study aimed at identifying the presence or absence of intent in SSA to gain insight into the preventive methods. Methods: This study was based on cross-sectional baseline data of an ongoing prospective study of suicide attempters undertaken in General Hospital Psychiatry Unit. Convenient sampling was done; data were collected using semi-structured pro forma. Consenting medically stable SSA referred for psychiatric evaluation were included, and grouped based on variations in intent. Using SPSS software version 20.0, descriptive and inferential statistics were done. Results: Two hundred and forty-two participants were included in the study. Majority of participants (73.55%) with suicide intent were impulsive and 15.29% were planned. About 11.16% of participants had no intent (accidental incidents). Participants in accidental group were significantly older and more often diagnosed with alcohol use disorder (AUD) than the other two groups. Significantly, more number of agriculturists attempted impulsively/accidentally. Planned attempters significantly had less social support, higher suicide intent, and were more depressed. Conclusions: A tetrad of rural background, agriculturist, poisoning with pesticides, and AUD was seen in accidental and impulsive attempters, a noteworthy finding requiring imposing restrictions on the availability of alcohol and pesticides to prevent such occurrences. Accidental incidents as a group need further research and classification for its clinical and legal impact.

Consultation-liaison psychiatry in newly established general hospital psychiatry unit: Scope and suggestions

Background: Consultation-liaison (C-L) psychiatry is the subspecialty of psychiatry dealing with mental health disorders in nonpsychiatric settings. The ubiquity of mental health problems has increased the need for such a service to exist in general hospital psychiatric units, as many psychiatric patients report to a different specialty of medicine for the first time. This study aims to evaluate the utilization of psychiatry C-L services by nonpsychiatric inpatient units in a general hospital psychiatry unit taking into consideration the paucity of data for understanding the trends and improving service provision in the future. Materials and Methods: A retrospective chart review of all inpatient referrals received by the psychiatry department from July 2015 to February 2017 was conducted. The sociodemographic profile, source of referral, reason for referral, and psychiatric diagnosis using the International Statistical Classification of Diseases-10 were analyzed using descriptive statistical methods. Results: A total of 605 patients were referred, which comprised 0.86% of total indoor admissions. Maximum number of consultations was sought from internal medicine. “Unexplained physical symptoms” was the most common reason for referral (35%). Consequently, neurotic, stress-related, and somatoform disorder (25.5%) was the most common psychiatric diagnosis followed by mood disorder (19.8%). Conclusion: Poor and variable referral rate from various departments highlights the increasing need to sensitize all clinicians regarding psychiatric comorbidity. There is a need to explore factors that would result in increasing referral rates and making psychiatric consultation services effective and efficient.

Does media influence suicide attempt in people from the rural background?

Introduction: Suicide is a serious public health problem. Many factors are known to influence suicide. Much has been studied about the influence of media on suicide attempters. Less studied is the effect of media from a rural background. Aim: To study the profile of suicide attempters from a rural background and the role of media. Materials and Methods: This study was undertaken in a General Hospital Psychiatry unit attached to Government Medical College. Total of 189 medically stable suicide attempters with the rural background was included in the study. The profile of the participants influenced by media was studied. SPSS version 20.0, was used for descriptive and inferential statistics. Results: One hundred and eighty-nine participants were included. Based on the type of influence, three groups were formed [influenced by media (television) (n=37) / influence by other attempters (n=57) / own inner feelings (n=95)] who differed significantly with respect to age (?2= 4.134, p=0.018) and type of attempt (?2= 6.619, p=0.037). Regression analysis showed the presence of adjustment disorder predicting the person to be influenced by internal feelings to attempt suicide. Conclusion: One in five was influenced by media. Majority of the participants were influenced by their own internal feelings. Influence of media was higher in the younger age group. There is a dire need to spread mental health awareness to prevent suicide attempts/suicides and to improve appropriate help-seeking behavior. Television was the common source of influence, hence using this media would help to create awareness in rural population. Keywords: Suicide attempt, Media influence, Rural.