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   Table of Contents - Current issue
Coverpage
October-December 2021
Volume 37 | Issue 4
Page Nos. 341-453

Online since Thursday, November 25, 2021

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EDITORIAL  

Leadership for mental health p. 341
Nitin Gupta, R Srinivasa Murthy
DOI:10.4103/ijsp.ijsp_324_21  
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INVITED PERSPECTIVES/VIEWPOINTS Top

Home-based care in the community p. 343
Shikha Tyagi, Akshit Katoch, Subhash Das, Nitin Gupta
DOI:10.4103/ijsp.ijsp_327_21  
Treatment gap in mental health is vast and continues to remain a grim reality. Amongst community mental health care, one approach available is home based care (HBC). However, HBC services are almost lacking in India. Nevertheless, the limited evidence points towards a successful utility of HBC till date. In this article, the Chandigarh experience of HBC is presented and discussed in detail in order to demonstrate its utility and effectiveness. Lastly, recommendations are provided for the future of HBC.
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Vision for total care of persons with developmental disabilities p. 346
R Srinivasa Murthy, B Divya, S Nischitha
DOI:10.4103/ijsp.ijsp_325_21  
During the last 75 years of Independent India, there has been significant progress in the care and recognition of the rights of persons with disabilities (PwDs). The setting up of the National Institute for Mentally Handicapped in 1984, Rehabilitation Council in 1992, the National Trust in 1999, the revision of the legislation covering the rights of the PwDs in 2016 are all indicative of the recognition of the rights of persons living with developmental disabilities and their caregivers. However, in spite of the articulation of a need for a National Plan, over four decades back, there is much that needs to be addressed. The most recent program to disseminate from village level to national level, the rights of persons with disability is a positive step. There is an urgent need to initiate pilot programs in geographically limited areas to develop care programs from birth to the end of life. This article presents a comprehensive vision for the future with the hope this will find support from the public, professionals, and policymakers.
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Psychiatric rehabilitation in indian general hospital psychiatry unit settings p. 352
Thanapal Sivakumar, Amrita Roy, K Shanivaram Reddy, Hareesh Angothu, Aarti Jagannathan, Krishna Prasad Muliyala, Poornima Bhola, Sailaxmi Gandhi, Devvarta Kumar
DOI:10.4103/ijsp.ijsp_318_21  
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.
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Community management of substance use disorders: Past, present, and future p. 360
Kshitiz Sharma, Tathagata Mahintamani, BN Subodh, Debasish Basu
DOI:10.4103/ijsp.ijsp_314_21  
Substance use disorder (SUD) is a common entity in the Indian population, with a huge treatment gap of around 90%. Poor availability, accessibility and acceptability due to various reasons contribute to the treatment gap. The management of SUD at the community level can reduce this gap. Various private, government, and nongovernmental organizations (NGOs) are the leading agencies to provide pharmacological and nonpharmacological treatment at the community level in India. Historically, addiction treatment “camps” were efficient, cost-effective, and resource-saving community treatment approaches. Conventionally, there has been an attempt to integrate SUD treatment in primary healthcare, but this requires training and resource development at the community level. Outreach clinics, organized by tertiary care hospitals, help in training and research, besides catering to the community need for treatment. NGOs also help in the provision of treatment, awareness generation and capacity building at the community level. Currently, integration of screening and brief intervention with primary care is being tried in various community setups. This approach would be more effective with an efficient referral system. Telemedicine emerged as a new tool during the Coronavirus disease-19 pandemic. Telemedicine has been efficiently incorporated in the hub and spoke model and has been found to enhance the community treatment of difficult to reach patients with SUD. Various modifications in telemedicine help in more efficient diagnosis, decision-making, and treatment. Proper integration of multiple approaches can help in effective service delivery in a resource-limited setup in the community.
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Role of nongovernmental organizations in community mental health p. 366
Thara Rangaswamy, D Kotteswara Rao, Sujit John
DOI:10.4103/ijsp.ijsp_302_21  
This article focuses on the work done by nongovernmental Organizations (NGOs) in mental health (MH) in India and will illustrate in broad strokes the growth of NGOs in the MH sector. It describes the evolution of MH services over the years with specific emphasis on community MH activities undertaken by NGOs. The role of the MH NGO in bridging the MH gap and the activities that have been undertaken ranging from primary prevention work to tertiary care is discussed. The inherent strengths that the NGOs have in working with communities and their ability to provide holistic care and services beyond the medical model by involving a wide array of workers ranging from MH professionals to peer support providers is examined. The need for private–public partnership in MH is emphasized as the way forward along with leveraging digital technologies that has now come into sharp focus following the COVID pandemic.
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Family caregivers of persons living with mental health conditions: Challenges and concerns p. 371
Amrit Bakhshy
DOI:10.4103/ijsp.ijsp_319_21  
A vast majority of persons diagnosed with mental disorders live with their families in most of the low- and middle-income countries. There is a growing evidence of the adverse impact of caregiving on the caregivers. There is a need to recognize the significant contribution of caregivers. Specific programs to improve skills of self-care for emotional health, skills of caregiving, social welfare, and legislative support to caregivers will make them more effective and further decrease the demand on mental health services. This is an urgent need. India has the opportunity to show the way through innovative training, legislative, and other measures.
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INVITED BOOK REVIEWS Top

Schizophrenia research foundation-caring for the mind: A journey of 35 years….and counting p. 378
R Srinivasa Murthy
DOI:10.4103/ijsp.ijsp_320_21  
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Mental illness and caregiving – Challenges, concerns, and complications p. 380
S Nischitha, R Srinivasa Murthy
DOI:10.4103/ijsp.ijsp_321_21  
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Gifted p. 382
B Divya, R Srinivasa Murthy
DOI:10.4103/ijsp.ijsp_322_21  
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PERSPECTIVE Top

Mental hospitals and historical trauma: Stop blaming stigma, address the trauma p. 385
Sarah Ann Pinto
DOI:10.4103/ijsp.ijsp_198_20  
Background: India is facing a mental health crisis but to change community stigma, we need to address historical trauma. This article discusses the issue of community stigma toward mental health care in India. Objective: The research aimed to trace the roots of community stigma toward mental health care facilities. Method: This study primarily used the archival method of data collection in constructing its narrative. Primary sources including colonial records, some vernacular newspapers, and a few Indian sources were analysed. The Maharashtra State Archives and the National Archives of India, New Delhi, served as the main repository of primary sources. Additionally, India Office Records at the British Library, London, provided further evidence for this research. Digitized copies of Annual Asylum Reports made available by the National Library of Scotland added to the evidence. The study also involved fieldwork at the Thana, Yerawada, and Ratnagiri mental hospitals in 2014. Results: Community stigma to the use of mental health care facilities is a historical problem. The establishment of lunatic asylums in India (as they were referred to in the 19th century, the nomenclature changed in 1921 to the term mental hospitals) caused disruption to local communities and families and left a legacy of trauma and fear. Conclusions: Acknowledging the trauma will disrupt patterns of coercion and cultures of abuse within mental health institutions and it will enable new narratives in mental health care.
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ORIGINAL ARTICLES Top

Depression, anxiety, stress, and resilience among the primary survivors of natural disaster: A study with special reference to Kerala Flood p. 388
SR Rahana, Juby Merin Sam, P Udhayakumar
DOI:10.4103/ijsp.ijsp_238_20  
Background: Kerala, the southernmost state in India experienced the worst flood in its history, in August 2018. The disaster led its survivors to psychological trauma, along with several other impacts. Aims: The present study assessed the mental health status and level of resilience among the primary survivors in the postdisaster phase of Kerala flood, and the possible interlinkage of demographic factors with the study variables. Materials and Methods: The study has done on a sample of 50 primary survivors of flood selected using a purposive sampling method. Two rating scales-Depression Anxiety Stress Scale-21 and brief resilience scale-were used for collecting data, along with a sociodemographic information sheet prepared by the researcher, which was administered in a face to face interview with the participants. IBM SPSS software (version 21) was used for data analysis and statistical tests such as t-test, analysis of variance, and Pearson's correlation tests were used to interpret the data. Results: Results revealed the prevalence of depression, anxiety, and stress among the survivors in the postdisaster phase. Statistically significant difference was found in depression and stress scores in terms of education, where survivors with higher education showed lower stress and depression. Results also showed a comorbidity of depression, anxiety, and stress and a negative correlation between resilience and stress scores. Conclusions: The disaster had a significant impact on the survivors' mental health and need medical interventions to address it. The educational status and resilience level of the survivors are important determinants of postdisaster mental health.
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A qualitative study to explore various meanings of mental distress and help-seeking in the Yamuna Valley, North India Highly accessed article p. 394
Meenal Rawat, Sushrut Jadhav, Clement Bayetti, Kaaren Mathias
DOI:10.4103/ijsp.ijsp_63_21  
Context: In rural India, mental healthcare remains limited due to scant state services and incongruency between provider- and patient-framing distress. Help-seeking by people with mental health problems is related to how meanings of distress are understood differently by individuals, based on their interaction with various actors in the community and the available cultural explanation within their local ecologies. Methodology: This study examines the mutually constituted relationship between meanings of mental distress and help-seeking among people residing in the Upper Yamuna Valley, Uttarakhand, North India. This qualitative study builds on six in-depth interviews with people with severe mental health issues and one person with epilepsy, referred as people with psychosocial disability (PPSD) in the study. The data analysis was iterative and followed thematic approach. Results: The study found that personal belief based on one's experience, such as negative self-judgment and wider cultural explanations, such as supernatural beliefs, as well as gender roles, impacted the way people address their mental health problems, in turn shaping their help-seeking behavior. Participants lost hope for a cure after years of trying to find an effective solution. Moreover, lack of access to care and remoteness of the mountainous area made help-seeking and recovery feel impossible. Conclusions: This study underscores the need for researchers and policy professionals to explore the local context and culture to improve care and treatment quality. The study also explains that personal explanation of psychosocial problems and help seeking are not unidirectional. It is a complex phenomenon layered with the local contexts which should be addressed in clinical practice, as well as future research. Finally, clinicians' training should address the local cultural language of distress to identify the problem and suggest an effective solution.
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Mental health impact of the COVID-19 pandemic on reverse migrant workers in Uttarakhand: A cross-sectional study p. 407
Kanupriya Verma, Zeeshan Mujawar, Swaleha Mujawar, Amiya Banerjee
DOI:10.4103/ijsp.ijsp_19_21  
Introduction: The announcement of a nationwide lockdown in India in March 2020 in response to the CoVID-19 pandemic led an exodus of migrant workers back to their homes. The significant adverse impact of this event in its early phase on these reverse migrants has been well documented. With the passage of several months, these reverse migrants eventually reached their homes and re-entered their own communities. This study was conducted amongst a rural community on the interior regions of Almora in hill state of Uttarakhand. Aim: It aims to assess the impact of the later phase of the CoVID-19 pandemic and lockdown on the reverse migrants, and compare this impact with the residents, who have never migrated. Methodology: Door-to-door survey was conducted in the study population, 5-9 months after the lockdown was announced. The participants were matched and grouped into residents and reverse migrants and were evaluated on PHQ-9, GAD-7, IES, and BRIEF-COPE to assess the impact on the participants. Results: No significant depression or anxiety was found in the reverse migrants group, even though the impact of the pandemic and lockdown was felt more by them as compared to the residents group. In addition, there was no significant difference between the two groups for depression or anxiety. Conclusion: These findings can be attributed to factors such as social support from the community members, engagement in work and the use of approach based coping mechanisms.
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Nature and drivers of suicide in a rural community of Western Maharashtra p. 413
Richa Sharma, Mitchell G Weiss, Nachiket Sule, Nerges F Mistry
DOI:10.4103/ijsp.ijsp_137_20  
Context: The National Crime Records Bureau reports that 134,516 deaths result from suicide in India every year. Maharashtra accounts for 13.4% of the total reported suicides. Aims: This documentation study in the framework of a community mental health program (CMHP) aimed to identify local features of suicide in a rural community, namely sociodemographics and drivers of suicide. Settings and Design: The study was conducted in a community of rural Purandhar block in Western Maharashtra from January 2014 to March 2016 where a CMHP was ongoing since 2013. Data were collected as a part of process documentation through its local community health workers (CHWs). Subjects and Methods: CHWs involved in the program were interviewed, and data were analyzed manually. Results: Seventeen completed and seven attempted suicides who were not a part of the ongoing CMHP among the population were documented. Majority were men under 30 years of age. Pesticide consumption was the most common method of self-harm, and domestic strains were the major driver for suicides. Conclusions: The local pattern of suicidal behavior and its context are relevant for consideration in suicide prevention plans responsive to culture-specific features of suicide.
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Mortality among patients with severe mental disorders from a rural community in South India p. 418
Vijaya Raghavan, Shruti Rao, A Kulandesu, S Karthick, S Gunaselvi, S Senthilkumar, Kotteswara Rao, Sujit John, R Thara
DOI:10.4103/ijsp.ijsp_337_20  
Background: Even though excess mortality in patients with severe mental disorders (SMD) has been established in many high-income countries, literature on this from the low- and middle-income countries including India is rather scant. Our study seeks to estimate the standardized mortality ratio (SMR) of patients with SMD from a rural community in Tamil Nadu for the years 2011–2015. Materials and Methods: We included patients with SMD from four taluks of Pudukkottai district, Tamil Nadu, during the years 2011–2015. We collected information on a total number of patients with SMD registered, their sociodemographic details, alive/dead status, and cause of death from the clinic registers and patient case records. We used the crude death rates for rural Tamil Nadu for the years 2011–2015 for the calculation of SMR, which is calculated by the formula observed deaths/expected deaths. Results: The SMR of patients with SMD was 3.33, 2.76, 2.11, 1.91, and 1.89 in the years 2011–2015. Of the 74 total deaths in these 5 years, 62 (83.7%) were due to natural causes, while 12.2% died by suicide. Statistically significant differences were observed in age, education, and marital status between patients with SMD who were alive and dead. Conclusion: We observed nearly two-times higher mortality among patients with SMD in rural Tamil Nadu. Further research is needed to examine the reasons for increased mortality among patients with SMD and interventions to reduce this excess mortality.
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Accessing mental health care among people with schizophrenia: Data from an Indian rural psychiatric setting p. 423
Ammu Lukose, Rahul K Venkatesh, Anish V Cherian, Shrinivasa Undaru Bhat, Santosh Prabhu, Praveen Arahanthabailu, Shishir Kumar, Aneesh Bhat, Naveen Chandra Shetty
DOI:10.4103/ijsp.ijsp_141_20  
Background: “Duration of untreated psychosis” (DUP) remains a major predictor of poor outcome among people with schizophrenia (SCZ). Reducing DUP remains a challenging public health concern. Studies from various low- to middle-income countries demonstrate that many patients with SCZ remain untreated for long, especially in rural communities. However, there is paucity of data from rural India on DUP and pathways to care. Methodology: We consecutively recruited 106 patients registered at a rural psychiatric center in South India who met the International Classification of Disorders-10 criteria for SCZ. The delay from the onset of psychotic symptoms to seeking psychiatric help was measured and the pathways to care were assessed. Results: The patients were nearly equally distributed across the genders and were predominantly <40 years of age from rural and low- to middle-income backgrounds. The mean and median DUP were 3.15 ± 5.61 years and 1 year (interquartile range = 2.79), respectively. Although the longest time to contact was 28.5 years, 80% had DUP shorter than 5 years. Three major gateways to care were identified, with native/faith healers being the most popular (73.58%). Conclusion: In rural India, patients with SCZ tend to take longer to seek psychiatric help after their first psychotic episode compared to urban counterparts. Our results emphasize the necessity of developing early identification, improving mental health literacy, and providing community-based interventions for people with SCZ.
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Community-based psychosocial intervention for persons with severe mental illness in Rural Kerala: Evaluation of training of lay mental health workers p. 430
Rekha Pallikkuth, T Manoj Kumar, L S Sam Manickam, Anish V Cherian, Joske F. G Bunders-Aelen, Barbara J Regeer
DOI:10.4103/ijsp.ijsp_126_19  
Background: High-quality mental health care is scarce in rural India. The Mental Health Action Trust a Nongovernmental Organization based in Kozhikode, South India, has been providing free mental health services to the economically disadvantaged people in the surrounding districts. Comprehensive multidisciplinary care is provided through existing health-care clinics through training of lay mental health workers (LMHW). The current paper evaluates the classroom training methods employed to educate the LMHW. Materials and Methods: The training module designed after coordination and need assessment was delivered through classroom training sessions by trained trainers over 2 months weekly 6 h and completed by 13 volunteer LMHW (5 males and 8 females and who were in the age range of 22–56 years) could complete all the modules of training. The evaluation of training was done quantitatively and qualitatively. Results: The LMHW's knowledge, attitudes, perceived interpersonal skills, and confidence levels demonstrated a noticeable change following the classroom training program. Conclusion: It is feasible to train LMHWs to deliver psychosocial interventions for people with severe mental disorders and their families in rural India. In addition to classroom training, case-based training and proper ongoing supervision are required to improve their skills, attitudes, and knowledge.
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Felt needs of the caregivers for the home based care for their family members with severe mental illnesses p. 437
Deepika Kartikeyan, Gobinda Majhi, Vijay K G. Kumar
DOI:10.4103/ijsp.ijsp_413_20  
Background: Home-based care for persons with severe mental illness is a family-focused approach and addresses the caregiver's responsibility. It is cost-effective compared to the inpatient hospital settings, and it also allows the patients to stay with families in their communities while treatment is going on. In this context, this study aimed to explore the barrier to access mental health services and the caregivers' felt needs for home-based care for their family members with severe mental illness. Methods: This study adopted a cross-sectional descriptive design with 60 caregivers of family members with severe mental illnesses. Quantitative data were collected through a semi-structured interview schedule prepared and validated for this study, and the severity of illness was measured using the Clinical Global Impression Scale. Results: Caregivers faced difficulty in traveling along with their family members to the hospital for treatment (76.7%), accessibility issues (65%), and problems in mobilizing the patient to the hospital (54%). The majority of the caregivers (75%) preferred home-based care to manage the illness of the patient, with a focus on pharmacotherapy (83.3%), and the patient considered there should be appropriate training at home (63.3%). Conclusion: The majority of the caregivers felt the need for home-based care with a preference for both pharmacotherapy and self-care for their family members with severe mental illnesses.
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Psychosocial rehabilitation, disability, and quality of life in patients with schizophrenia residing in long-stay homes p. 446
Rajith K Ravindren, Kurian Jose
DOI:10.4103/ijsp.ijsp_44_20  
Background: Schizophrenia is a chronic mental illness that results in significant disability. Many patients have difficulties in self-care, communication, and employment. The study assessed the effectiveness of a psychiatric rehabilitation program in reducing disability and improving quality of life (QOL) in patients with schizophrenia residing in long-stay homes. Methods: Forty-two patients with schizophrenia who were inmates of two long-stay homes were the subjects. A rehabilitation program consisting of training in activities of daily living, social skills, medication self-adherence, cognitive training, and psychoeducation was imparted for 6 months. Pre- and post-intervention evaluations were done using IDEAS and WHOQOL-BREF. Wilcoxon signed-rank test was used to assess the significance of the change in outcomes. Results: Scores in self-care, interpersonal activities, communication, and work domain of IDEAS showed a significant reduction with large effect sizes. Domains one, two, and four of WHOQOL-BREF also showed significant improvements with medium to large effect sizes. Conclusion: The rehabilitation program reduces disability and improves the QOL in patients with chronic schizophrenia. Our model of rehabilitation is inexpensive and can be delivered by lay health workers under supervision.
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LETTER TO EDITOR Top

Creating comprehensive youth mental health services in low-resource settings: Schizophrenia research foundation experience p. 452
Shiva Prakash Srinivasan, Greeshma Mohan, Syed Rabiya, Sangeetha Chandrasekar, Vijaya Raghavan
DOI:10.4103/ijsp.ijsp_451_20  
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