Aims:We describe the process of development and evaluation of manualized approaches for two types of telephone outreach: Telephone contacts (TC) and Telephone-based psychosocial intervention (TBPI). TC comprised inquiry into suicidal ideation and reminders for mental health hygiene. TBPI comprised psychosocial counseling in addition to TC components. Trained research associates (RAs) delivered TC and TBPI to individuals with a history of suicide attempts. Telephone outreach was an addon to the usual follow-up care in such individuals. Methods:We developed manuals from extensive literature review and consensus. We evaluated the approaches by fidelity assessments to specific components of the outreach and overall acceptability. We used a cross-sectional study design for evaluation of approaches. An independent rater evaluated fidelity by reviewing audio recordings of TC and TBPI. Individuals who received the telephone outreach rated the acceptability on a visual Likert scale of 1-10 (1 was the least and 10 was the maximum acceptable score). Results:We developed two telephone outreach manuals structured in a narrative format in an algorithmic approach with similar sections for rapport, inquiry into suicidal ideation and reminders for mental health hygiene. The TBPI manual included a psychosocial counseling section. Fidelity assessment of 168 telephone outreach sessions showed adherence of 80% or more to the manuals in 78.57% of the participants. The mean acceptability score was 7.6 out of 10 for the telephone outreach (SD: 1.75, n = 239). Conclusion:We demonstrate that manualized approaches for telephone outreach in suicide prevention are an acceptable strategy that can be delivered with optimal fidelity.
Depression is highly prevalent among individuals with type 2 diabetes mellitus (T2DM), contributing to increased morbidity, mortality, and healthcare costs. Given the shortage of mental health professionals, task-sharing with primary care personnel (PCP) are essential for early identification and management of depression in primary care settings. To evaluate the effectiveness of a brief depression training program (BDTP) in enhancing PCPs' knowledge of depression management in T2DM. A 3-hour module-based BDTP was conducted at primary care centers in Bengaluru, New Delhi, and Bhubaneswar. Knowledge was assessed pre- and post-training (immediately) using multiple-choice questions (MCQs) and case vignettes. Forty-nine PCPs participated. Post-training scores significantly improved across all sites, irrespective of prior mental health training. BDTP is effective in improving PCPs' short-term knowledge. Ongoing training supervision and virtual skill-based training are recommended to sustain and translate knowledge into clinical practice.
Physical health issues are frequent and often inadequately addressed in individuals with severe mental illness (PWSMI) because of several lifestyle influences. Hence to screen and estimate the prevalence of physical disorders and lifestyle factors like physical activities among community-dwelling mentally ill (PWSMI) a door-to-door survey was conducted in the catchment area of a Primary Health Center. A total of 71 participants with SMI were screened and diagnosed with severe mental illness. They were evaluated for comorbid physical illnesses and lifestyle factors like substance use and the extent of daily physical activity (work, recreation, remaining idle). The prevalence of diabetes and hypertension was 38.5% each, while that of tobacco and alcohol use was 24.3% and 21.1% respectively. Only 22.8% reported work-related physical activity, and 7% reported recreational physical activities. Physical illnesses are common, while physical activity is restricted in people with severe mental illness.
Background:In the context of public mental healthcare delivery in India, in contrast to the often highlighted challenges related to the supply side, the demand-side challenges (DSC) are rarely examined systematically. Objective:To assess the DSC in patients with psychiatric disorders and their caregivers in a rural South Indian community. Methods:This study was conducted as part of a larger implementation research in which all adults in a predefined catchment area were screened for mental disorders, followed by confirmation of diagnosis by mental health professionals. The patients were counseled about (a) the need to start/resume/continue treatment and (b) the availability of services at the nearest health facility. DSC were evaluated by a targeted question to the patient/family members on reasons for not accessing/continuing treatment. Results:Among the 268 confirmed treatment-naïve patients at baseline, only 6 (0.02%) could be convinced to contact a treatment facility within the next 8 weeks. Regarding DSCs, for all disorders put together, factors related to the illnesses themselves (aggression, hostility, intoxication with substances, absence of insight, and, in instances specific to substance use, lack of motivation to stop its use were present in almost all (98.7%) patients. Lack of perceived dysfunction/disability (42.3%) and poor awareness (24.9%) formed the other two common factors. Disorder-wise breakup showed that poor awareness was predominant in Common Mental Disorders (CMDs; 60%). Illness-related factors predominated in Severe Mental Disorders (SMDs; 66.6%) and Substance Use Disorders (SUDs; 98.7%). Lack of perceived dysfunction mattered next for SUDs (42.3%), followed by poor awareness (24.9%). For SMDs, family support-related factors (47.9%) ranked second, followed by poor awareness (25%). Conclusion:DSCs significantly contribute to the treatment gap. Merely making the treatment available and accessible will not be sufficient for people to accept it. Aggressive and sustained public health measures/campaigns need to be incorporated to effectively tackle DSCs.
Background:Depression is the most prevalent psychiatric disorder among women during pregnancy but often goes undetected and untreated. Aim:This study aimed to assess whether a brief psychological intervention for depression in pregnancy (BIND-P) delivered by nurses is efficacious in the treatment of depression as compared to Treatment as Usual (TAU). Methods:A multi-centric, hospital-based open-label parallel group, randomized controlled trial was conducted at four sites across India (one each in Northern and Central India, and two in Southern India) from 2018 to 2022. A total of 1,352 participants were randomly allocated (1:1) to BIND-P and TAU groups. The primary outcome assessment was a reduction in PHQ-9 scores (from baseline to 8 weeks post recruitment). The secondary outcome was the outcome of pregnancy and infant development at 6/10/14 weeks post pregnancy. Results:Both groups demonstrated a reduction in PHQ-9 scores from baseline to follow-up. However, the between-group difference was not statistically significant (adjusted mean difference [BIND-P vs TAU]: 0.03; P = 0.91). The overall effect size was small (Cohen's d ≈ 0.05). Discontinuation rates were lower in the BIND-P group compared to TAU (17.34% vs 30.35%). Subgroup analyses suggested greater likelihood of remission among women who were older, had higher education, were from rural settings, had lower income, were primigravida, or had high-risk pregnancies. No significant differences were observed between groups in pregnancy or infant outcomes. Conclusion:The BIND-P intervention was not inferior to TAU in reducing depressive symptoms but demonstrated lower discontinuation rates. As a low-intensity psychosocial intervention (LIPI), BIND-P may be a feasible and acceptable option for integration into routine maternal healthcare services, with potential to help reduce the treatment gap in perinatal mental health.
Background:The role of Accredited Social Health Activists (ASHAs) in improving short-term outcomes-symptoms, burden, and disability-for individuals with severe mental disorders (SMDs), common mental disorders (CMDs), and alcohol use disorders (AUDs) remains inadequately studied. Methods:This randomized controlled trial compared enhanced ASHA training (one-day in-person plus seven online modules over 18 months; Study Group (SG), n = 35) to training-as-usual (one-day in-person; Control Group (CG), n = 36). Both groups supported persons with SMDs (SG = 24; CG = 37), CMDs (SG = 15; CG = 20), and AUDs (SG = 31; CG = 20). Outcomes were measured using standardized disability (Indian Disability Evaluation and Assessment Scale; IDEAS), burden (Burden Assessment Scale; BAS), quality of life [EuroQol 5-Dimension 5-Level Questionnaire (EQ-5D-5L)], and disorder-specific scales (Clinical Global Impression-Schizophrenia; CGI-SCH, Kessler Psychological Distress Scale (K-10); Brief Addiction Rating Scale (BARS) and Timeline Follow back scores; TLFB) at baseline and 6-8 weeks post-baseline. Results:For CMDs, the SG showed significant improvements (P < 0.05) across IDEAS, WHO-DAS, BAS and K-10 than CG (only IDEAS and WHO-DAS had improved significantly), though no group-by-time interaction emerged. For SMDs, both groups improved (P < 0.05) on IDEAS, WHO-DAS and BAS; CG did better on CGI-SCH and EuroQol-5 as well. Additionally, only CG had a significant group-by-time effect for CGI-SCH (P < 0.05). In AUDs, both groups improved (P < 0.05) on BARS, WHO-DAS and EuroQol-5, with SG showing additional gains (P < 0.05) in TLFB, BAS, and IDEAS. Time*Group interaction was not significant for any of these scores. Conclusion:Trained ASHAs, with or without supplementary support, can facilitate notable short-term clinical improvements for psychiatric disorders in community settings.
Background:Depression and type 2 diabetes mellitus (T2DM) share a bidirectional relationship. This comorbidity is associated with poor glycemic control, reduced medication adherence, and impaired quality of life. Evidence comparing pharmacological and psychological interventions for mild depression in T2DM within primary care settings remains limited. Objectives:To compare the effectiveness of Fluoxetine, Mindfulness therapy, combination Fluoxetine + Mindfulness, and treatment as usual (TAU) in reducing depressive symptoms among individuals with T2DM and mild depression. Methods:This single-blind randomized controlled trial (RCT) was conducted among individuals (n = 200) with T2DM and mild depression recruited from the Bengaluru site of the multi-center diabetes mellitus and depression (DIAMAND) study. Participants were randomized to Fluoxetine, Mindfulness therapy, combination treatment, or TAU. Depression severity, medication adherence, diabetes self-management, quality of life, HbA1c, and random blood sugar (RBS) were tested over 4 months. Repeated Measures ANOVA (RMANOVA) and effect size estimates were used for analysis. Results:Depressive symptoms improved significantly over time across all study arms; and no significant between-group differences were observed in depression outcomes. No significant differences were found between groups for glycemic control, medication adherence, diabetes self-management, or quality of life. Effect sizes for reduction in depressive symptoms compared with TAU were 0.48 for Mindfulness, 0.45 for fluoxetine, and 0.31 for combination treatment. Conclusions:In this RCT, depressive symptoms and medication adherence improved across all study arms; however, none demonstrated superiority over TAU. Mindfulness-based interventions may represent feasible, scalable, low-intensity approaches for mild depression in primary care settings. Future adequately powered studies with longer follow-up are needed to evaluate long-term effectiveness of psychological and pharmacological interventions.
Background and Aim: Evidence on factors associated with successful methadone tapering in India is limited. This study aims to identify positive and negative factors associated with successful tapering of methadone maintenance treatment (MMT). Materials and Methods: This retrospective study reviewed records of 88 patients undergoing MMT tapering at a tertiary care drug treatment clinic (DTC). Demographic, clinical, withdrawal, motivational, and treatment-related factors associated with taper outcomes were analyzed. Results: Seventeen participants (19.3%) successfully completed tapering without relapse. Successful tapering was associated with lower baseline methadone dose, lower withdrawal severity, greater motivation, and absence of tobacco use. Participants who relapsed after taper completion had significantly higher taper rates than those who remained abstinent (6.4 vs. 3.3 mg/week; P = 0.039). Fear of relapse, withdrawal symptoms, family instability, economic instability, and fear of death were common barriers to tapering. Conclusion: Successful tapering was associated with lower baseline methadone dose, slower taper rate, lower withdrawal severity, greater motivation, and absence of tobacco use.
Background and Aims:Motivation is an important predictor of outcome in alcohol dependence. This study aimed to translate the Stages of Change Readiness and Treatment Eagerness-Alcohol Version 8A (SOCRATES-8A) scale into Hindi and evaluate its psychometric properties among individuals with alcohol dependence. Methods:This cross-sectional study included 200 outpatient males with alcohol dependence recruited by purposive sampling. The scale was translated into Hindi using forward and back translation and administered to participants. Other scales included Severity of Alcohol Dependence Questionnaire, Patient Health Questionnaire-9, General Anxiety Disorder, and Motivation to Addiction Treatment-Hindi (MAT-H) Scale. Validity and reliability were assessed, and correlation analysis was conducted between the socio-demographic and clinical variables. Results:The findings supported a three-factor structure: Recognition, Ambivalence, and Taking Steps. The Confirmatory Factor Analysis model retained 15 items and revealed good fit indices (CFI = 0.91, TLI = 0.89, and RMSEA = 0.07). Internal consistency was strong for Taking Steps (α =0.89), moderate for Recognition (α =0.69), and lower for Ambivalence (α =0.51). Modest correlation exists between SOCRATES-Hindi and MAT-H scale. Taking Steps showed positive correlation with age of the participant (r = 0.17, P = 0.01), and age of onset of day drinking (r = 0.16, P = 0.03), while Recognition and Ambivalence factors had a positive correlation with amount of alcohol consumption. Conclusion:The findings suggest that the Hindi version of the scale has acceptable psychometric properties in this population, though further validation across other substances and settings is needed.
Background: Antipsychotics are commonly used in the long-term treatment of schizophrenia and bipolar disorder, but rare blood-related adverse effects can complicate therapy. Cases: We report three Indian patients who developed pancytopenia during prolonged Olanzapine use. Thorough clinical and laboratory evaluation ruled out nutritional deficiencies, infections, autoimmune disorders, and primary hematological diseases. A 43-year-old woman with schizophrenia developed severe anemia, hyponatremia, and recurrent infections that improved after stopping Olanzapine. A 40-year-old woman with paranoid schizophrenia developed cytopenia’s during leptospirosis and recovered after drug withdrawal. A 36-year-old man with bipolar disorder experienced recurrent typhoid infections and transfusion-dependent anemia, with gradual recovery after switching to Quetiapine. Conclusion: Olanzapine-associated pancytopenia may easily be mistaken for infection or nutritional deficiency. Regular blood count monitoring and timely use of safer alternatives are important to ensure both patient safety and psychiatric stability.
