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Symposium 1 - Neuromodulation in Psychosis

PRESENTATION 1

Topic: Electroconvulsive Therapy (ECT) in Schizophrenia: A Case of Shocking Neglect

Author: Dr. Jagadisha Thirthalli, National Institute of Mental Health & Neurosciences (NIMHANS), Bengaluru

Across the world, more patients with schizophrenia are likely to be receiving Electroconvulsive Therapy (ECT) than those with depression. Nevertheless, research regarding the use of ECT in schizophrenia makes up a minuscule proportion of the entire ECT research. There is little consorted effort to clarify and define the role of ECT in the treatment of persons with schizophrenia. In contrast to the case with ECT for depression, a number of questions remain unanswered in ECT for schizophrenia. Thousands of patients with schizophrenia continue to receive ECT with little efforts to optimize the treatment for them. This talk would discuss the current state of knowledge about the use of ECT in schizophrenia, raise clinically relevant questions that remain to be answered, and propose the way forward in this aspect of care of one of the most severely afflicted patients.

PRESENTATION 2

Topic: TMS in Psychotic Disorder

Author: Dr Samir Kumar Praharaj, MD, DPM., Kasturba Medical College, Manipal, India

Affiliation: Professor & Head, Department of psychiatry, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India; Email: Samir.kp@manipal.edu

Abstract: Transcranial Magnetic Stimulation (TMS) is a non invasive brain stimulation technique which has wide applications in the field of neuropsychiatry, including schizophrenia and related psychotic disorders. Investigative TMS in schizophrenia is being used to measure cortical reactivity, cortical oscillatory activity, cortical connectivity, and cortical plasticity, which could help in elucidating the pathophysiology of schizophrenia. In combination with neuroimaging, electrophysiological and genetic techniques, TMS perturbation studies could be used to understand the basis of treatment resistance in schizophrenia. The therapeutic uses of TMS are being explored in several psychiatric disorders including schizophrenia. Both conventional and patterned TMS is being used in the treatment of auditory verbal hallucinations and other positive symptoms, negative and cognitive symptoms. Specifically, symptoms not responding to conventional pharmacotherapy are of interest for trial with TMS. However, the stimulation parameters still require optimization for routine clinical applications.

Samir Praharaj completed his MBBS from Gauhati Medical College, Guwahati and DPM, MD from Central Institute of Psychiatry, Ranchi. He is currently holds the position as, Professor & Head, Dept. of Psychiatry & Coordinator, Clinical Research Centre for Neuromodulation in Psychiatry, Kasturba Medical College, Manipal, Karnataka. He was the GSMC-FAIMER Fellow (2017) and DBT India Alliance Fellow (2020). His interest areas include Clinical Psychopharmacology, Addiction Medicine, Non-Invasive Brain stimulation, Medical Education. He has published in peer reviewed journals and contributed to book chapters. He is the Chief Associate Editor of IJPM, Associate Editor of MJMS, IJPP. He has received the best resident award, CIP Ranchi (2007), Samuel Gershon Young Investigator Award, ISBD (2008), Travel awards for Early Career Psychiatrists, Prof. Raguram Distinguished Young Teacher Award, IPSKC (2016)

PRESENTATION 3

Topic: Transcranial Direct Current Stimulation in Schizophrenia: Recent Advances

Author: Dr. Nishant Goyal MD, DPM, Central Institute of Psychiatry, Ranchi, India

Abstract: The idea of modulating dysfunctional brain regions using Non Invasive Brain Stimulation techniques in the treatment of psychiatric disorders has gained momentum in the last decades. These include newer paradigms including transcranial electrical stimulation (tES) which encompasses techniques like transcranial direct current stimulation (tDCS), high definition tDCS (HD-tDCS), transcranial alternating current stimulation (tACS), etc. tDCS is a brain stimulation technique that induces cortical plasticity noninvasively via subthreshold neuronal membrane polarization with constant weak direct currents. The direction of tDCS-induced plastic changes depends on stimulation polarity - anodal stimulation conventionally results in excitability enhancement, while cathodal tDCS reduces it. Promising results have been reported for the effects of rTMS and tDCS on various symptom clusters in schizophrenia and related psychotic disorders including auditory hallucinations, negative symptoms and cognitive symptoms. High-definition tDCS (HD-tDCS) is an advancement of the conventional tDCS that has the potential for precise and focalized neuromodulation further increasing the effect sizes of treatments implied. Modifications in the type, duration and stimulation parameters in tES hold exciting hope for management of psychotic disorders further strengthening the armamentarium of management.

Keywords: tDCS, tES, Psychosis, neuromodulation

Nishant Goyal holds the position as the Professor of Psychiatry and incharge of the Centre for child and adolescent psychiatry, fMRI centre and centre for cognitive neurosciences at the Central Institute of Psychiatry, Ranchi. He is also the joint secretary and founder member of the Neuromodulation society (India). His area of interests includes Child and Adolescent Psychiatry, Non-Invasive Brain Stimulation, Public Mental Health. He has published more than 90 articles in national and international journals and received more than 20 awards and research fellowships.

Symposium 2 - Psychoses in Old age

PRESENTATION 1

Topic: Psychosis in dementia (including Dementia in Lewy Body Disease & BPSD)

Author: Ipsit Vahia, McLean Hospital, USA

Ipsit Vahia, MD, is a geriatric psychiatrist, clinician, and researcher. He is the associate chief of the Division of Geriatric Psychiatry and director of Digital Psychiatry Translation at McLean Hospital. He is also director of the Technology and Aging Laboratory. His research focuses on the use of technology and informatics in the assessment and management of older adults and currently, he oversees a clinical and research program on aging, behavior, and technology. He has published extensively in major international journals and textbooks. Dr. Vahia heads the Technology and Aging Laboratory at McLean Hospital, which studies how digital tools can impact the psychiatric care of older adults

PRESENTATION 2

Topic: Schizophrenia and schizophrenia-like psychosis in late-life

Author: Ellen Eun-Ok Lee, M.D. University of California San Diego, USA

Ellen Lee completed her MD from Cleveland clinic Learner college of medicine at Case Western Reserve University. She completed a fellowship in geriatric psychiatry from V A San Diego Healthcare system and University of California, San Deigo. She has extensively worked with elderly population and involved in various aging studies. Has published around 80 and more articles in various peer reviewed journals and contributed to various book chapters.

PRESENTATION 3

Topic: Psychosis in elderly with mood disorders

Author: Prof. Palanimuthu T Sivakumar, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru

Affiliation: Professor of Psychiatry, Head, Geriatric Psychiatry Unit, Department of Psychiatry

Abstract: Mood disorders in elderly is a significant public health problem with depression being the major contributing factor to the morbidity and mortality. Psychotic depression is more common among older adults aged above 60 years. Recent changes in ICD-11 and DSM V have recognized that psychotic symptom can be present across the entire spectrum of severity of depression. Challenges in establishing the diagnosis of psychotic depression contributes to significant under diagnosis and under treatment. Co-existence of cognitive and functional impairment may lead to challenges in differentiating this condition from dementia. Recent evidence from randomized controlled trials have established the evidence of the combination therapy of antidepressant and antipsychotic drug. Electro-convulsive therapy has remained the gold standard treatment with very good response rates. Suicidal risk and the possible conversion to dementia during follow up are important concerns. Psychotic symptoms are common in elderly with Early onset and late onset bipolar disorder both in the manic and depressive episode. The risk for manic switch from unipolar depression continues to exist later in the life despite some possible reduction in the risk. The tolerability of antipsychotics has improved to some extent with the second generation drugs like aripiprazole, quetiapine etc. But still the possibility of akathisia, sedation, increased risk for falls, drug induced parkinsonism needs to be monitored. This talk would discuss the epidemiology, clinical features, diagnosis and the treatment related issues in psychosis occurring in elderly with mood disorders.

Symposium 3 - INTREPID II: a multi-site programme of psychosis in the Global South

PRESENTATION 1

Topic: Psychosis research in diverse settings

Author: Alex Cohen, London school of Hygiene and Tropical Medicine, London, UK

The great majority of epidemiological studies of psychosis have been conducted in North America and Western Europe. As a result, almost everything we know about these mental disorders is based on evidence from a relatively homogeneous and small proportion of the world’s population. The INTREPID programme is conducting incidence, case-control and cohort studies from three settings in India, Nigeria and Trinidad in an attempt to provide a more global perspective on psychotic disorders.

PRESENTATION 2

Topic: Cannabis use amongst people with untreated psychosis and comparison with matching controls

Author: Joni Lee Pow, Psychologist and Research Coordinator

Abstract: Cannabis use has been linked to psychotic disorders in recent studies but it is unclear if this association extends to the Global South. We investigate patterns of cannabis use and associations with psychoses in three diverse settings. This case-control study within the International Programme of Research on Psychotic Disorders (INTREPID) II conducted between May 2018 and September 2020 recruited over 200 pairs of population-based cohorts of cases with untreated psychosis, and individually-matched controls in each setting (Kancheepuram India; Ibadan, Nigeria; northern Trinidad). Inclusion criteria for cases were age 18-64, resident in catchment area, presence of ICD-10 psychotic disorder, and no more than one continuous month of antipsychotic treatment prior to assessment. Controls, with no past or current psychotic disorder, were individually-matched to cases by 5-year age group, sex and neighbourhood. Cases reported higher lifetime and frequent cannabis use than controls in each setting. In Trinidad, cannabis use was associated with increased odds of psychotic disorder: lifetime cannabis use (adj. OR 1.58, 95% CI 0.99-2.53); frequent cannabis use (adj. OR 1.99, 95% CI 1.10-3.60); high ASSIST score (adj. OR 4.70, 95% CI 1.77-12.47), early age of first use (adj. OR 1.83, 95% CI 1.03-3.27). Cannabis use in the other two settings was too rare to examine associations. In line with previous studies, we found associations between cannabis use and the occurrence and age of onset of psychoses in Trinidad. These findings have implications for strategies for prevention of psychosis and for the movement in the Caribbean towards decriminalization of cannabis use.

Dr Joni Lee Pow is a psychologist and research coordinator for the Trinidad site of the International Programme of Research on Psychotic Disorders (INTREPID II) and a psychology instructor at the University of the West Indies, St Augustine Campus. She was recently awarded an Early Career Researcher Award from Schizophrenia International Research Society in April 2022.

PRESENTATION 3

Topic: Help-seeking and care pathways of people with psychoses

Author: Vijaya Raghavan, Schizophrenia Research Foundation, Chennai, India

This presentation will report some initial findings on help-seeking patterns

PRESENTATION 4

Topic: Physical health comorbidities with untreated psychosis

Author: Oye Gureje, University of Ibadan, Ibadan, Nigeria

This presentation will present findings on physical comorbidities among people with untreated psychosis

Symposium 4 - Psychological Intervention in Psychosis

PRESENTATION 1

Topic: Psychological interventions for Psychosis: current issues

Author: Frances Dark, Australia

There are several evidence based interventions for psychosis that are recommended in respected clinical practice guidelines. The research largely comes from developed countries. Research into the adaptation of these therapies in low- and middle-income countries is emerging. There is research into psychological interventions in all stages of psychosis from at risk/prodromal states to first episode psychosis and persistent and treatment resistant psychosis.

Refinement of the interventions has occurred to target predominant symptom domains rather than the full spectrum of the experience of psychosis for example predominantly positive symptoms or negative symptoms or depression. Psychological interventions are the first line intervention for the neurocognitive impairment of psychosis despite concerted efforts to develop pharmacological agents for this domain of psychosis. Generally psychological interventions are an adjunct to pharmacological interventions. The impact of COVID -19 as well as long standing issues of access and broad dissemination has led to a focus on flexible modes of delivery of psychological interventions. The evidence base for these adaptations is still developing. Psychological interventions are particularly important for functional recovery from psychosis and form key interventions in modern recovery orientated mental health rehabilitation.

Psychosis usually has a profound impact on an individual’s sense of self. It is generally accepted that psychotic illnesses currently termed schizophrenia are illnesses impacting on brain function. It follows that biological intervention such as effective pharmacotherapy and psychosocial interventions will be the mainstay of care. The current issues in psychological interventions for psychosis is how do we implement what we know works and ensure people with psychosis have access to the full “menu” of evidenced based psychological care to aid their recovery.

Frances Louise Dark is the Director of the Rehabilitation Metro South Addiction and Mental Health service Brisbane. She is also the Director of the Deafness and Mental Health service, Queensland and Associate Professor University of Queensland Medical School, Australia

She did her PhD in the year 2019 on “Cognitive Remediation and Social Cognition interaction”. She has published many articles in various peer reviewed journals.

PRESENTATION 2

Topic: Metacognitive Training In Schizophrenia

Author: Subhashini Gopal, Schizophrenia Research Foundation, India

Schizophrenia is the most disabling illness and it affects 1% of the world’s population. First line of treatment includes pharmacotherapy although the effectiveness of the same is coupled with adverse side effects. CBT is found to be an effective non pharmacological intervention for persons with schizophrenia. It yields small to medium effect size. CBT uses a confrontational approach while addressing the cognitive biases. On the other hand a non confrontational approach targeting the metacognitive dysfunctions in persons with schizophrenia called Metacognitive Training (MCT) has gained so much importance in the recent years. Metacognition is the high-level cognitive function that can be defined as any knowledge or cognitive process that refers to, monitors, or controls any aspect of cognition. Metacognitive dysfunction is the inability to make a complex sense of experience and integrate interpersonal information into a larger whole. Moritz and his colleagues have developed a new group treatment program entitled Metacognitive Training (MCT) for patients with schizophrenia. MCT seems to be a promising intervention for persons with psychosis and has different variants targeting depression, borderline personality, OCD, etc.,

The initial section of the talk would focus on introducing metacognition and the impact of metacognitive dysfunction in individuals with schizophrenia. The next section would focus on the evidence base for MCT along with SCARF experience in adapting MCT for use in patients diagnosed as schizophrenia with comorbid depressive symptoms.

Brief CV:

Dr.Subhashini Gopal

Coordinator – Psychological services,

Schizophrenia Research Foundation (India)

Subhashini Gopal currently holds the position as Senior Coordinator – Psychological services at SCARF (India). She also coordinates the one-year diploma course on "Mental Health Care and Counselling" and holds the position as Member Secretary of the SCARF ethics committee. She has recently completed her PHD and her thesis is on Metacognitive Training. She has expertise in providing psychotherapies and psycho social interventions for persons with serious mental illness. Apart from the regular clinical work, she has been actively involved in research, teaching, spreading awareness about mental health to various groups like students, teachers and the general public. Involved in training volunteers and various self help groups on Mental health. Has published various research articles in national and international journals, co-authored chapters with regard to serious mental illness in few psychiatry textbooks.

PRESENTATION 3

Title of talk: Compensatory Cognitive training for schizophrenia- evidence base and experience from India

Author: Lakshmi Venkatraman, Schizophrenia Research Foundation, India

Cognitive deficits are a core feature of schizophrenia with significant impact on functioning and quality of life. Existing biological interventions are not sufficient to improve the cognitive symptoms. Add on cognitive remediation strategies can be used to improve cognitive symptoms. Research evidence indicates that cognitive strategies have a positive impact on psychosocial functioning and quality of life. Whilst various cognitive interventions are available, very few are adapted to suit local population in India. This talk will focus on the evidence base for compensatory cognitive training for schizophrenia and about our experience of adapting this intervention and implementing it in Chennai.

Name: Dr. Lakshmi Venkatraman

Qualifications: MBBS, DPM, MRCPsych

Current Employment: Consultant Psychiatrist, SCARF India

Areas of interest : Psychosocial interventions for persons with severe mental illness

Symposium 5 - Youth and Mental Health

PRESENTATION 1

Topic: Working with vulnerable children in the Juvenile Justice settings – The JAMS approach

Author: Dr. Shiva Prakash Srinivasan, Schizophrenia Research Foundation, India

Abstract: The care of vulnerable children who are unable to be cared for by their families or those children who have allegedly engaged in criminal activities falls under the purview of the Juvenile Justice System (JJS) in India. These children are burdened with multiple vulnerabilities which increase their risk of developing mental health issues. There is very little knowledge about the health and well-being of youth in these Child Care Institutions.

The Juveniles Accessing Mental health Services (JAMS) project is a unique intervention that applies a multipronged approach to mental health care for children in the JJS. The project consists of a multi-level, multi-faceted co-developed intervention that is directed toward enhancing the mental health knowledge of all the stakeholders involved in the care of these children, creating of youth safe spaces for children to learn and practice skills related to well-being and development of locally sustainable pathways of care and referral for appropriate mental health services. We share through this presentation the learnings, challenges, and successes of the process of creation of such services for this extremely vulnerable group of individuals.

Dr. Shiva Prakash is a consultant psychiatrist in the Department of Youth Mental Health at SCARF (I). He has finished his master’s in Psychiatry from AIIMS, New Delhi, and then trained in the US at SUNY at Buffalo and pursued specialist training in Child and Adolescent Psychiatry from the Johns Hopkins Hospital in Baltimore. He started working at SCARF initially in the early psychosis program and then moved on to develop clinical services for youth from the ages of 12-24 years at SCARF. He is actively involved in creating and testing systems to enhance the mental wellbeing of youth while empowering them to seek help for themselves and their peers. He is a Co-PI on a project funded by the Grand Challenges Canada, NIHR and another project across two countries funded by the Templeton World Charities Foundation in collaboration with citiesRISE. He is a proponent of youth safe spaces and actively works with the LGBTQIA+ communities.

PRESENTATION 2

Topic: Mental health interventions for young people in Chennai: A collaborative effort of citiesRISE, SCARF and Nalandaway

Author: M Suresh Kumar MD DPM MPH , Consultant Psychiatrist, Chennai

citiesRISE’s Mental Health Friendly City (MHFC) framework provides a pathway for city-based action across the inner, social, and environmental dimensions of young people’s mental health and well-being. In doing so, the framework’s elements lay the groundwork for improving individual and social functioning and scaling up of successfully integrated mental health interventions globally. The theory of change underlying the MHFC framework is based on the transformative potential of collaboration between young people, mental health professionals, system leaders, and other stakeholders as respected partners. citiesRISE’s city programs such as in Chennai serve as living labs for testing and scaling innovations toward more MHFCs. Subsequent to a rapid situation analysis carried out among young people recruited from colleges, communities and workplace settings, school-based interventions have been identified as a core aspect of the action to enhance mental health among youth in Chennai. SCARF in collaboration with citiesRISE conducted a cluster, parallel arm, single-blind, randomized controlled trial among students of four secondary schools. Delivery of mental health literacy curriculum alongside contact-based education through those with lived experiences of mental disorders has shown to be effective in bringing about a change in student’s attitudes towards mental health. However, no significant difference was observed in mental health knowledge and stigma. Based on our experience with primary and secondary schools we have proposed a whole school approach in consultation and collaboration with school management, teachers, parents and students. In next two years, we will implement the whole school approach in fifteen schools in Chennai through a collaborative effort between citiesRISE and Nalandaway and identify the resilient team members. The identified members will receive training and the objectives of the training for the resilient team members are: to introduce skills essential to engaging students in schools; to provide an introduction to mental health problems in students; to provide a framework for assessment of youth in schools; and, to create a referral pathway for youth. In addition, a randomised clinical trial to study the effectiveness of the curriculum on improving the mental health and wellbeing of youth recruited from schools and communities through developing the character strengths of gratitude, kindness and hope will be implemented during the next two years by a collaborative effort between citiesRISE and SCARF. College based interventions are also proposed to enhance mental health among students from two selected colleges in Chennai by SCARF and citiesRISE.

● Hubert H Humphrey Fellow in Substance Use, Johns Hopkins University, USA

● Extensive involvement in the field of mental health and substance use as a teacher, trainer, researcher and international consultant

● Working with several International and UN organizations (UNODC, WHO, UNAIDS) on substance use and related issues

● Assisted substance use disorder prevention/treatment interventions in several countries such as Afghanistan, Bangladesh, Bhutan, China, Iran, Kazakhstan, Lao PDR, Malaysia, Maldives, Mauritius, Myanmar, Nepal, Sri Lanka, Thailand and Vietnam

● Published articles in several international, peer reviewed journals; is on the editorial board of International Journal on Drug Policy

PRESENTATION 3

Topic: MindKind study: Lessons learned in co-designing a global mental health databank with youth in India

Author: Jasmine Kalha, Centre for Mental Health Law & Policy, India

Growing evidence points to the importance of co-designing research and interventions with communities we want to reach out to, in this case, youth. The two-way engagement for co-producing research with youth has various benefits, including empowerment and increased feasibility. While there has been an emphasis in mental health research on involving youth, people with lived experience, there exists a known-do gap on practical recommendations for researchers to build a meaningful engagement.

To address some of the gaps, we use the MindKind study as an example to discuss how to centre the voices of young people, especially those with lived experience of mental health challenges, by grounding our work in a participatory research approach whereby we seek to involve youth stakeholders as equal partners. MindKind was designed to understand the feasibility of developing a global mental health databank of digital data collected from young adults using smartphones. The project was run in collaboration with partners in the United States, United Kingdom, South Africa and India funded by the Wellcome Trust, UK.

MindKind project governance was driven by the desire to foreground stakeholder voices while co-designing, both those of young people and researchers/users of the eventual databank. We will highlight key steps taken by the site team to promote youth engagement, and share challenges, facilitators and lessons learned in co-designing the study in the background of a pandemic.

Jasmine is a Research Fellow & Programme Manager at the Centre for Mental Health Law & Policy, Indian Law Society. She is trained in social work from a gender perspective from Tata Institute of Social Sciences, Mumbai, and has an MPhil in Sociology from the Delhi School of Economics, Delhi University. She has worked on implementing innovative research interventions at scale for mental health and human rights in low resource settings since 2014. She co-leads the scale-up and implementation of Atmiyata, a large rural community-led intervention to reduce mental health care and social care gap. She co-leads the UPSIDES (peer support) project in Gujarat, and is involved with the capacity building suicide prevention initiatives, and works on youth mental health. She has also co-led projects on recovery and mental health in India, and has experience in health systems reform through the WHO’s QualityRights framework.

PRESENTATION 4

Topic: Outlive – Engaging & Enabling Urban Youth for Suicide Prevention

Author: Arjun Kapoor, Centre for Mental Health Law & Policy, Indian Law Society (Pune)

Suicide is the single leading cause of death in young people aged 15-29 years (1st among women and 2nd among men) in India. Youth suicides are the result of a unique interaction of different social, economic, cultural, and health-related factors which impact young people in their specific contexts. Currently, there are few suicide prevention programmes in India which specifically address the needs of a diverse youth population. Outlive is a four-year (2020-2024) suicide prevention programme jointly implemented by the Centre for Mental Health Law & Policy, Indian Law Society (ILS), Sangath and Quicksand Design Studio. Outlive addresses urban youth suicide in India by engaging young people aged 18-24 with experiences related to suicide or self-harm, distress or mental health problems and belonging to marginalised communities in Delhi, Mumbai and Pune. Outlive is working with young people to co-design and implement the following activities:

  • developing a national public engagement campaign to increase awareness and tackle stigma around suicide;
  • training a network of youth peer support volunteers to provide emotional support through a chat-based mobile app to youth who are in distress or having thoughts of ending their life;
  • training a group of 10 youth advocates to engage with policy makers and and work towards systemic change for youth suicide prevention.

Outlive has been conceptualised with the understanding that a “one size fits all” approach does not apply to suicide prevention. Inter-sectoral, coordinated, and collaborative actions are needed to target the range of risk factors impacting India’s youth today. The talk will address Outlive’s approach to engage young people for tackling stigma; increase access to peer support; and build capacities of youth advocates to engage with policy makers for systemic changes.

Arjun Kapoor is Programme Manager and Research Fellow at the Centre for Mental Health Law & Policy. He is a lawyer and psychologist with experience in human rights, access to justice and mental health in South Asia. Previously, he was appointed as Law Clerk to the Supreme Court of India and also developed socio-legal interventions with community lawyers and paralegals on access to justice in Gujarat, India. Currently, Arjun works at the intersection of law & policy reform, mental health and suicide prevention in India. He co-leads the India Mental Health Observatory and provides capacity building and technical support to a range of stakeholders for implementation of the Mental Healthcare Act, 2017 and National Mental Health Policy, 2014. He also co-leads project Outlive - a suicide prevention programme which addresses urban youth suicides and project ENGAGE which focuses on adolescent suicide prevention in rural settings.

Symposium 6 - Ethics in contemporary Mental Health

PRESENTATION 1

Topic: Ethical issues in contemporary community mental health care services

Author: Dr. Anant Bhan, India

Affiliation: Researcher, Global Health, Bioethics, Mental Health & Health Policy Mentor, Sangath (Bhopal Hub).

Abstract: Based on work being done by the presenter, collaborators and colleagues, this presentation will speak to the ethical issues in evidence generation, as well as delivery of community mental health care services. This work will draw from the challenges, barriers, and complexities of navigating working with the health system, and also delve into the innovative solutions which have been used to respond which have used an ethics lens. This presentation will also highlight challenges emerging for community mental health teams which are working with specific populations such as school students, adolescents and young people in terms of ethical issues around consent, gatekeeping, as well as protecting autonomy.

The importance of co-developing interventions with individuals with lived experience and working on strategies to develop capacity among relevant stakeholders such as media professionals, persons with lived experience including caregivers, and policymakers will be emphasized. This can help ensure sensitive reporting on mental health, make persons with lived experience better aware of their rights and support them in advocating for quality mental health care, as well as bring more policy attention to mainstreaming mental health in health systems.

The role for public engagement and the need to tackle stigma and discrimination around mental health as a key public health ethics issue will be covered. With more focus on use of digital health platforms and tele-mental health delivery, the need to reinforce ethical norms and ensure privacy, confidentiality, and data security will also be highlighted. The presentation will also delve into issues around professionalism, cultural competence, and the need for inclusive care which responds to the health needs of marginalized communities, such as LGBTQIA+ individuals.

Anant Bhan is trained as a medical doctor with a masters' degree in bioethics from the University of Toronto. Anant is an Adjunct Visiting Professor, Yenepoya (deemed to be University), India. Anant is Immediate Past President, International Association of Bioethics. His work is focused on ethics and equity in health, mental health, digital health, public health ethics, research ethics, community engagement, ethics of innovative technologies and ethics training for professionals

Anant has been a resource person for trainings in global health, research methodology, research ethics and public health ethics, and also serves as guest faculty in various educational institutions in India and abroad. He has been a reviewer for multiple journals, conference scientific committees and international grant competitions.

He serves as the Bhopal hub lead and mentor for (Sangath /Bhopal), and is the PI/site-PI for the various projects conducted at the hub, funded by both international and national funders.

Linkedin: https://in.linkedin.com/in/anant-bhan-53233b11

Twitter: @AnantBhan

PRESENTATION 2

Topic: "Human rights approach to mental health:India’s Mental Healthcare Act and beyond"

Author: Amar Jesani ,India Co-founder, Forum for Medical Ethics Society (FMES)

Amar Jesani is an independent researcher and teacher in bioethics and public health. He is a co-founder of the Forum for Medical Ethics Society and its journal, Indian Journal of Medical Ethics (www.ijme.in), published since 1993. He is its editor since 2012. He is also a co-founder of Anusandhan Trust (retired in 2013) and its institutions, CEHAT (Mumbai) & SATHI (Pune). He is a Visiting Professor at Yenepoya University, Mangalore (since 2011), the Centre for Biomedical Ethics and Culture, Karachi (since 2010) and Kenya Medical Research Institute (KEMRI), Nairobi (since 2017).

PRESENTATION 3

Author: Russel D’Souza, Australia

Topic: Ethical Aspects in Mental Health Care


Symposium 7 - Institutional care and chronic mental illness

Author: Mohan Isaac – Chair , University of Western Australia

Abstract: Institutional care and chronic mental illness: Foreword

Mohan Isaac is Clinical Professor of Psychiatry at the Faculty of Medical and Health Sciences, The University of Western Australia, Perth, Australia and Consultant Psychiatrist, currently in charge of the “Early Interventions in Psychosis” (EIP) Team at Fremantle Hospital, Fremantle, Australia. He was formerly Professor and Head of the oldest and largest academic Department of Psychiatry in India at the National Institute of Mental Health and Neurosciences (NIMHANS) in Bangalore, where he is currently a Visiting Professor. During more than 30 years of his academic and clinical work in India, Mohan was actively involved in the development and implementation of India’s National Mental Health Programme (NMHP).

His research interests include delivery of mental health services in low-income countries. He is presently involved in a programme for “Capacity building for mental health care services, training and research in low- and middle-income Asian countries”.

Mohan has assisted the World Health Organization (WHO) in various capacities in numerous locations and on numerous occasions, including a stint at the headquarters of WHO in Geneva for about three years. Mohan has also assisted various other International Organizations such as the United Nations Relief and Works Agency for Palestinian Refugees (UNRWA), the Asian Development Bank (ADB) Manila, United Mission to Nepal (UMN) Kathmandu, the Royal Netherlands Embassy in India, New Delhi etc., on matters related to mental health.

PRESENTATION 1

Author: Ajit Bhide

PRESENTATION 2

Author: Poorna Chandrika

Topic: Institutionalization of the chronic mentally ill; Government Perspectives

Abstract: The chronic mentally ill are defined as those persons whose emotional or behavioral functioning is so impaired to interfere grossly with their capacity to remain in the community without supportive treatment or services of a long term or indefinite duration, eventually leading to institutionalization.

Government policies for the chronically mentally ill patients, started with the development of the National Mental Health Programme in 1982, where the objective was to ensure the availability and accessibility of minimum mental health care for all, particularly to the most vulnerable and underprivileged sections of the population. And around the same time, during the implementation of the Mental Health Act 1987, humane treatment of chronically mentally ill persons “No mentally ill person shall be subjected to any indignity or cruelty during treatment ‘’ was emphasized. The National Mental Health Program (1982) and Mental Health Act (1987) provided the implicit policy directions for community and institutional mental health care in India, during the early 2000s.

National Human Rights Commission has carved out 2 systematic, intensive and critical examination of the mental hospitals in 1998 & 2008.In pursuance of the directions given by the apex court, NHRC has adopted a totally, open, transparent and monitoring pace and progress of activity in the hospitals keeping the human rights dimension uppermost in view.

The World health Report 2001, described the changes over the last two centuries where the shift of care has moved from institutions to the community as follows; Over the past half century, the model for mental health care has changed from institutionalization of individuals suffering from mental disorders to a community care approach backed by the availability of beds in general hospitals for acute cases. This change is based both on respect for the human rights of individuals with mental disorders and on the use of updated interventions and techniques.

Based on this, one of the strategies of NMHP in the tenth five year plan ( 2002 – 2007) was streamlining and modernization of the mental hospitals to transform them from the custodial mode to tertiary care centers of excellence with a dynamic social orientation for providing leadership, research and development in the field of community mental health. And during the eleventh five year plan(2007 – 2013), modernization of state run mental hospitals were done.

India’s Mental Health Policy group was formed in May 2011. The National mental health policy of India entitled “New Pathways New Hope “was published by the Government of India, in October 2014 And National Mental Health Policy stated that all inpatient facilities must be linked to community care to support persons who are discharged ( as indicated by the principle of continuing care ), or who are being managed in the community. This policy recognizes a spectrum of need, ranging from appropriately transitioned community care for a majority to long term institutional care for a small number. As such, the need is of developing multiplicity of care models that maybe seamlessly integrated with each other In continuation with the National Mental Health Policy 2014, on homelessness, Mental Health Care Act 2017 has brought a list of rights for people in the institutions with chronic mental illnesses. Section 19 details on the right to community living and makes it mandatory for the government to ensure the reintegration of people with chronic mental illnesses to his / her family home. The MHCA emphasizes a shift from institutionalization to community-based treatment and care. This means any person can be admitted to a mental health establishment as a last resort and as the least restrictive option if they meet the relevant criteria for admissions. As far as possible, community based mental health treatment and care options are to be provided to persons seeking those services.

Government of TamilNadu‘s state policy framed in February 2022, to address the needs of homeless persons with mental health issues, aims to establish a framework of perspectives and strategies to guide public investments and initiatives that preclude pathways into homelessnes, offer culturally resonant care in hospitals and dignified exit options from institutionalized settings, where possible and needed

The current policy of strengthening and upgrading, existing mental hospitals to centers of excellence along with provisions for strengthening of the mental health training being incorporated into the mental health program will provide the essential blocks for successful community-based services as envisioned by the National Mental Health Programme. However, periodic reappraisal of the goals, set achievement thus far and course corrections is essential and the mechanism ensuring this must be built into the program to prevent skewed development.

Community care implies the development of a wide range of services within local settings. De institutionalization is a complex process leading to the implementation of a solid network of community alternatives. Closing mental hospitals without community alternatives is as dangerous as creating community alternatives without closing mental hospitals. The community alternative model needs to be integrated with the infrastructure of the mental hospital. There is a need for mental hospitals to be integrated with an inclusion model. A sound deinstitutionalization has three essential components, namely

1) Prevention of inappropriate mental hospital admissions through the provision of community facilities
2) discharge to the community of long-term institutional patients who have received adequate preparation
3) establishment of community support systems for non-institutionalized patients.

PRESENTATION 3

Author: Tasneem Raja

Topic: Evidence based psychiatric hospital reform in the contest of Low Income and Middle Income countries- Findings of the SITAR trial.

Background: Low- and Middle-Income countries (LMICs) like India have large treatment gaps in mental health care. People with Severe Mental Disorders (SMD) face impediments to their clinical and functional recovery and have many unmet needs. The infrastructure and standards of care are poor in colonial-period mental hospitals, with no clear pathways to discharge and reintegration into the community. Despite concerns over quality of care and human rights violations these hospitals continue to provide the majority of mental health care for SMD in most LMICs. LMICs need a pragmatic approach to implementing mental health, with evidence-based reforms of psychiatric institutions to meet the needs of service users today.

Objective: The aim of the research was to examine the impact of hospital reform on outcomes for long-stay patients. We compared whether larger structural and process reform of a mental hospital brings about change in patient outcomes or a case management based individual service package is needed to effectively translate larger hospital reform into discernible difference in outcomes for long-stay patients often living in closed hospital wards.

Methods: This research study comprised three interlinked phases in a mixed methods design. In phase one, a systematic literature review was undertaken to examine evidence on psychiatric hospital reform in LMICs. Phase two comprised a pragmatic randomised clinical trial, called Structured Individualised inTervention And Recovery (SITAR), to study the impact of psychiatric hospital reform. The trial also aimed to study the modality in which reform would reach the service user. SITAR used Need-Based Intensive Case Management (NB-ICM) within the context of the hospital. ’Patients’ experiences of reform were also studied using qualitative methodology. In the third phase, an economic evaluation was undertaken to study the affordability of psychiatric hospital reform as a viable care pathway for very vulnerable people who are long-stay in psychiatric hospitals.

Results: Systematic psychiatric hospital reform has a positive impact on outcomes of disability, symptom, social and occupational functioning, and quality of life. NB-ICM has an important role to play in terms of patient’s lived experience of reformed care, it however, did not show a significant impact on measured outcomes in the time period of the study.

Conclusion: Systematic reform of psychiatric hospitals appears feasible and affordable and might be an important alternative to the limited care pathways for people with Severe Mental Disorders who have high care needs in LMICs.

Symposium 8 - Peer support in mental health systems in LMIC

PRESENTATION 1

Topic: Addressing the obstacles to move towards integration of peer support into mental health systems in LMICs

Author: Charlene Sunkel, Global Mental Health Peer Network

Evidence is clear about the multiple benefits of peer support work as a peer-led service in mental health care. These benefits goes beyond just the individual gaining from giving and received peer support, but peer support work has the ability to strengthen mental health care systems and ultimately reducing high costs of specialised care. While HICs have advanced in creating peer support work as a speciality in mental health care models, LMICs however still have not yet recognised peer support work as a valuable resource. The obstacles may be attributed to stigma and discrimination, paternalistic approaches of care, and exclusion of people with lived experience in service development and policy review. I will be discussing how peer support work could potentially be an ideal solution to much of the challenges in the mental health care system, specifically in LMICs.

Ms Sunkel is the Founder/ CEO of the Global Mental Health Peer Network (www.gmhpn.org). She is a global mental health advocate with lived experience with schizophrenia. She has published internationally on issues related to mental health and human rights, stigma and the needs of people with mental illness in low- and middle-income countries. Ms Sunkel has been involved in provided technical assistance to national and international mental health related policies, reports and documents. She serves on a number of international boards and committees, and received a number of national and international awards for her work.

PRESENTATION 2

Topic: The Role of Peer Support Communities in Supporting Mental health - the Bipolarindia model

Author: Vijay Nallawala, Bipolarindia, Mumbai

The gap in awareness around mental health and stigma around it is perhaps much greater in LMIC nations like India than the developed North. A Peer Support Community fills in a vital gap by being a safe space for conversations to happen, for PLMIs to feel less isolated and for psychoeducation to be facilitated. These communities also facilitate sharing of insights and knowledge from lived experience among peers. These range from support in terms of how to overcome day to day challenges to tips about a holistic health approach to recovery.

BipolarIndia is just such a community for peers and led by peers that initially began its journey as purely a web-based resource in 2013 and later expanded to a hybrid model with meetings that took place both offline and virtually. From originally being focused exclusively on people living with bipolar disorder, it has become more inclusive now towards persons with any mental health diagnosis. There is evidence that such communities led by lived experience ‘experts’, can help in a person’s recovery from chronic and serious mental health conditions. In the Indian context, families are a support system by themselves and are often the most neglected part of the system.

Recognising this, family carers are a vital part of our peer community. Beyond psychoeducation, members also get to learn about their rights under various Acts such as the MHCA2017 and RPWDA2016. An initiative focused on livelihood opportunities and inclusion at workplaces has recently been launched.

I have been an entrepreneur with an experience spanning over three decades. Am now fully involved in leading and managing our organisation, Bipolarindia, a peer community initiative. A writer at heart, my communication and organisational skills have helped me forge a well-knit community.

Education: Commerce Graduate (1982) in Financial Accountancy: Bombay University

PRESENTATION 3

Topic: More than a fad: Embedding and sustaining peer support initiatives within an early intervention service.

Author: Ang Suying, Institute of Mental Health, Singapore

The Early Psychosis Intervention Programme (Singapore) has developed structured peer involvement under an initiative known as EPIP Peers4Rs (Remembering Resilience, Respect & Recovery) since 2010. Peer delivered services are undertaken by those with lived experience of mental health issues or their family members with lived experiencing of caregiving. During the early years, efforts were channelled to developing opportunities to increase user involvement and user representation within EPIP services. Processes were also looked into building a continuous pool of contributors and promoting their sense of efficacy in the work they do through training. Peer support specialists who are formally employed and recognised as part of EPIP’s multi-disciplinary team were eventually incorporated into the team. Opportunities for peer empowerment were further created through adaptation of a tiered involvement with apprentice and volunteer roles. As the peer support initiatives expanded, Peers4Rs initiative revamped its objectives towards the promotion of recovery-oriented ethos to the department, emphasising on values of respect and empowerment that underpin our services. While the initial efforts were borne from a “top-down” approach, a gradual shift towards shared responsibility and ownership took place across multi-disciplinary team members and the peers. A description of the continuous efforts made to facilitate the organisational readiness and safeguard authentic and meaningful peer involvement will be expanded.

Suying is a Principal Case Manager and Deputy Head of EPIP. Her background as a social worker has influenced her to be a change agent through the empowerment of service users. As a case manager in the Early Psychosis Intervention Programme, she works with young persons aged 12 – 40 years old who experience psychosis, supporting them and their caregivers. She also provides clinical supervision and take an administrative lead to the team of case managers in EPIP. Her interest lies in the provision of recovery-oriented practices through user involvement and co-creation. She had developed a peer support programme in EPIP; creating opportunities for peer connections and sustaining the efficacy of the peer support specialists. She believes in the value and meaning of growth in both people and plants.

Symposium 9 - Pharmacological Management in Psychosis

PRESENTATION 1

Topic: Pharmacological Management of Psychosis - From Chlorpromazine to Cariprazine…

Author: M Karthikeyan MD, (Psychiatry)

Affiliation: SENIOR CONSULTANT and HOD, Department of Psychiatry Meenakshi Mission Hospital and Research centre,Madurai since 2002.

The Pharmacotherapy for Schizophrenia spanning across a few decades has spawned a wide gamut of molecules - most of which have withered away and quite a few molecules have withstood the tests of time and a number of molecules have arrived with much fanfare and hopes only to belie our expectations and whimpering away into the forgotten oblivions of the history of psychopharmacology.

Effectiveness and Tolerability and ease of administration and enhanced drug adherence are some of the factors that have influenced the longevity of the molecules that have survived as effective treatment options for schizophrenia.

The choice of antipsychotics among them have mostly been influenced by therapist’s perceptions of clinical effectiveness, the availability of research evidence, the client preference and peer psychiatrist influence and personal clinical experiences. Inspite of increased therapeutic options with enhanced effectiveness, a significant number of non responders to treatment and decreased adherence due to poor tolerability are the clinical problems that remain unresolved and as psychopharmacology advances in multiple frontiers - future molecules could provide better solace to clients afflicted with psychotic disorders.

Working as - SENIOR CONSULTANT and HOD, Department of Psychiatry Meenakshi Mission Hospital and Research centre,Madurai since 2002.

Formerly,

Assistant Professor Of Psychiatry,Madurai Medical College and Associate Professor Of Psychiatry, Tirunelveli Medical College

Educational details-

MBBS- 1992-98 Madurai Medical CollegeMD ( Psychiatry )- 1999-2002 IMH-INSTITUTE OF MENTAL HEALTH,Kilpauk,Chennai

PRESENTATION 2

Topic: Pharmacological management of Negative & Cognitive symptoms- Beyond Dopamine

Author: Dr. Rishikesh V. Behere, DBT Wellcome India Alliance Fellow and Associate Consultant Psychiatry, KEM Hospital Research Center, Pune India.

Schizophrenia is understood by its symptom domains of positive, negative and cognitive symptom domains. Pharmacological management based on dopaminergic modulation focusses on amelioration of positive symptoms. However, the negative and cognitive symptoms largely contribute to disability in schizophrenia. Rehabilitative strategies are the mainstay of management of these symptom domains. Our understanding of schizophrenia beyond dopamine opens newer avenues to target negative and positive symptom domains by novel pharmacological strategies. This talks reviews our understanding of molecular mechanisms beyond dopamine in schizophrenia and its clinical applications.

● MD Psychiatry NIMHANS 2005

● Former Associate Professor, Kasturba Medical College, MAHE, Manipal

● India Alliance Fellow since 2017

● Over 60 Indexed publications, 5 – funded projects as PI

PRESENTATION 3

Topic: “Managing psychosis in the elderly – The challenges & options”

Author: Sridhar Vaitheswaran,MD, MRCPsych, Assistant Director & Consultant Psychiatrist, Dementia Care in SCARF (DEMCARES), Schizophrenia Research Foundation (India) – SCARF, Chennai, India.

I am a clinician with an interest in applied research in dementia in low and middle-income country settings. I run a clinic and an inpatient unit for the elderly with mental illnesses including dementia in SCARF hospital, Chennai.

Current research: implementing cognitive stimulation therapy for dementia in India, implementing psycho-social interventions for dementia in rural communities in India, adapting interventions for caregivers of persons with dementia in India, testing the feasibility of using hybrid-face robots in engaging persons with dementia in India.

Symposium 10 - Women and mental health

PRESENTATION 1

Topic: Sexual dimorphism in schizophrenia: How much can neurobiology explain this?

Author: Rakshathi Basavaraju, India

Abstract: Schizophrenia is a major psychiatric disorder whose characteristics differ between the two sexes. Women are more likely to have a later and bimodal distribution of age of onset, better premorbid functioning, fewer negative and cognitive symptoms, higher affective symptoms, better remission and lower relapse rates, and lesser disability compared to men. These differences could be explained by sex-specific biological effects or gender-specific psychosocial factors. Though the biology driving the sexual dimorphism of schizophrenia is largely understudied, there are myriad factors ranging from the phase of fetal development to menopause.

Neurodevelopmentally, greater placental susceptibility and a slower rate of brain maturation in males compared to females exposes the male brain to an extended critical period of prenatal vulnerability resulting in a higher preponderance of pre and perinatal complications in males.There are sex-specific genetic effects in early brain development that can be modulated by gonadal steroids later during puberty. A greater bihemispheric representation of functions in females in contrast to a more pronounced lateralization in males lends credence to the conceptualization of schizophrenia as a defect in cerebral lateralization. Gross brain morphology shows that either the normal neuroanatomical sexual dimorphism is exaggerated or reversed in schizophrenia. Estrogen hypothesis is the most robust theory explaining the sex differences given its anti-psychotic and neuroprotective effects through modulation of D2, 5HT and GABA receptors. Studying the basis of sexual dimorphism yields insights into the disease pathogenesis and leads the path for discovery of novel treatments like adjunctive estrogen and SERMs for schizophrenia.

I am a psychiatrist who received my MD from NIMHANS in 2015. I am interested in studying the neurobiology underlying major symptom domains of psychosis that are persistent, treatmentresistant and disabling. I have extensive training and experience in transcranial magnetic stimulation, structural and resting state functional neuroimaging, and advanced biostatistics obtained from NIMHANS; Beth Israel Deaconess Medical Center, Harvard Medical School, Boston; and, Columbia University Medical Center, New York, USA. I am interested in understanding the pathophysiology of and developing novel treatments for negative symptoms of schizophrenia. I am the principal investigator of two research grants, the latest one being an RCT of an optimized brain stimulation technique for treatment of negative symptoms. I have conducted research and published on the human mirror neuron system, social cognitive deficits in schizophrenia and mania, neuromodulation for negative symptoms, neuroimaging (structural MRI/MRS) correlates of behavioural phenotypes in dementias, PTSD, and psychotic prodromal states.


PRESENTATION 2

Topic: Parenting in women with schizophrenia

Author: Dr. Sonia Shenoy, Kasturba medical college, Manipal.

The majority of women with severe mental illness are mothers. Motherhood can contribute to giving meaning to their lives. However, women with schizophrenia have to deal with the stressful dual demands of poor mental health and parenting.

They are perceived to be violent and harsh by society but in reality, they are more likely to struggle with difficulties in interacting with children, have decreased ability to read children’s cues, have laxness style of parenting and be self-absorbed or intrusive depending on the predominant type of psychotic symptoms. However, it does not necessarily exclude the possibility of developing a positive attachment relationship.

Women with schizophrenia also face challenges in motherhood which include stigma, social adversity, fluctuating nature of symptoms, side effects (sedation, passivity),cognitive deficits including social cognition deficits, interpersonal problems, poor social support, intimate partner violence and separation which can lead to losing the custody of their children.

A large register based Finnish study concluded that maternal Schizophrenia is a strong risk factor for placement of children in an out-of-home care. In more collestivistic cultures like India, often multiple family members play a significant role in child-rearing, which can help share the load of parenting.

The session will focus on the various challenges in motherhood faced by women with schizophrenia, the impact of parenting on the outcomes of offspring and the different need-based interventions which can help in empowering them in their journey of motherhood.

Dr.Sonia Shenoy currently working as an Associate professor at Kasturba medical college, Manipal. She is also an investigator at the multicentric- (NIMHANS/CIP/Manipal) funded initiative –Clinical research center for neuromodulation in Psychiatry, supported by DBT Wellcome Trust Alliance.

Sonia received my MD from NIMHANS in 2014 and post-doctoral fellowship in clinical neuroscience and therapeutics of Schizophrenia from NIMHANS in 2015.

Her areas of interest include Schizophrenia, perinatal psychiatry and neuromodulation (primarily tDCS). She has published original research in parenting and facial emotion recognition deficits (FERD) in women with schizophrenia, first ever application of tDCS in a pregnant woman with schizophrenia, frequency and reasons for antipsychotic polypharmacy in schizophrenia, neural correlates of effect of add-on tDCS for schizophrenia, effect of tDCS on corollary discharge in Schizophrenia and FERD in bipolar disorder. She have also developed and validated a tool called KIDDIE-TRENDS specifically to assess FERD in patients with Schizophrenia who are parents to figure out the challenges in recognizing the facial emotions of children and its effect on parenting.

PRESENTATION 3

Author: Harish Thippeswamy


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