Narsimha Pinninti

Mental health service provision in low and middle income countries

This article discusses the provision of mental health services in low- and middle-income countries (LMICs) with a view to understanding the cultural dynamics–how the challenges they pose can be addressed and the opportunities harnessed in specific cultural contexts. The article highlights the need for prioritisation of mental health services by incorporating local population and cultural needs. This can be achieved only through political will and strengthened legislation, improved resource allocation and strategic organisation, integrated packages of care underpinned by professional communication and training, and involvement of patients, informal carers, and the wider community in a therapeutic capacity.

Yoga and Mindfulness-Based Cognitive Therapy for Psychosis ( Y - MBCT p © ): A Pilot Study on Its Efficacy as Brief Therapy

Yoga and Mindfulness Based Cognitive Therapy for Psychosis (Y-MBCTp©) is a newer evidence-based translational mindfulness therapy designed by Pradhan for stress management and various psychiatric disorders. Drs Pradhan and Pinninti have adapted it as a brief therapy for psychotic disorders and it can be used in an extended therapy format as well. Y-MBCT p

Multinational comparative cross-sectional survey of views of medical students about acceptable terminology and subgroups in schizophrenia

Aim The aim of this study was to inform thinking around the terminology for ‘schizophrenia’ in different countries. Objectives The objective of this study was to investigate: (1) whether medical students view alternative terminology (psychosis subgroups), derived from vulnerability-stress models of schizophrenia, as acceptable and less stigmatising than the term schizophrenia; (2) if there are differences in attitudes to the different terminology across countries with different cultures and (3) whether clinical training has an impact in reducing stigma. Design This is a cross-sectional survey that examined the attitudes of medical students towards schizophrenia and the alternative subgroups. Setting The study was conducted across eight sites: (1) University of Southampton, UK; (2) All India Institute of Medical Science, India; (3) Rowan University, USA; (4) Peshawar Medical College, Pakistan; (5) Capital Medical University, China; (6) College of Medicine and Medical sciences, Bahrain; (7) Queens University, Kingston, Canada and (8) University of Cape Town, South Africa. Method This study extended an initial pilot conducted by the Royal College of Psychiatrists on the term schizophrenia and psychosis subgroups to assess whether the subgroup terminology might have an effect on the attitudes of a convenience sample of medical students from eight different countries and potentially play a role in reducing stigmatisation. Results 1873 medical students completed a questionnaire recording their attitudes to schizophrenia and the psychosis subgroups. A reduction in negative perceptions were found for the psychosis subgroups, especially for the stress sensitivity psychosis and anxiety psychosis subgroups. Negative perceptions were found for drug-related psychosis. Participants who had undergone clinical training had overall positive attitudes. Differences across different countries were found. Conclusion The attitudes towards psychosis subgroups used in this study have shown mixed results and variation across countries. Further research is warranted to investigate acceptability of terminology. Methods of reducing stigma are discussed in line with the findings. Ethics The study received ethical approval from ERGO (Ethics and Research Governance Online; ID: 15972) and subsequently from the ethics committee at each site.

Brief Interventions for Psychosis: Overview and Future Directions

Psychosis (etymology: Gk. psyche + osis, condition) as defined in the Merriam-Webster dictionary (http://www.merriam-webster.com/dictionary/psychosis) is a mental and behavioral disorder due to fundamental derangement of the mind (as in schizophrenia) and is characterized by defective or lost contact with reality especially as evidenced by delusions, hallucinations, and disorganized speech and behavior. This causes gross distortion or disorganization of a person’s mental capacity, affective response, and capacity to recognize reality, communicate, and relate to others to the degree of interfering with that person’s capacity to cope with the ordinary demands of everyday life. The word psychosis has become a part of the vocabulary of general population including the media and is extremely stigmatizing. For many in general public, psychosis is synonymous with schizophrenia and is associated with dangerousness and negative stereotypy, often leading to social distancing, discrimination, and even victimization (Diefenbach 1996; Wood et al. 2014). Societal stigma combined with self-stigma leads to diminished opportunities, demoralization, and impaired recovery process for individuals with schizophrenia and other psychotic illnesses (Corrigan and Wassel 2008; Horsfall et al. 2010). Also, mental health practice until very recently was guided by the belief that individuals with serious mental illnesses like psychosis do not recover. The course of their illness was either seen pessimistically, as deteriorative, or optimistically, as a maintenance course (Harding and Zahniser 1994). The pessimistic outlook goes hand in hand with biomedical conceptualization of psychosis that neglects environmental risk factors (Mizrahi 2015). While the biomedical hypothesis is a driver of pharmacological research and current practice, meta-analyses of first person accounts of mental illness show that there are a variety of opinions about the cause of psychosis. Different individuals view the cause of their condition as spiritual crisis, environmental cause, and political, biological, or specific trauma (Farkas 2007). Psychosis can be attributed to one or other medical illnesses (most importantly neurologic or endocrine), and determination of a cause-effect relationship between a medical illness and psychosis is not always easy. Importantly, the disconnect between the opinion of professionals and individuals extends to the focus of treatment. While professionals have been focused on symptom remission and reduction in hospitalization, people with psychosis are more focused on regaining life roles and improvement in quality of their life. In fact, a recent report of the state of mental health systems in the USA has concluded that mental health care in America fails a wide variety of individuals but particularly fails those with serious mental illnesses (IOM 2006) because it is “not oriented to the single most important goal of the people it serves, that of recovery” (The President’s New Freedom Commission on Mental Health 2003). An objective look at the outcomes for psychosis shows that contrary to prevailing professional opinion, there is evidence from several studies that a sizable proportion of individuals with psychotic disorders have good outcomes. For example, in a 15–25-year follow-up of individuals with psychotic disorders in 18 different countries, it has been revealed that the majority (56 %) showed recovery. A sixth of them were completely recovered to the point of not requiring any treatment (Harrison et al. 2001). In addition, people with serious mental illnesses have themselves published accounts of their own recovery as well as advocated for the development of recovery promoting services (Farkas 2007). All the above point to an urgent need for us in the profession of behavioral health to rethink how we conceptualize, label, and treat psychotic disorders. We need to look at our existing services, how they are delivered, and their focus to make them align with the goals of individuals who are suffering with these disorders, their families and communities supporting them.

Integrated Pathways of Care for Psychosis: An Overview

In this chapter the authors distinguish literature that diligently distinguishes between the psychotic experiences - normal versus pathological. They provide compelling information from many different sources that make the readers rethink and possibly challenge the long held (mis-)conception that psychotic symptoms as are always pathological and/or dangerous. Adapting from the concepts of evidenced-based integrated pathways that have been used successfully in stroke and cardiovascular illnesses, these authors make a case for integrated path-ways of care for psychosis which provides a standardized framework for good clinical practice that include but are not limited to reducing the wide variations and heterogeneity in care, providing timely access to interventions, and paving the way for achieving improved outcomes for individuals suffering from psychosis.

Policy Implications in Psychosis

In this book, we have thus far reviewed the current effective psychosocial interventions for psychosis adapted for a brief format at an individual or microlevel. The overarching theme has been providing these effective interventions within the context of enduring resource constraints and imperfect systems of care. Interventions at the microlevel are dependent on the agenda set by macrolevel policies, priorities, and practices. In this chapter, we describe the scenarios at a macrolevel, looking at systems of care; we examine the current limitations in the systems of care and suggest steps to address these limitations. We do recognize that the health-care systems of the USA, most European countries, and low- and middle-income countries (LAMI) differ significantly but share the same common goals of providing effective evidence-based interventions for most people in the most efficient way. The discussion will be initially global and relevant for all systems followed by more specific discussion about the different systems.