Sudhir K. Khandelwal

India mental health country profile

India, the second most populated country of the world with a population of 1.027 billion, is a country of contrasts. It is characterized as one of the worlds largest industrial nations, yet most of the negative characteristics of poor and developing countries define India too. The population is predominantly rural, and 36% of people still live below poverty line. There is a continuous migration of rural people into urban slums creating major health and economic problems. India is one of the pioneer countries in health services planning with a focus on primary health care. Improvement in the health status of the population has been one of the major thrust areas for social development programmes in the country. However, only a small percentage of the total annual budget is spent on health. Mental health is part of the general health services, and carries no separate budget. The National Mental Health Programme serves practically as the mental health policy. Recently, there was an eight-fold increase in budget allocation for the National Mental Health Programme for the Tenth Five-Year Plan (2002–2007). India is a multicultural traditional society where people visit religious and traditional healers for general and mental health related problems. However, wherever modern health services are available, people do come forward. India has a number of public policy and judicial enactments, which may impact on mental health. These have tried to address the issues of stigma attached to the mental illnesses and the rights of mentally ill people in society. A large number of epidemiological surveys done in India on mental disorders have demonstrated the prevalence of mental morbidity in rural and urban areas of the country; these rates are comparable to global rates. Although India is well placed as far as trained manpower in general health services is concerned, the mental health trained personnel are quite limited, and these are mostly based in urban areas. Considering this, development of mental health services has been linked with general health services and primary health care. Training opportunities for various kinds of mental health personnel are gradually increasing in various academic institutions in the country and recently, there has been a major initiative in the growth of private psychiatric services to fill a vacuum that the public mental health services have been slow to address. A number of non-governmental organizations have also initiated activities related to rehabilitation programmes, human rights of mentally ill people, and school mental health programmes. Despite all these efforts and progress, a lot has still to be done towards all aspects of mental health care in India in respect of training, research, and provision of clinical services to promote mental health in all sections of society.

Eating Disorders: an Indian Perspective

Anorexia nervosa and related eating disorders are rare in non-western cultures. In India the information regarding these disorders is very limited. The authors dsecribe five cases of young women who chiefly presented with refusal to eat, persistent vomiting, marked weight loss, amenorrhea and other somatic symptoms. They did not show overactivity or disturbances in body image seen characteristically in anorexia nervosa. Though finally diagnosed and treated as cases of eating disorder, they presented considerable difficulty in diagnosis. The paper discusses the reasons for the seeming rarity of anorexia nervosa in India and sociocultural reasons for its atypical presentation.

The International Consortium on Mental Health Policy and Services: objectives, design and project implementation

The concept of the burden of disease, introduced and estimated for a broad range of diseases in the World Bank report of 1993 illustrated that mental and neurological disorders not only entail a higher burden than cancer, but are responsible, in developed and developing countries, for more than 15% of the total burden of all diseases. As a consequence, over the past decade, mental disorders have ranked increasingly highly on the international agenda for health. However, the fact that mental health and nervous system disorders are now high on the international health agenda is by no means a guarantee that the fate of patients suffering from these disorders in developing countries will improve. In most developing countries the treatment gap for mental and neurological disorders is still unacceptably high. To address this problem, an international network of collaborating institutions in low-income countries has been set up. The establishment and the achievements of this network—the International Consortium on Mental Health Policy and Services—are reported. Sixteen institutions in developing countries collaborate (supported by a small number of scientific resource centres in industrialized nations) in projects on applied mental health systems research. Over a two-year period, the network produced the key elements of a national mental health policy; provided tools and methods for assessing a countrys current mental health status (context, needs and demands, programmes, services and care and outcomes); established a global network of expertise, i.e., institutions and experts, for use by countries wishing to reform their mental health policy, services and care; and generated guidelines and examples for upgrading mental health policy with due regard to the existing mental health delivery system and demographic, cultural and economic factors.

The Mental Health Country Profile: background, design and use of a systematic method of appraisal

This article describes the construction and use of a systematic structured method of mental health country situation appraisal, in order to help meet the need for conceptual tools to assist planners and policy makers develop and audit policy and implementation strategies. The tool encompasses the key domains of context, needs, resources, provisions and outcomes, and provides a framework for synthesizing key qualitative and quantitative information, flagging up gaps in knowledge, and for reviewing existing policies. It serves as an enabling tool to alert and inform policy makers, professionals and other key stakeholders about important issues which need to be considered in mental health policy development. It provides detailed country specific information in a systematic format, to facilitate global sharing of experiences of mental health reform and strategies between policy makers and other stakeholders. Lastly, it is designed to be a capacity building tool for local stakeholders to enhance situation appraisal, and multisectorial policy development and implementation.

Apparent male gender identity in a patient with complete androgen insensitivity syndrome.

Clinicians universally agree on female sex of rearing inpatients with complete androgen insensitivity syndrome(CAIS).Thesepatientshaveafemalephenotypethoughtheyhave an XY karyotype and testis. Long-term studies haveshown an overall patient satisfaction with the assigned fe-male sex, female gender identity, and heterosexual prefer-encesinpatientswithCAIS(Hines,Ahmed,HMazur,2005;Wisniewskietal.,2000).WereporthereacaseofCAIS(rearedasafemaleuntilage11 years)whopresentedwith a desire to live as a male at age 11 years.This 11 year, 3 month old girl was the youngest of fivesiblings (one brother and three sisters). She had undergonesurgery for bilateral inguinal swellings one year prior at alocal hospital. Testicular tissue was found on exploration.The wound was closed without any surgical manipulationand the patient was referred to the endocrine department ofthis hospital. The child was accompanied by father andbrotheratthefirstvisit.ThiswasaHindufamilythathadbeenresiding in a village in Haryana. The father, around 45 yearsof age, was a farmer. The father and brother expressed theirdesire for masculinizing genitoplasty to rear the child as amale.Theyreportedthattheyhadobservedboy-likebehaviorin the child from early childhood and the revelation of thetesticular tissue had made them all convinced about the truemale identity of the child. She had been the most aggressiveamong all the female siblings and her play preferences anddressingpatternweresimilartoherelderbrother.Thepatientreturned with her mother in the subsequent visit (1 monthlater).Motherwasahousewife.Duringthesevisits,thischildwas dressed like a boy, expressed a desire to go to a boy’sschool as a boy, and said that she preferred boy’s company.Oncarefulquestioning,motherrevealedthat,duringthebirthofthischild,bothparentshadnursedastrongdesireforaboyafter three girls were born. She had always preferred a malepattern of dressing for the child and took pleasure in seeingmale appropriate behavior in her. Examination revealed acomplete female phenotype with no development of secon-darysexualcharacters(A1B1P

The Mental Health Policy Template: Domains and elements for mental health policy formulation

Mental disorders are a major and rising cause of disease burden in all countries. Even when resources are available, many countries do not have the policy and planning frameworks in place to identify and deliver effective interventions. The World Health Organization (WHO) and the World Bank have emphasized the need for ready access to the basic tools for mental health policy formulation, implementation and sustained development. The Analytical Studies on Mental Health Policy and Service Project, undertaken in 1999–2001 by the International Consortium for Mental Health Services and funded by the Global Forum for Health Research aims to address this need through the development of a template for mental health policy formulation. A mental health policy template has been developed based on an inventory of the key elements of a successful mental health policy. These elements have been validated against a review of international literature, a study of existing mental health policies and the results of extensive consultations with experts in the six WHO regions of the world. The Mental Health Policy Template has been revised and its applicability will be tested in a number of developing countries during 2001–2002. The Mental Health Policy Template and the work of the Consortium for Mental Health Services will be presented and the future role of the template in mental health policy development and reform in developing countries will be discussed.

Assessment of burden in caregivers of Alzheimer's disease from India

INTRODUCTION Most of existing literature on dementia caregiving comes from Western countries but the caregiving experience appears to vary in different societies. The cultural norms and socioeconomic resources of India are in stark contrast to western societies, however the dementia caregiver burden remains understudied in Indian context. AIM We aim to assess the burden in relation to key variables and explore its predictors in caregivers of Alzheimers disease. METHOD Thirty-two patient-caregiver dyads were selected. The dementia characteristics were assessed with Hindi Mental State Examination and Clinical Dementia Rating; burden was evaluated using Burden Assessment Schedule. RESULTS The caregiver sample had an overall moderate degree of burden. The burden in patients behavior and external support area increased with the degree of cognitive impairment. Caregivers for male patients were found to have a higher burden. The female caregivers perceived higher burden in physical and mental health, spouse related and caregivers routine. The burden in caregivers from joint families did not differ from nuclear families except for a lower burden in external support area. On stepwise multiple regression, spousal relation, HMSE score and male patient emerged as significant predictors of total burden. CONCLUSION There is a need to devote more research attention towards dementia caregivers from developing countries and to understand the culture-specific impact of caregiving.

A follow-up study of family burden in patients with bipolar affective disorder

Introduction: Research in the last two decades has documented a high level of burden in caregivers of bipolar disorder. The present study is aimed at studying family burden among relatives of patients with bipolar affective disorder. Methods: Thirty four consecutive hospitalized patients with bipolar affective disorder currently in mania and their relatives were assessed twice: at the time of admission and during follow-up four weeks after discharge. A semi-structured performa designed for the study was completed. Patients were assessed on Young’s Mania Rating Scale and relatives were assessed on Family Burden Assessment Scale. Results: More than 90% of family members reported severe subjective (rated by relative) and objective burden (rated by interviewer) at admission; none of them was free of burden. At the time of follow-up, about one quarter (23.5%) and two thirds (64.7%) of family members did not experience any objective and subjective burden respectively; subjective and objective family burden was moderate in about one third (35.3%) and a half (52.9%), respectively. None of the family members reported severe burden subjectively, while the objective burden was rated to be severe in a quarter (23.5%) of family members. Limitations: The study was limited by the lack of a control group from an outpatient setting as hospitalization increases family burden. Also, the rater at the second assessment was not blind to ratings at the first assessment. Conclusions: Almost all the family members experienced severe burden initially. Even when symptoms subsided, family members continued to experience burden specifically related to finances. Objective burden was significantly higher than subjective burden.

Thailand mental health country profile.

Thailand, a constitutional monarchy, has undergone a rapid shift in its demography and economy in last two decades. This has put a great burden on the health services, including mental health care of the country. The current emphasis of the Ministry of Public Health is to change its role from health care provider to policymaker and regulator of standards, and to provide technical support to health facilities under its jurisdiction as well as in the private sector. The Department of Mental Health, established in 1994, has laid down a mental health policy that aims to promote mental health care within the community with the help of peoples participation in health programmes. Focus has been placed on developing suitable and efficient technology by seeking cooperation both within and outside the Ministry of Public Health. Consequently, the Department of Mental Health has been receiving increasing budgetary allocations. Since there is a paucity of trained manpower, the emphasis is being laid on the utilization of general health care for mental health care. Some of the specific interventions are community services, prison services, psychiatric rehabilitation, and use of media in mental health operations. There have been active efforts towards international cooperation for developing technologies for specific programmes. Private and non-governmental organizations are supported and encouraged to provide mental health care to the marginalized sections of society. Efforts have also been made by the Department of Mental Health to inspect and raise the efficiency of its operations to result in quality service.

Neurochemicals measured by 1 H-MR spectroscopy: putative vulnerability biomarkers for obsessive compulsive disorder

AbstractObjectObsessive compulsive disorder (OCD) is the fourth most common psychiatric disorder characterized by recurrent, intrusive thoughts and repetitive, ritualistic behaviors that are debilitating to the patient. Despite its high prevalence and the attendant morbidity, the pathophysiology of OCD remains unclear. Magnetic resonance spectroscopy (MRS) provides a noninvasive method to characterize the molecular biochemistry that may contribute to the pathophysiology of OCD. This study aimed to identify alterations in neurochemical measures that are specific to OCD using in vivo proton (1H) MRS of the caudate nucleus, anterior cingulate cortex, and medial thalamus in these patients, and to identify their role as vulnerability markers by comparing them with the healthy first degree relatives of these patients and healthy controls. Materials and methodsAppropriate psychometric instruments were applied in the study population followed by 1H- MRS. The absolute neurochemical measures were quantified using a linear combination model.ResultsSignificant differences in neurochemical measures were demonstrated in two of the three candidate regions (except the medial thalamus) between the three study groups.ConclusionsOur results lend support to the neurodegenerative hypothesis of OCD, and also raise the possibility of exploring these neurochemical measures (as measured by MRS) as putative vulnerability biomarkers in OCD that may aid in early identification and devising early prevention or management strategies for the population vulnerable to OCD.