Publications by authors named "Jagadisha Thirthalli"

225 Publications

Intermittent theta burst stimulation of cerebellar vermis enhances fronto-cerebellar resting state functional connectivity in schizophrenia with predominant negative symptoms: A randomized controlled trial.

Schizophr Res 2021 Oct 12;238:108-120. Epub 2021 Oct 12.

Department of Psychiatry, National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore 560029, Karnataka, India. Electronic address:

Objective: Negative symptoms of schizophrenia are substantially disabling and treatment resistant. Novel treatments like repetitive transcranial magnetic stimulation (TMS) need to be examined for the same using the experimental medicine approach that incorporates tests of mechanism of action in addition to clinical efficacy in trials.

Methods: Study was a double-blind, parallel, randomized, sham-controlled trial recruiting schizophrenia with at least a moderate severity of negative symptoms. Participants were randomized to real or sham intermittent theta burst stimulation (iTBS) under MRI-guided neuro-navigation, targeting the cerebellar vermis area VII-B, at a stimulus intensity of 100% active motor threshold, two sessions/day for five days (total = 6000 pulses). Assessments were conducted at baseline (T0), day-6 (T1) and week-6 (T2) after initiation of intervention. Main outcomes were, a) Scale for the Assessment of Negative Symptoms (SANS) score (T0, T1, T2), b) fronto-cerebellar resting state functional connectivity (RSFC) (T0, T1).

Results: Thirty participants were recruited in each arm. Negative symptoms improved in both arms (p < 0.001) but was not significantly different between the two arms (p = 0.602). RSFC significantly increased between the cerebellar vermis and the right inferior frontal gyrus (p = 0.033), right pallidum (p = 0.042) and right frontal pole (p = 0.047) in the real arm with no change in the sham arm.

Conclusion: Cerebellar vermal iTBS engaged a target belonging to the class of cerebello-subcortical-cortical networks, implicated in negative symptoms of schizophrenia. However, this did not translate to a superior clinical efficacy. Future trials should employ enhanced midline cerebellar TMS stimulation parameters for longer durations that can potentiate and translate biological changes into clinical effects.
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http://dx.doi.org/10.1016/j.schres.2021.10.005DOI Listing
October 2021

Barriers in Accessing Social Welfare Benefits for Families of Children With Intellectual and Developmental Disorders in Rural Karnataka: A Situation Analysis.

Indian J Psychol Med 2021 Sep 17;43(5):403-409. Epub 2021 Mar 17.

Dept. of Psychiatric Social Work, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India.

Background: Several government schemes exist for the welfare of families having children with intellectual and developmental disorders (IDDs) in India. However, these schemes are often not utilized. An understanding of the barriers to access these social welfare benefits, especially in rural areas of India, can aid in planning social action toward the implementation of these schemes.

Methods: A situation analysis of the resources and potential barriers to access social welfare benefits for families of children with IDD was conducted in a rural community. Stakeholder interviews were conducted with families of children with IDD ( = 20), government officials responsible for implementing education at the state level ( = 5), local officials responsible for facilitating social welfare benefits ( = 5), and nongovernmental organization () working in the area of children with IDD ( = 3). Qualitative thematic analysis was used to understand the barriers to access social welfare benefits for the families of children with IDD.

Results: Barriers encountered by families of children with IDD, local officials, and NGOs included lack of awareness about the available welfare schemes, unavailability of social welfare facilities in the local areas, lack of social auditing in the provision of social welfare schemes to the needy, and stringent process of application and regulation for financial aid under the National Trust schemes.

Conclusion: There are multiple barriers to access social welfare benefits for families having children with IDD in rural Karnataka. There is a strong need to empower families, sensitize local officials, and advocate for social policies to effectively implement National Trust schemes in rural areas of Karnataka.
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http://dx.doi.org/10.1177/0253717621994706DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8450745PMC
September 2021

A transdiagnostic evaluation of cortical inhibition in severe mental disorders using Transcranial Magnetic Stimulation.

J Psychiatr Res 2021 Sep 24;143:364-369. Epub 2021 Sep 24.

Department of Psychiatry, National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, 560029, India.

Multiple lines of investigations suggest the presence of cortical inhibition aberrations as central to the phenotypic manifestations of severe mental disorders. Transcranial Magnetic Stimulation (TMS) combined with electromyography can characterize these inhibitory processes in the motor cortex with satisfactory temporal precision. We examined TMS-evoked short- (SICI) and long-interval intracortical inhibition (LICI) and cortical silent period (CSP) as markers of GABA- (SICI) and GABA-mediated (LICI and CSP) cortical neurotransmission in symptomatic individuals with mania (n = 40), schizophrenia (n = 76), unipolar depression (n = 86), and OCD (n = 43), and compared them against similar recordings in healthy subjects (n = 125). We hypothesized transdiagnostic GABA deficits across all the clinical groups and diagnosis-specific GABA alterations in mania (increased) and OCD (decreased). After controlling for potential confounder variables (gender, education, benzodiazepine prescription, and motor threshold) using the ANCOVA, we observed no significant group difference in SICI (F = 1.04, P = 0.38), but a significant group effect in LICI (F = 16.29, P < 0.001) and CSP (F = 3.02, P = 0.018). Post-hoc analyses revealed that LICI was significantly reduced in OCD but increased in mania and schizophrenia with reference to the healthy group. Similarly, CSP was significantly reduced in OCD and depression groups as compared to the reference group. We observed that LICI and CSP, both followed similar descending gradients from mania through schizophrenia and depression to OCD; with significant elevation in mania, and reduction in depression and OCD, as compared to the healthy group. This pattern of GABA-mediated cortical inhibition aberrations needs independent validation as potential state-markers of distinct clinical categories.
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http://dx.doi.org/10.1016/j.jpsychires.2021.09.049DOI Listing
September 2021

Resting-state functional connectivity predictors of treatment response in schizophrenia - A systematic review and meta-analysis.

Schizophr Res 2021 Sep 15;237:153-165. Epub 2021 Sep 15.

Beth Israel Deaconess Medical Center and Massachusetts Mental Health Center, Harvard Medical School, Boston, MA, United States of America.

We aimed to systematically synthesize and quantify the utility of pre-treatment resting-state functional magnetic resonance imaging (rs-fMRI) in predicting antipsychotic response in schizophrenia. We searched the PubMed/MEDLINE database for studies that examined the magnitude of association between baseline rs-fMRI assessment and subsequent response to antipsychotic treatment in persons with schizophrenia. We also performed meta-analyses for quantifying the magnitude and accuracy of predicting response defined continuously and categorically. Data from 22 datasets examining 1280 individuals identified striatal and default mode network functional segregation and integration metrics as consistent determinants of treatment response. The pooled correlation coefficient for predicting improvement in total symptoms measured continuously was ~0.47 (12 datasets; 95% CI: 0.35 to 0.59). The pooled odds ratio of predicting categorically defined treatment response was 12.66 (nine datasets; 95% CI: 7.91-20.29), with 81% sensitivity and 76% specificity. rs-fMRI holds promise as a predictive biomarker of antipsychotic treatment response in schizophrenia. Future efforts need to focus on refining feature characterization to improve prediction accuracy, validate prediction models, and evaluate their implementation in clinical practice.
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http://dx.doi.org/10.1016/j.schres.2021.09.004DOI Listing
September 2021

Parental consanguinity among patients with schizophrenia in a rural community of South India: A clinical and genetic investigation.

Asian J Psychiatr 2021 Oct 15;64:102814. Epub 2021 Aug 15.

Department of Psychiatry, University of Pittsburgh School of Medicine, Western Psychiatric Hospital, Pittsburgh, USA; Department of Human Genetics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, USA.

Background: Studies from certain regions of the world indicate that consanguineous marriages are a risk factor for the development of schizophrenia in offspring. However the evidence is inconsistent partly due to methodological limitation of which hospital based recruitment contributing to significant bias. The studies from the Indian subcontinent, is scarce, where rates of consanguinity is high.

Methods: The schizophrenia patients living in a geographically defined rural south Indian community and randomly selected controls dwelling in the same community sharing sociocultural, economic and lifestyle factors were recruited. They were assessed for parental consanguinity using the clinical interviews as well as DNA-based estimates. The latter was conducted by calculating the coefficient of inbreeding 'f'. A participant was considered to have consanguineous parentage if his/her parents shared a common ancestor no more remote than a great-great-grandparent, corresponding to DNA-based estimates of 'f' ≥ 0.0156.

Results: The rates of parental consanguinity assessed by clinical interview were comparable in both groups (Cases: 10.71 %, Controls: 7.25 %; χ = 0.493, p = 0.4825). However, DNA-based rates of parental consanguinity showed that 'f' was significantly higher among cases than controls (Mann-Whitney U = 11315.5; p = 0.022). Seventy-five cases (62.5 %) and 108 control participants (48.6 %) had 'f' ≥ 0.0156 (χ = 6.008; p = 0.014). The results were consistent across different quality control measures.

Conclusion: Schizophrenia is associated with higher parental consanguinity, suggesting a role for multiple recessive risk alleles in its etiology. Replication in future studies in diverse settings would add further strength to this.
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http://dx.doi.org/10.1016/j.ajp.2021.102814DOI Listing
October 2021

Carbamazepine/oxcarbazepine and valproate have different effects on the electroconvulsive therapy seizure threshold.

Psychiatry Res 2021 Oct 2;304:114149. Epub 2021 Aug 2.

Professor, Department of Clinical Psychopharmacology and Neurotoxicology, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India.

Patients receiving mood stabilizers such as valproate (VAL) and carbamazepine (CMZP)/Oxcarbazepine (OX) may be referred for electroconvulsive therapy (ECT). The relative effects of these anticonvulsants on seizure threshold and seizure duration are unknown. We extracted data for a 20-month period from the medical records of patients who received bilateral ECT while on treatment with VAL (n=102) or CMZP/OX (n=31; 20 on CMZP, 11 on oxcarbazepine). Age-matched ECT-treated anticonvulsant-free patients (n=133) formed the control group. Seizure threshold in these patients had been determined by stimulus dose titration. The effect of VAL vs CMZP/OX on seizure threshold was examined using multivariable regression with adjustment for confounders. The mean (standard deviation) seizure threshold at the first ECT was highest in the CMZP/OX group (243.9 [106.1] mC), intermediate in the VAL group (177.7 [97.0] mC), and lowest in the control group (138.7 [86.0 Mc]). The regression model explained 37.5% of the variance in seizure threshold at the first ECT. Age, use of CMZP/OX, and anticonvulsant dose were each significantly associated with higher seizure threshold. CMZP/OX was associated with a higher initial ECT seizure threshold than VAL. ECT practitioners may prefer to start with a higher initial stimulus dose in patients receiving CMZP/OX or VAL, and more so for CMZP/OX than VAL, to avoid repeated sub-convulsive stimuli being administered.
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http://dx.doi.org/10.1016/j.psychres.2021.114149DOI Listing
October 2021

A Community Participation Initiative During COVID-19 Pandemic: A Case Study From India.

Indian J Psychol Med 2021 Mar 19;43(2):154-157. Epub 2021 Feb 19.

Dept. of Psychiatric Social Work, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka 560029, India.

Background: A community participation initiative of stitching personal protective equipment (PPE), masks, and face shields for healthcare professionals working in the hospital during the COVID-19 pandemic was conducted using a case study design.

Methods: The hospital tailoring unit was used to cater to the in-house demand for stitching safety gear kits for healthcare professionals. A transect walk was conducted to survey hospitals for selecting material for stitching the safety gears and to draw up a plan to meet future demand. The psychiatric social worker induced a community participatory initiative using the method of social work of community organization. A flyer was prepared to invite participants with prior experience in tailoring for this initiative. All participants were trained by the master trainers of the tailoring unit. The participants were also interviewed about their views on this initiative in an informal interview.

Results: A total of 83 participants, including 26 individuals (8 volunteers and 18 who received an honorarium), 2 boutiques ( = 12), and 1 government organization, participated in the activity ( = 45). A total of 1700 complete PPE kits and 13,000 masks were stitched during this period. The participants reported that the benefit of being a part of this initiative was reduced boredom, sense of purpose and satisfaction, and improved mental health due to structured activity.

Conclusions: A community participation initiative using the principles of community organization, a method of social work, can help produce desired outputs and improve the well-being of the participants.
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http://dx.doi.org/10.1177/0253717621991012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8313456PMC
March 2021

Karnataka telemedicine mentoring and monitoring program for complete integration of psychiatry in the general health care.

Indian J Psychiatry 2021 Mar-Apr;63(2):171-174. Epub 2021 Apr 14.

Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India.

The National Mental Health Survey of India reported a higher prevalence and treatment gap of psychiatric disorders among the general population. Task shifting is one of the important solutions to meet this requirement. The prevalence of psychiatric disorders among primary care is about 30%-50%. Digitally driven primary care psychiatry program (PCPP) designed to innovate different module to upscale the skills of primary care doctors (PCDs) in live consultation of PCDs in their general patients. To exponential coverage of PCDs, Karnataka Telemedicine Mentoring and Monitoring (KTM) Program is been implemented across all districts of Karnataka. It is the training of trainer version of PCPP where psychiatrists serving in District Mental Health Program of all districts of Karnataka become trainers to implement of two digital modules (Telepsychiatric On-Consultation Training and Collaborative Video Consultations) of PCPP with the target to train all PCDs of Karnataka. This paper aims to provide a glimpse of this innovative KTM program and current progress with a preliminary analysis of translational quotient indicating skill transfer and retention.
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http://dx.doi.org/10.4103/psychiatry.IndianJPsychiatry_134_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8214123PMC
April 2021

Establishing Performance Indicators of Telemedicine-Based "On-Consultation Training" of Primary Care Doctors: An Innovation to Integrate Psychiatry at Primary Care.

Indian J Community Med 2021 Jan-Mar;46(1):75-79. Epub 2021 Mar 1.

Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India.

Background: A "functional treatment gap" exists in primary care of India despite the higher prevalence of psychiatric disorders at primary care. Traditional classroom training for primary care doctors (PCDs) fails to translate into adequate clinical skills to provide basic psychiatric treatment. An innovative telepsychiatric on-consultation training (Tele-OCT) is designed exclusively for practicing PCDs where a telepsychiatrist trains PCDs in live video streaming of their own real-time general consultations of primary health centres. The aim of this study is to establish performance indicators of Tele-OCT for its effective implementation.

Methodology: The data collected using a file review method from a naturalistic design of the implementation of Tele-OCT for 73 PCDs from August-2016 to October-2018 across Mandya district, Karnataka, India.

Results: Flexibility in the scheduling of Tele-OCT sessions is key to success. Personal smartphones of PCDs with available videoconference applications are the popular choice. Four consecutive Tele-OCT sessions are planned for each PCD with a gap of 2-4 weeks over two months. The first three sessions are considered the "optimum Tele-OCT training package" for each PCD, followed by the fourth one as a 'Tele-OCT impact evaluation session' in a live, real-time general consultation. Each Tele-OCT is conducted in an average ten general patients in about two hours per session, totalling about 30 patients in 6 hours of Tele-OCT training package per PCD. Patient's profiles especially common mental disorders are reflective of a true picture of Indian primary care.

Conclusions: Performance indicators of Tele-OCT for future implementation are established. Tele-OCT appears to be a path-breaking training model for PCDs to integrate psychiatric care in their general practice.
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http://dx.doi.org/10.4103/ijcm.IJCM_223_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8117904PMC
March 2021

Admission of persons with disabilities into nursing and midwifery courses: Progress made by the Indian Nursing Council.

Indian J Med Ethics 2020 Oct-Dec;V(4):1-18

Professor of Psychiatry, NIMHANS, Bengaluru. 560 029 INDIA.

India's Persons with Disabilities Act, 1995 (PWD Act, 1995) mandated a minimum enrollment reservation of 3% for persons with disability (PwDs) across all educational courses supported by government funding. Following this, the Indian Nursing Council (INC) issued regulations limiting such an enrollment quota to PwDs with lower limb locomotor disability ranging between 40%-50%. The Medical Council of India (MCI) also restricted admissions under the PwD category to PwDs with a lower limb locomotor disability to comply with the Act. The Rights of Persons with Disabilities (RPwD) Act, 2016, which replaced the PwD Act, 1995, raised the minimum reservation to 5% for all government-funded institutions of higher education and extended this reservation to PwDs under 21 different clinical conditions, rather than the seven conditions included under the PwD Act, 1995. Following the enactment of the RPwD Act, 2016, the MCI issued regulations that allowed PwDs with locomotor disability and those with a few other types of disabilities in the range of 40%-80%, to pursue graduate and postgraduate medical courses, while the INC has not made any changes. This article addresses the complexities of inclusion of PwDs in the healthcare workforce, offers suggestions for inclusive measures; and compares the INC admission regulation released in 2019 to the MCI 2019 admission guidelines for graduate and postgraduate medical courses.
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http://dx.doi.org/10.20529/IJME.2020.111DOI Listing
August 2021

Admission of persons with disabilities into nursing and midwifery courses: Progress made by the Indian Nursing Council.

Indian J Med Ethics 2020 Oct-Dec;V(4):1-18

Professor of Psychiatry, NIMHANS, Bengaluru. 560 029 INDIA.

India's Persons with Disabilities Act, 1995 (PWD Act, 1995) mandated a minimum enrollment reservation of 3% for persons with disability (PwDs) across all educational courses supported by government funding. Following this, the Indian Nursing Council (INC) issued regulations limiting such an enrollment quota to PwDs with lower limb locomotor disability ranging between 40%-50%. The Medical Council of India (MCI) also restricted admissions under the PwD category to PwDs with a lower limb locomotor disability to comply with the Act. The Rights of Persons with Disabilities (RPwD) Act, 2016, which replaced the PwD Act, 1995, raised the minimum reservation to 5% for all government-funded institutions of higher education and extended this reservation to PwDs under 21 different clinical conditions, rather than the seven conditions included under the PwD Act, 1995. Following the enactment of the RPwD Act, 2016, the MCI issued regulations that allowed PwDs with locomotor disability and those with a few other types of disabilities in the range of 40%-80%, to pursue graduate and postgraduate medical courses, while the INC has not made any changes. This article addresses the complexities of inclusion of PwDs in the healthcare workforce, offers suggestions for inclusive measures; and compares the INC admission regulation released in 2019 to the MCI 2019 admission guidelines for graduate and postgraduate medical courses.
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http://dx.doi.org/10.20529/IJME.2020.111DOI Listing
August 2021

Care at Doorsteps for Persons with Severe Mental Illnesses as a Part of District Mental Health Program (DMHP): A Qualitative Needs Assessment and Psychosocial Framework.

Community Ment Health J 2021 Mar 15. Epub 2021 Mar 15.

Department of Psychiatric Social Work, NIMHANS, Bengaluru, India.

Care at Doorstep (CAD) is a home care service that includes medical and social care by skilled professionals. The purpose of this paper is to explore the need for CAD among users of the district mental health programme (DMHP) in Ramanagaram, Karnataka, India who have severe mental illness. The design of this study was descriptive where a qualitative inductive methodology was adopted. Data was collected from interviews of 20 caregivers and 7 mental health service providers linked to the DMHP. Socio demographic information was collected from participants and a semi-structured interview guides were used to explore needs and challenges in delivering care at home by the professionals. The themes that emerged from the manually transcribed and coded data were categorized as needs and challenges and used for developing a CAD model.
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http://dx.doi.org/10.1007/s10597-021-00803-yDOI Listing
March 2021

Electroconvulsive therapy during the COVID-19 pandemic.

Indian J Psychiatry 2020 Sep-Oct;62(5):582-584. Epub 2020 Oct 10.

Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India.

The COVID-19 pandemic has forced substantial changes in the practice of psychiatry, including that of electroconvulsive therapy (ECT). There is higher risk of transmission of the SARS-CoV-2 virus during ECT unless due care is taken. However, in many cases, ECT cannot be avoided. In this paper, we discuss various measures that may be adapted to reduce the risk of transmission of the virus during ECT. We also suggest certain modifications to the practice of ECT in order to achieve a balance between risks and benefits of the procedure during the pandemic.
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http://dx.doi.org/10.4103/psychiatry.IndianJPsychiatry_335_20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7909042PMC
October 2020

Dissimilar social cognition signatures in remitted schizophrenia and bipolar disorder.

Asian J Psychiatr 2021 Mar 5;57:102593. Epub 2021 Feb 5.

Department of Psychiatry, National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, India.

In the light of shared genetic underpinnings of schizophrenia and bipolar disorder, their comparative profile of social cognition (SC) performance - an intermittent phenotype and determinant of functional outcome - is poorly understood. Using data from 160 individuals, we identify unique patterns of composite and domain-specific SC-abilities between these groups after controlling for their neurocognition. Individuals with schizophrenia and not bipolar disorder demonstrated deficits in composite SC-measures, which were not associated with their functional status. While patients with bipolar disorder had significantly lower scores on emotion recognition, they outperformed the healthy and schizophrenia groups on the second-order theory of mind.
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http://dx.doi.org/10.1016/j.ajp.2021.102593DOI Listing
March 2021

Telephonic follow-up during COVID-19 to maintain continuity of care for persons with psychiatric disorders.

Asian J Psychiatr 2021 Mar 21;57:102564. Epub 2021 Jan 21.

Department of Psychiatry, National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, India.

We describe the utility of telephonic aftercare services (including liaising with primary healthcare providers) rendered to persons with psychiatric disorders (n = 1049) during the lockdown period of COVID 19 pandemic in India. Such consultations can be continued even after the COVID 19 period for suitable patients.
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http://dx.doi.org/10.1016/j.ajp.2021.102564DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7825953PMC
March 2021

Global visuospatial processing - a screening tool to predict cognition in schizophrenia.

Schizophr Res 2021 02 23;228:311-313. Epub 2021 Jan 23.

Department of Psychiatry, National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, India.

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http://dx.doi.org/10.1016/j.schres.2020.12.039DOI Listing
February 2021

Impact Evaluation of VKN-NIMHANS-ECHO Model of Capacity Building for Mental Health and Addiction: Methodology of Two Randomized Controlled Trials.

Indian J Psychol Med 2020 Dec 7;42(6 Suppl):S80-S86. Epub 2020 Dec 7.

University of Pittsburgh, Pittsburgh, Pennsylvania, United States.

Background: Bridging the alarming treatment gap for mental disorders in India requires a monumental effort from all stakeholders. Harnessing digital technology is one of the potential ways to leapfrog many known barriers for capacity building.

Aim And Context: The ongoing Virtual Knowledge Network (VKN)-National Institute of Mental Health and Neurosciences (NIMHANS)-Extension of Community Health Outcomes (ECHO) (VKN-NIMHANS-ECHO: hub and spokes model) model for skilled capacity building is a collaborative effort between NIMHANS and the University of New Mexico Health Sciences Centre, USA. This article aims to summarize the methodology of two randomized controlled trials funded by the Indian Council of Medical Research (ICMR) designed to evaluate the effectiveness of the VKN-NIMHANS-ECHO model of training as compared to training as usual (TAU).

Methods: Both RCTs were conducted in Karnataka, a southern Indian state in which the DMHP operates in all districts. We compared the impact of the following two models of capacity building for the DMHP workforce (a) the VKN-NIMHANS-ECHO model and (b) the traditional method. We use the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) statement to describe the methods of these two trials.Trial 1 is to evaluate the "Effectiveness of addition of Virtual-NIMHANS-ECHO tele-mentoring model for skilled capacity building in providing quality care in alcohol use disorders by the existing staff of DMHP districts of Karnataka." Hub for trial 1 was set up at NIMHANS and the spokes were psychiatrists and other mental health professionals headquartered in the district level office. Trial 2 assesses the implementation and evaluation of the NIMHANS-ECHO blended training program for the DMHP workforce in a rural south-Indian district of Karnataka state. The hub for trial 2 was set up in the district headquarter of Ramanagaram. Hub specialists are DMHP psychiatrists, whereas spokes are the non-doctor workforce (including auxiliary nurse midwives [ANMs] and accredited social health activists [ASHA] workers) medical officers of primary health centers. The location of the HubHub differs in these two studies. Both trials are funded by the ICMR, Government of India.

Discussion: Both these trials, though conceptually similar, have some operational differences which have been highlighted. If demonstrated to be effective, this model of telementoring can be generalized and widely merged into the Indian health care system, thus aiding in reducing the treatment gap for patients unable to access care.
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http://dx.doi.org/10.1177/0253717620969066DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7802042PMC
December 2020

Community-Based Rehabilitation for Persons with Severe Mental Illness in a Rural Community of Karnataka: Methodology of a Randomized Controlled Study.

Indian J Psychol Med 2020 Dec 7;42(6 Suppl):S73-S79. Epub 2020 Dec 7.

Dept. of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India.

Background: Task shifting has been recommended as a strategy to reach out to persons with mental illness and bridge the treatment gap. There is a need to explore task-shifting using existing health staff like Accredited Social Health Activists (ASHAs).

Aim And Context: ASHAs are involved in ongoing community-based rehabilitation (CBR) program run with a public-private partnership over the last 5 years at Jagaluru Taluk (an administrative block) in Davanagere district (Karnataka, India). This article aims to summarize a randomized controlled trial (RCT) to examine whether CBR delivered by ASHAs is more effective than treatment as usual (TAU) control group in reducing disability associated with severe mental illness (SMI).

Method: A group of proactive ASHAs is already working with us for a follow-up of persons with SMI. For the study, we would allocate areas that are currently not being covered proactively by ASHAs randomly in a 1:1 ratio via computer-generated randomization list to receive either ASHAs delivered CBR arm or TAU control group. A sample size of about 100 in each arm is enough to identify an effect size of 0.5 in total IDEAS score between the intervention and control arms with a power of 90% and an alpha of 0.05. We use the SPIRIT (Standard Protocol Items: Recommendations for Interventional Trials) statement to describe the methods of the trial.

Result: The study has been approved by the institute ethics committee and registered with CTRI (CTRI/2019/08/020585 dated 6th August 2019). The recruitment of subjects is ongoing. The patients will be followed up for 1 year and assessed. The trial is funded by the Indian Council of Medical Research, Government of India.

Discussion: The results of the study will be helpful from a public health perspective in delivering cost-effective and replicable CBR for persons with SMI through ASHAs. If the model turns successful, this could be expanded throughout the state/country. This would go a long way in bridging the huge treatment gap.
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http://dx.doi.org/10.1177/0253717620971203DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7802032PMC
December 2020

Non-pharmacological interventions for smoking in persons with schizophrenia spectrum disorders - A systematic review.

Asian J Psychiatr 2021 Feb 14;56:102530. Epub 2021 Jan 14.

Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, 560029, India. Electronic address:

Introduction: The rates and intensity of tobacco use are higher in persons with schizophrenia spectrum disorders (PwS) compared to the general population, contributing to increased morbidity and mortality. We aimed to systematically review randomised control trials (RCTs) that used non-pharmacological interventions to reduce or cease tobacco use in PwS.

Methods: We searched PubMed, EBSCO, ProQuest and PsycINFO for RCTs, published between January 2004 and December 2019, which included adult PwS. Studies providing self-reported or biochemically measured reduction of tobacco use and cessation after a minimum follow-up period of 6 months were included. We used the Cochrane Risk of Bias (ROB) tool for assessing the quality of selected studies.

Results: Of the six included trials, two compared non-pharmacological interventions alone while four compared combinations with pharmacological interventions with routine care. The non-pharmacological interventions varied widely. Continuous abstinence and seven days point-prevalence abstinence (7 PPA) were reported in 2 and 4 studies respectively, with one study assessing both. All six trials measured reduction in the number of cigarettes smoked, but only two trials reported significant reductions in intervention groups. No worsening of psychiatric symptoms was reported.

Conclusions: Two trials were rated as "low risk", and 4 trials as "some concerns" on the ROB tool. Heterogeneity among trials precluded meta-analysis. Abstinence was significantly higher among groups who were given combination interventions, and intervention groups in studies showed significantly greater or a trend towards reduction in the number of cigarettes smoked than controls. No specific method of non-pharmacological management was conclusively favoured.

Implications: Reduction in cigarettes smoked seemed to significantly favour or show non-significant trends favouring intervention groups over controls, while abstinence was significantly higher among groups in studies that used specific combination interventions. Combinations of pharmacological and non-pharmacological treatment were better than non-pharmacological interventions used in isolation, for facilitating abstinence and reduction in cigarettes smoked. Specific interventions such as home visits and contingent reinforcement merit further study. Trials included in this study were conducted in high-income and upper-middle-income countries. Thus, the application of these interventions to low and middle-income countries (LAMICs) needs to be further studied.
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http://dx.doi.org/10.1016/j.ajp.2020.102530DOI Listing
February 2021

Reasonable Accommodation at the Workplace for Professionals with Severe Mental Illness: A Qualitative Study of Needs.

Indian J Psychol Med 2020 Sep 11;42(5):445-450. Epub 2020 Aug 11.

Psychiatric Rehabilitation Services, Dept. of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India.

Background: Professionals with Severe Mental Illness (PwSMI) often face challenges in obtaining and retaining employment. For equal and effective participation, they may require reasonable workplace adjustments. The recently legislated Rights of Persons With Disabilities Act 2016 in India defines such adjustments as reasonable accommodations.

Methods: In-depth qualitative interviews were conducted with 15 consenting PwSMI availing psychiatric rehabilitation services at a tertiary mental health institute in India, five mental health professionals, and five employers. The audio-recorded interviews were transcribed and coded manually by two independent investigators. Inductive content analysis approach was used for qualitative analysis.

Results: The detected themes included modifications in work schedule, supports to improve work efficiency, modifications in the work environment, modifications in the work-related appraisal, supportive employer policy, and integration of services. The participants described the term "undue burden" to be ambiguous.

Conclusions: The reported reasonable accommodations are non-structural and mainly dependent on human assistance. Vocational rehabilitation and job reintegration efforts can focus on guided negotiations between employers and PwSMI. This is dependent on at least some degree of disclosure. Awareness regarding reasonable accommodation and stigma reduction is necessary for successful implementation.
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http://dx.doi.org/10.1177/0253717620939771DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7750859PMC
September 2020

"Kundalini-like experience as psychopathology: A case series and brief review".

Complement Ther Clin Pract 2021 Feb 8;42:101285. Epub 2020 Dec 8.

Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, India.

Kundalini concept comes from ancient yogic philosophy in which it is believed that certain spiritual practices will cause Kundalini awakening. The phenomenon of Kundalini awakening can sometimes mimic mental illness and results in difficulty for mental health practitioners to distinguish between them. While there are ample literatures suggesting the benefits of yogic practices in mental illness, it is also worth understanding the side effects of these practices, especially if advanced yogic practices are not performed properly with necessary preparations and precautions under the guidance of an expert. In this context, we discuss a series of cases demonstrating altered mental experiences related to Kundalini, from both modern psycho-pathology and traditional yoga view points and try to differentiate severe mental illness from advanced spiritual states perceived after practicing Kundalini yoga.
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http://dx.doi.org/10.1016/j.ctcp.2020.101285DOI Listing
February 2021

Care at door-steps for persons with severe mental disorders: A pilot experience from Karnataka district mental health program.

Int J Soc Psychiatry 2020 Dec 24:20764020983856. Epub 2020 Dec 24.

Department of Psychiatry, Bangalore Medical College and Research Institute, Bangalore, Karnataka, India.

Background: Public funded outreach services for persons with severe mental disorders (SMDs), a norm in developed nations, is non-existent in India. We share our pilot experience with an indigenous model named 'Care at Doorsteps' (CADs) for persons with SMDs who dropped out from clinical care of District Mental Health Program (DMHP) at three sites of Karnataka, a south Indian state.

Aim: The objectives of this study were to identify the reasons for drop outs from routine care and to assess the burden of illness and disability after the intervention.

Methodology: Six-month prospective observational study on patients aged 18-60 years, diagnosed as Schizophrenia or bipolar disorder was conducted. Three home visits were made by the team and provided medications, also offered brief psychoeducation and counselling. Care-givers were interviewed to identify the reasons for drop outs and their expectations from the treating team. Patients were also assessed using the Clinical Global Impression Scale (CGI), Indian Disability Evaluation and Assessment Scale (IDEAS) and Burden Assessment Schedule (BAS) during each visit.

Results: Ninety-six patients (50 males and 46 females) were followed up, of which 85 had a diagnosis of schizophrenia and 11 with bipolar illness. Common reasons for drop out were: single caregiver (breadwinner) unable to accompany the patient, loss of faith in medical treatment and financial constraints. Symptomatic improvement and restoration of productive work were the priority expectations. Over the course, the mean CGI-S showed significant reduction (4.81 ± 1.57, 4.46 ± 1.32 and 4.11 ± 1.39 respectively;  = 0.001). Mean score on BAS showed a significant reduction (85.76 ± 12.15, 83.46 ± 11.30, 84.27 ± 11.82;  = 0.04). Mean total IDEAS scores did not show significant change (13.27 ± 4.78, 12.82 ± 4.24, 13.17 ± 4.40;  = 0.16).

Conclusion: Meaningful assertive outreach care is feasible in India and is found to be useful for persons with SMDs by utilising the already existing public sector resources.
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http://dx.doi.org/10.1177/0020764020983856DOI Listing
December 2020

Telerehabilitation in Psychiatry.

Indian J Psychol Med 2020 Oct 1;42(5 Suppl):57S-62S. Epub 2020 Nov 1.

Psychiatric Rehabilitation Services, Dept. Psychiatry, NIMHANS, Bengaluru, Karnataka, India.

The COVID-19 pandemic has interrupted the usual mechanisms of healthcare delivery and exacerbated symptoms of mental illnesses. Telemedicine has morphed from niche service to essential platform, with newly released guidelines that cover various aspects of tele-mental health delivery. Rehabilitation services, which incorporate a range of psychosocial interventions and liaison services, have been significantly impacted too. They are currently more institute-based than community-based in India. However, recent legislation has mandated that community-based rehabilitation options be available. While a large treatment gap for mental health issues has always existed, telemedicine provides an opportunity to scale services up to minimize this gap. Community-based rehabilitation can be delivered over various platforms, from text to phone to videoconferencing, and various devices. Telemedicine is cost-effective, and enables delivery of services where existing services are inadequate. The recent guidelines allow other healthcare workers to be involved in mental health service delivery. Hence, in addition to direct delivery of services, telerehabilitation can facilitate task-shifting, with mental health professionals mentoring and supervising existing human resources, such as ASHA workers, VRWs, DMHP programme staff, and others. Tele-rehabilitation also poses challenges - not all needs can be met; access and privacy can be a problem in resource-scarce settings; liaison with existing services is required; and organisations need to plan appropriately and re-allocate resources. Digital access to welfare benefits and interventions must be expanded without disadvantaging those without internet access. Yet, many rehabilitation interventions can be adapted to telemedicine platforms smoothly, and task-shifting can broaden access to care for persons with disability.
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http://dx.doi.org/10.1177/0253717620963202DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7736738PMC
October 2020

Shorter cortical silent period is associated with manic symptom severity.

Brain Stimul 2021 Jan-Feb;14(1):129-130. Epub 2020 Dec 4.

Department of Psychiatry, National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore, India.

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http://dx.doi.org/10.1016/j.brs.2020.12.001DOI Listing
December 2020

Study of neuropsychological deficits in late onset depression.

Asian J Psychiatr 2020 Dec 7;54:102435. Epub 2020 Oct 7.

Geriatric Clinic and Services, Department of Psychiatry, National Institute of Mental Health and Neurosciences, Bangalore, 560029, India. Electronic address:

Background: Older adults with depression often have cognitive deficits contributing to higher morbidity and increased risk for conversion to dementia. Research on this area is limited from India.

Objective: The objective of the current study is to examine the neuropsychological measures in older adults with Late-onset depression (LOD) compared to healthy controls (HC).

Method: Sample included older adults with depression as per DSM-IV TR criteria seeking treatment from Geriatric Clinic and Services, National Institute of Mental Health and Neurosciences (NIMHANS). Geriatric depression scale, Montgomery Asberg depression rating scale and Hamilton anxiety rating scale were applied to screen and measure the severity of depression. Comprehensive assessment of neurocognitive function was done using NIMAHNS Neuropsychological Battery for Elderly (NNBE, 2013).

Results: Sample included 76 LOD patients and 76 healthy controls (HC) who were matched for age, gender and education. The mean age of onset of illness was 63.17(SD-6.54) years and median duration of total illness was 29.5 months. In the standard assessments, the mean score on GDS was 9.28 (SD-3.32) and MADRS was 18.88 (SD-6.07). The LOD group had lower Hindi Mental Status Examination (HMSE) score compared to HC (28.64 ± 2.09 vs 30.05 ± 1.26, p < 0.001). Compared to HC, LOD group performed poorly on tasks of attention, executive function, verbal and visual memory, verbal fluency and visuo-spatial skills. Recognition memory and logical memory were relatively preserved in LOD compared to HC.

Discussion And Conclusion: Cognitive deficits were seen predominantly in attention and executive function, visuo-spatial skills and memory similar to previous studies. It is advisable to routinely assess cognitive symptoms in older adults presenting with depression.
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http://dx.doi.org/10.1016/j.ajp.2020.102435DOI Listing
December 2020

Embracing Technology for Capacity Building in Mental Health: New Path, Newer Challenges.

Psychiatr Q 2021 09 19;92(3):843-850. Epub 2020 Nov 19.

The ECHO Institute, University of New Mexico, Albuquerque, NM, USA.

Technology driven capacity building initiatives are the way to break the barrier of shortage of mental health human resources in India. This new path, while is a welcome step, comes with its own set of challenges. In one prototypic project that is being implemented in Ramanagara District of Karnataka, a south Indian state, we encountered many such issues. They ranged from issues related to availability of dedicated space to set up the hub-studio, inconsistent internet connectivity (particularly in remote areas) and inadequate digital literacy among the grassroot community health workers who hail from villages. This article summarises these challenges and ends by looking into ways and means of overcoming them.
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http://dx.doi.org/10.1007/s11126-020-09859-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7676753PMC
September 2021

Adjuvant intermittent theta burst stimulation over dorsomedial prefrontal cortex in treatment-resistant obsessive-compulsive disorder type: Letter to the editor.

Brain Stimul 2021 Jan-Feb;14(1):74-76. Epub 2020 Nov 16.

Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru, India.

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http://dx.doi.org/10.1016/j.brs.2020.11.011DOI Listing
November 2020

Comparable effects of 0.5 ms and 1.5 ms pulse-widths on cardiovascular response in schizophrenia patients receiving electroconvulsive therapy.

J Psychiatr Res 2021 01 16;132:195-197. Epub 2020 Oct 16.

Senior Professor, Department of Psychiatry, National Institute of Mental Health and Neuro Sciences, Bangalore, India. Electronic address:

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http://dx.doi.org/10.1016/j.jpsychires.2020.10.013DOI Listing
January 2021
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