Community Intervention Programmes at Karnataka

            The Thirthahalli (CoInPsyD) program

                       The community intervention program in Thirthahalli taluk, Shivamogga district (Community Intervention Psychotic Disorders, CoInPsyD) was started in June 2005 with  research grants under the National Mental Health Program awarded to Dr. B N Gangadhar, Professor of Psychiatry, NIMHANS.

        Since then our team from NIMHANS and Dr. U Arunachala, a private psychiatrist practicing in Thirthahalli has been examining clinically relevant research questions among these representative, community-dwelling schizophrenia patients: these include, studies on course and outcome, disability, age at onset, metabolic syndrome, work functioning, family burden, substance use and tardive dyskinesia.

               Needless to mention that, in addition to studying this cohort scientifically, the team has as well been providing regular clinical services to these underserved patients. Nearly 2/3rds of these patients were out-of-treatment and our team has provided services to them virtually at their doorsteps – while most receive follow up care in their nearest primary health centers, a substantial proportion of patients is seen in their houses. Where there is no government supply of medications, the team has provided medications such as olanzapine, clozapine etc., free of cost.

                Though our research is focused on schizophrenia patients, for every patient with schizophrenia, the team has provided clinical services to four or five patients with various other disorders such as bipolar disorder, recurrent depressive disorders, alcohol use disorders, dysthymia, anxiety disorders, mental retardation, specific learning disabilities, etc., and neurological  disorders like epilepsy, migraine, etc. Enhancing the community’s awareness about mental illnesses was an expected byproduct of our efforts. We have written newspaper articles on psychiatric disorders. Other community service activities that our team has engaged in Thirthahalli are to conduct a ‘disability’ camp and conducting interaction programs with community leaders in Thirthahalli focusing on the burden and disability caused by severe mental disorders and the role that communities could play in reducing these disabilities. During the camp, disability certificates were issued to 230 persons with mental retardation. A significant academic activity that the team accomplished was the state-level Continuing Medical Education (CME) program for psychiatry post-graduate students in Kavishaila of Thirthahalli Taluk in December 2010.

Additionally, to commemorate a decade of this work, in December 2015, a national conference was held in Thirthahalli, titled “Deliberations on Care Delivery (DECADE) for Mental Illnesses in Rural Communities”. Following topics were discussed: (a) 10 years-experience of treating patients with severe mental disorders in their own communities (b) Challenges in reaching psychiatric care to patients: reflections on the National Mental Health Program (c) Role of Community Health Workers and how to harness them? (d) Challenging Neuropsychiatric cases in rural practice (e) managing alcohol use disorders at Primary Health Care Centers and (f) Relevance of Mental Health Care Bill 2013, on community treatment. Experts from all over the country actively participated in the deliberations.

For this work, our team has got excellent support from the department of health and family welfare and the taluk hospital of Thirthahalli. We have been able to manage funds from various sources to continue our service-cum-research activities thus far (i.e., from the National Mental Health Program’s research funds and grants from NIMHANS, including the team’s funds from pharmaceutical company supported clinical trials). These funds are used for the following purposes: travel, lodging and boarding for the research staff, salary support for the research staff, medication and in-patient admission costs for patients and other contingencies till date, 400 patients with schizophrenia have been identified. They are being treated and followed-up (around 12,000 follow-up visits). The number of patients with other disorders that the team has treated till now is about 4000 (totally 22,000 follow-ups till date). We have trained around 60 health workers in Thirthahalli taluk.  We have also been bearing the occasional inpatient admission charges for patients. Needless to say, this program has benefited patients and families immensely in terms of the easy access to psychiatric care and clinical benefits. From clinical, epidemiological and public health research points of view, this cohort is a unique one in the country, wherein the entire patient population of the taluk is accessible in their natural living environment. Consequently, the data that gets generated will not only be clinically meaningful, but also will have important public health and policy level implications.

The Turuvekere (TURUVECARE) Program:

This community intervention program (Treating the Untreated Psychosis in Rural Community: Variation in the experience of care, TURUVECARE) at Turuvekere taluk, Tumakuru district was started in December 2009. Like in Thirthahalli, our team aimed to identify and treat all patients with schizophrenia in the taluk in addition to the research questions. Initial funds came from the American Psychiatric Association as an award to Dr Naveen Kumar, one of our team members. The award was provided with the specific objective of studying metabolic complications of antipsychotic medications among patients with schizophrenia. After this, two more research grants were obtained, one from the
Government of Karnataka (Dr Jagadisha Thirthalli, to study the variation in experiences of caring patients with psychosis) and the other from the Department of Biotechnology, Government of India (Dr Jagadisha Thirthahalli for studying parental consanguinity in patients with schizophrenia and comparing with that of general population). Another important academic achievement from Turuvekere is related to post-graduate theses. Three MD dissertations and one PhD dissertation have come out from this program. In addition, one PhD thesis is ongoing from these cohorts. These theses form unique contributions to the area and have yielded interesting findings. Experience related to service delivery is identical to that of Thirthahalli. Till date, 260 patients with schizophrenia are identified, treated and are being followed-up (total of 3500 follow follow-ups till date). The total number of patients with other psychiatric disorders is 2500 (total 6000 follow-ups till date). As in the case of Thirthahalli, the team has treated four to five patients with other psychiatric disorders for every patient with schizophrenia.  In addition, we have liaised with the local Lion’s club of Turuvekere in conducting periodic health camps. The number of psychiatric patients who have been treated in these camps amounts to 3500. The team has issued around 500 disability certificates to patients with psychiatric disability. The team has trained 50 doctors, 50 nurses, 54 health workers and 300 ASHA workers. They all have been trained in the identification/treatment/referral of persons with psychiatric disorders. Even here, our team is getting excellent support from the taluk health administration.

In a recent development, we have partnered with Chitta Sanjeevini Charitable Trust, an NGO supported by the Infosys Foundation and Lions Club International in Thirthahalli and Turuvekere to provide psychiatric medications, which are not available through the government sources. With this, we have been able to provide medications that not only treat the illness, but also improve their productivity and quality of life.

Most recently, alumnus of NIMHANS, friends and well-wishers have been voluntarily donating funds to keep both these programs running. Finally, a three-years research project has been sanctioned to Dr Naveen Kumar by the Department of Science and Technology, Govt. of India.  The aim of this project is to examine the relevance of ‘social-cognition’ deficits with regards to functioning of persons with schizophrenia in these two taluks.

In the process of all these, we have gained awareness of the ways in which the health system and the community interacts at the grass-root level. Continuing these two endeavors would have immense benefits to all the stakeholders including patients, their families and local health administration. Needless to say, we could gain insights into a number of research questions with a lot of public health importance.

Summary of the activities from these two community intervention programs:

The details of the publications are given after the table

Schizophrenia patients identified660
Number of follow-ups for schizophrenia patients (Approximate)15,500
Number of other patients identified and followed up (Approximate)28,000
Numbers of disability certificates issued800
Publications15
Papers presented in conferences36
Number of awards/prizes won15
MD theses3 completed
PhD theses1 completed; 1 ongoing
Other dissertations1 MSW thesis, 1 MPhil (PSW) thesis
Number of Health Professionals including ASHAs trained500 (including doctors, nurses, health workers and ASHA workers
Continued Medical Education Programs held (December 2010)1 in Kavishaila of Thirthahalli Taluk, for psychiatry postgraduate students of Karnataka
National Conference on Community Psychiatry (December 2015)1 in Thirthahalli, titled “Deliberations on Care Delivery (DECADE) for Mental Illnesses in Rural Communities”
Number of trained stake holders in the community200 (such as anganwadi workers, traditional faith healers, community leaders etc)
Newspaper articles on these two programs and about severe mental disorders11
Interactive programs with community leaders5

PUBLICATIONS:

  1. Kumar CN, Kumar CN, Thirthalli J, Suresha KK, Venkatesh BK, Kishore Kumar KV, Arunachala U, Gangadhar BN. Antipsychotic Treatment, Basic Psycho-Education and Regular Follow-Up as a Public Health Strategy for Schizophrenia: Results from A Naturalistic Prospective Study (Under Peer Review Process)
  2. Kumar CN, Thirthalli J, Suresha KK, Venkatesh BK, Kishore Kumar KV, Arunachala U, Gangadhar BN. Reasons for schizophrenia patients remaining out of treatment. Results from a prospective study in a rural south Indian Community. Indian J Psychol Med (in Press)
  3. Kumar CN et al. Public Health Interventions in Psychotic disorders in India: Is it time to rethink? This paper won the Tilak Venkoba Rao Oration Award, ANCIPS 2015, Hyderabad, India
  4. Kumar CN, Thirthalli J, Suresha KK, Arunachala U, Gangadhar BN. Alcohol Use Disorders in patients with schizophrenia: comparative study with general population controls. Addictive Behaviors 2015; 45: 22-25
  5. Kumar CN, Suresha KK, Thirthalli J, Arunachala U, Gangadhar BN. Caregiver Burden in Schizophrenia Patients: Study from a Rural Setting of South India. International Journal of Social Psychiatry 2015; 61: 157-63 (Rated as 3rd topmost paper in the BioMedLib in this domain)
  6. Virupakshappa IB, Thirthalli J, Girish N Rao, Kumar CN, Suresh KK, Gangadhar BN. Standardized Mortality Ratio in patients with Schizophrenia – Findings from Thirthahalli, a rural south Indian community. (in Press; Indian J Psychol Med). This paper bagged the Dr SS Jayaram Award, IPSOCON 2014, Kumarakom, India
  7. Reddy KS, Thirthalli J, Kumar CN, Krishnareddy NR, Renukadevi NR, Rawat VS, Narayana M, Ramakrishna J, Gangadhar BN. Factors influencing access to psychiatric treatment in persons with schizophrenia: a qualitative study in a rural community. Indian J Psychiatry 2014; 56: 54-60.
  8. Reddy KS, Thirthalli J, Kumar CN, Reddy NK, Renukadevi NR, Rawat VS, Ramkrishna J, Gangadhar BN (2013). Schedule of factors influencing access to psychiatric treatment in persons with schizophrenia: validity and pilot testing. Indian Journal of Psychological Medicine. 35:364-367.
  9. Kumar CN, Thirthalli J, Suresha KK, Arunachala U, Gangadhar BN (2013). Metabolic syndrome among schizophrenia patients: Study from a rural community of south India. Asian Journal of Psychiatry. 6:532-536
  10. Suresh KK, Kumar CN, Thirthalli J, Bijjal S, Venkatesh BK, Arunachala U, Kishorekumar KV, Subbakrishna DK, Gangadhar BN (2012). Work functioning of schizophrenia patients in a rural south Indian community: status at 4-year follow-up. Social Psychiatry and Psychiatric Epidemiology 47:1865-1871
  11. Manjunatha N, Reddy SK, Renuka Devi NR, Rawat V, Bijjal S, Kumar NC, Kishrore Kumar KV, Thirthalli J, Gangadhar BN (2013). Delusional Procreation Syndrome: Report from TURUVECARE Community Intervention Program. Indian Journal of Psychological Medicine 35:214-216.
  12. Manjunatha N, Reddy KS, Renuka Devi NR, Rawat V, Bijjal S, Kumar CN, Thirthalli J, Gangadhar BN. Delusion of polygamy in proxy: An addition in delusional procreation syndrome. Indian J Psychiatry. 2011 Jul;53(3):266-9. doi: 10.4103/0019-5545.86822. PubMed PMID: 22135449; PubMed Central PMCID: PMC3221187
  13. Thirthalli J, Venkatesh BK, Naveen MN, Venkatasubramanian G, Arunachala U, Kishore Kumar KV, Gangadhar BN. Do antipsychotics limit disability in schizophrenia? A naturalistic comparative study in the community. Indian J Psychiatry. 2010 Jan;52(1):37-41. doi: 10.4103/0019-5545.58893.
  14. Gangadhar BN, Thirthalli J. Differential outcome of schizophrenia: Does cultural explanation suffice? Asian J Psychiatr. 2009 Jun;2(2):53-4. doi: 10.1016/j.ajp.2009.04.001. Epub 2009 May 20. PubMed PMID: 23051028.
  15. Thirthalli J, Venkatesh BK, Kishorekumar KV, Arunachala U, Venkatasubramanian G, Subbakrishna DK, Gangadhar BN. Prospective comparison of course of disability in antipsychotic-treated and untreated schizophrenia patients. Acta Psychiatr Scand. 2009 Mar;119(3):209-17. doi: 10.1111/j.1600-0447.2008.01299.x. Epub 2008 Nov 24. PubMed PMID: 19053968. This paper won the Poona Psychiatrists Association’s Award for the Best Published Paper by a Member of the Indian Psychiatric Society for the year 2009-10.
  16. Venkatesh BK, Thirthalli J, Naveen MN, Kishorekumar KV, Arunachala U,  Venkatasubramanian G, Subbakrishna DK, Gangadhar BN. Sex difference in age of onset of schizophrenia: findings from a community-based study in India. World Psychiatry 2008 Oct;7(3):173-6. PubMed PMID: 18836543; PubMed Central PMCID: PMC2559927
  17. Thirthalli J, Venkatesh BK, Gangadhar BN. Psychoses and illicit drug use: need for cross-cultural studies. Acta Psychiatr Scand. 2008 Jul;118(1):86; author reply 86-7. doi: 10.1111/j.1600-0447.2008.01209.x. Epub 2008 May 14. PubMed PMID: 18489616.
  1. AWARD PRESENTATIONS 

         1. Kumar CN et al. Public Health Interventions in Psychotic disorders in India: Is it time to rethink? This paper won the Tilak Venkoba Rao Oration Award, ANCIPS 2015, Hyderabad, India

         2Virupakshappa IB, Thirthalli J, Girish N Rao, Kumar CN, Suresh KK, Gangadhar BN. Standardized Mortality Ratio in patients with Schizophrenia – Findings from Thirthahalli, a rural south Indian community. (in Press; Indian J Psychol Med). This paper bagged the Dr SS Jayaram Award, IPSOCON 2014, Kumarakom, India

         3. Reddy et al. (2012). Why do persons with schizophrenia discontinue psychiatric treatment: a qualitative study from Turuvekere, a rural community? This poster won the best poster award at the Rehabilitation symposium, NIMHANS, September 2012. This poster highlighted the complex and dynamic reasons that drive each family to discontinue psychiatric treatment

          4. Suresha et al. (2012). Disability and its correlates in schizophrenia after six years of follow-up: A study from Thirthahalli, a south Indian taluk. This poster won the best posteraward at the Rehabilitation symposium, NIMHANS, September 2012. This piece of research also highlighted the importance of continued antipsychotic use for reducing the disability associated with schizophrenia

          5. Reddy et al. Barriers to Access Mental Health Care in a Rural Community: Preliminary findings from a Qualitative Analysis. Best paper award at the Annual National Conference of the Indian society for psychiatric social workers at Cochin, India, February 2011

          6. Shashank et al. (2011). Areca Nut Use among Rural South Indian Schizophrenia Patients: A Comparative Study. This paper won the best poster award at  IPSOCON-2011, Visakapatnam, India

         7. Kumar et al. (2012). Four year follow-up of schizophrenia in a rural community: Good outcome and public health implications. Won the travel award for the World Psychiatric Association Conference, Bali

         8. Suresh et al. (2009). Factors Associated with Caregiver Burden in Schizophrenia Patients: Study from a Rural Setting. Best paper award at the Annual National Conference of the Indian society for psychiatric social workers at Bheemavaram, India, February 2009, Bheemavaram, India

         9. Thirthalli J, Venkatesh BK, Kishorekumar KV, Arunachala U, Venkatasubramanian G, Subbakrishna DK, Gangadhar BN. Prospective comparison of course of disability in antipsychotic-treated and untreated schizophrenia patients. Acta Psychiatr Scand. 2009 Mar;119(3):209-17. doi: 10.1111/j.1600-0447.2008.01299.x. Epub 2008 Nov 24. PubMed PMID: 19053968. This paper won the Poona Psychiatrists Association’s Award for the Best Published Paper by a Member of the Indian Psychiatric Society for the year 2009-10

       10. Thirthalli J, Venkatesh BK, Naveen MN, Venkatasubramanian G, Arunachala U, Kishore Kumar KV, Gangadhar BN. Do antipsychotics limit disability in schizophrenia? A naturalistic comparative study in the community. Indian J Psychiatry. 2010 Jan;52(1):37-41. doi: 4103/0019-5545.58893. PubMed PMID: 20174516; PubMed Central PMCID: PMC2824979

Bombay Psychiatric Society Silver jubilee (BPSS) Award at the Annual Conference of Indian Psychiatric Society (ANCIPS) at Chennai, January 2007

Dr. SS Jayaram Award for the best paper at Annual Conference of Indian Psychiatric Society, South Zone – IPSOCON- at Mangalore, October 2006

PRESENTATIONS

  1. Kumar CN (2013). Why do Schizophrenia Patients discontinue Psychiatric Treatment? Study from a Rural Community of Southern India (Control ID 1529275). Selected for presentation at the 14th International Congress on Schizophrenia Research. The meeting will be held 21-25 April 2013 at the JW Marriott Orlando in Grande Lakes, Florida
  2. Bijjal et al. (2013). Prospective study of Metabolic Abnormalities in Schizophrenia Patients Living in a Rural Community. Selected for presentation at the 14th International Congress on Schizophrenia Research. The meeting will be held 21-25 April 2013 at the JW Marriott Orlando in Grande Lakes, Florida
  3. Reddy KS et al. (2013). Factors Affecting Access to Psychiatric Care: Results From a Study of Never Treated Schizophrenia Patients in a Rural Setting. Presented at the International conference on changing faces of Social Work Profession in the New Millennium 21-23 February, Karnatak University, Dharwad, India
  4. Suresha KK et al. (2013). Alcohol use among schizophrenia patients in a rural south Indian community. Presented at the Annual conference of the Professional Social Workers, Manipal, India
  5. Suresha KK et al. (2013). Role of Self Help Groups and Income Generation Programs towards Real World Functioning of Persons with Schizophrenia: Experience from the Thirthahalli Cohort. Presented at the International conference on changing faces of Social Work Profession in the New Millennium 21-23 February, Karnatak University, Dharwad, India
  6. Thirthalli et al. (2012). Metabolic Syndrome in Community-Dwelling Schizophrenia Patients. Presented at the 5th International Conference on Schizophrenia, Chennai, India
  7. Suresh et al. (2012). Factors Associated with Caregiver Burden in Schizophrenia Patients of Thirthahalli. Presented at the 5th International Conference of Schizophrenia, Chennai, India
  8. Reddy KS et al.(2012). Schedule to assess factors influencing access to psychiatric care in patients with schizophrenia (SOFIAc): Face and Content Validity. Presented at the 5th International Conference of Schizophrenia, Chennai, India
  9. Suresh et al. (2010). Work Functioning of schizophrenia Patients in a Rural South Indian Community: Status at 4 years Follow-up. Presented at the Annual Conference of professional social workers, Nellore, India
  10. Kumar et al. (2011). Four year follow-up of schizophrenia in a rural community: Good outcome and public health implications. Paper presented at ANCIPS-11 for the Marfatia award
  11. Jagadisha T (2010). Treating Psychiatric Patients in Rural India: Relevance to Practice-based Research. Presented at the Royal College of Psychiatrists’ conference, NIMHANS, Bangalore, India
  12. Thirthalli J (2009). Reasons for Schizophrenia Patients Remaining out of Treatment: Results from a Prospective Study in a Rural South Indian Community. Presented at the World Congress on Psychosocial rehabilitation, World Association for Psychosocial rehabilitation, Bangalore, India
  13. Kumar et al. (2008). Screening for metabolic syndrome among schizophrenia patients: Results from a rural community setting. Selected for presentation for the award for research by young mental health professionals at the 3rd International Conference of Schizophrenia (ICONS) at Chennai October 17-19, 2008
  14. Thirthalli J, Kudumallige S, Suma KV, Venkatesh BK, Naveen M, Venkatasubramanian G, Aruachala U, Kishore Kumar K, Gangadhar BN (2007). Ethical issues in community study of severe mental disorders in India: The Thirthahalli Experience. Presented in the second National Bioethics Conference, NIMHANS, Bangalore, December 2007

List of funded research projects that operated in these two community intervention programs

Sl No

Name of the Research Project

Granting agency

Funding amount

1

Community Intervention in Psychotic Disorders

National Mental Health Program, Government of India

Rs 15,00,000

2

Incidence and determinants of metabolic complications of antipsychotics in community-dwelling schizophrenia patients in India

American Psychiatric Association (APA)/American Psychiatric Institute of Research and Education (APIRE)

Rs 15,00,000

3

Epidemiology of Tardive Dyskinesias in a sample of schizophrenia patients in rural south India

NIMHANS, Bangalore

Rs 2,00,000

4

Parental consanguinity among schizophrenia patients living in a rural community of south India: A clinical and genetic investigation

DBT, Government of India

Rs 36,00,000

5

Treating Untreated psychosis in Rural community: Variation in the Experience of Care (TURUVECARE)

Government of Karnataka

Rs 25,00,000

6

Real-World Functioning of Schizophrenia Patients living in a Rural South Indian Community

NIMHANS, Bangalore

Rs 1,80,000

7

Prospective study of metabolic abnormalities among patients with schizophrenia in a rural south Indian taluk

NIMHANS, Bangalore

Rs 1,65,000

8

Rehabilitation needs of persons with schizophrenia living in a rural south Indian community

NIMHANS, Bangalore

Rs 3,50,000

9

Explanatory Models of Illness and the use of Traditional Complementary and Alternative System of Medicine among Rural Patients with Psychiatric Disorders

NIMHANS, Bangalore

Rs 2,00,00

* This grant was part of the APA/AstraZeneca Young Minds in Psychiatry International Awards Program is a commitment by the American Psychiatric Association (APA) and Astra Zeneca to recognize and support promising international young psychiatrists within 5 years of completing a psychiatric residency. This award was granted to Dr Naveen Kumar in the year 2009.

 

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