Primary Care Psychiatry Program (PCPP) – DMHP Uttarakhand

Primary care psychiatry program (PCPP) is a four-module based one-year specialized program to train the primary care doctors (PCDs) for identifying, diagnosing and managing psychiatric conditions. The four modules are,

1. Basic (Onsite, 10 days, residential)
2. Advanced (Tele-On Consultation Training (OCT)
3. Videoconference based Continuing Skill Development (V – CSD)
4. Collaborative Video Consultation (CVC) modules

The program has been currently implemented in the state of Uttarakhand and 10 PCDs from different districts of Uttarakhand are currently undergoing training. The program commenced from March 2018.

Other than the basic module, the remaining 3 modules are digitally driven. It uses the principle of adult learning, bottom-up approach and Indian psychiatry is customized to Indian PHC practice. PCPP follows Clinical Schedules for Primary care psychiatry (CSP) version 2.1 as a teaching manual for the PCDs. CSP is an adopted version of psychiatry for the use of PCDs for rapid screening and to provide early diagnosis and first-line treatment in an outpatient setting for adult patients of primary healthcare. CSP uses trans diagnostic, cluster approach for diagnosis, and pharmacological approach for the treatment purpose. The list of psychiatric disorders covered in CSP 2.1 are Tobacco addition, Alcohol disorders, Psychotic, Somatization, Anxiety (generalized anxiety and panic disorders), and Depressive disorders (Mnemonic for this list is TAP SAD).

1. Basic module

In the basic module, all 10 PCDs came to NIMHANS from 15^th – 24^th march, 2018. They were provided accommodation in the resident’s hostel and food was arranged from catering service of NIMHANS. In this module, PCDs were trained through demonstrating psychiatric history-taking and mental state examination. In-Person On-consultation Training (I-OCT) of first contact outpatient patients was conducted. During I-OCT, 10 PCDs were trained to identify, investigate, treatment, follow up and referral advice of CMDs, SUDs and SMDs conditions using validated CSP version 2.1 (Manjunatha et al., 2017b; Karishma et al., 2018). Along with I-OCT, all PCDs  underwent didactic teaching sessions in Common mental disorders (CMDs), teaching sessions on specialised topics such as Emergency psychiatry, Electro Convulsive Therapy (ECT), Child psychiatry, Forensic and legal aspects of psychiatry along with visits to few PHCs of Karnataka. They also received orientation on Tele-OCT sessions.         

The schedule of the basic module is given in table Ia and Ib. It involves introduction to the program, live demonstration of first contact OPD, discussion about CSP, didactic sessions about the common metal disorders, field visit to PHCs of Karnataka, Tele –OCT orientation and etc. 

Table Ia – Content of Class room based training (CRT) curriculum of the basic module of PCPP

Table Ib – Overall clinical teaching/ training in the basic module 

2. CVC module

In the CVC module, the Tele Psychiatrist will be available to the PCDs from 9 am to 4.30 pm for discussion of cases. PCDs choose to discuss their patients to decide best treatment for the particular patient. Some of these patients will also been seen in follow-ups up to 6 months whenever these patients visit these doctors.

3. V CSD module

In the V CSD module, there will be peer learning approach. Weekly 1 hour online session (Tuesday, 3-4 pm) is scheduled for didactic lecture by the participant PCDs on various topics of the psychiatric illness. The content of presentation is collaborative prepared by Tele-Psychiatrist hired for this project & verified by the consultant before presentation.

4. Tele OCT module

In the Tele OCT module, live consultation of their general patients happen from entry to exit and includes prescription template/writing. Tele-psychiatrist assist for psychiatric patients, if found. PHC doctors provide regular treatment to their non-psychiatric/ general patients and we learn from them.

The program has evaluation criteria based on 10 factors and the PCDs are assessed periodically on these criteria’s and updated to the NMHP Uttarakhand and the PCDs.

Evaluation Criteria –

1. One case conference (collaborative & verified)
2. One seminar (collaborative & verified)
3. 25 CVC consults
4. 6 months follow-up of at least 5 patients
5. Weekly patients audit of total and psychiatric disorders (TAP DAS)
6. Weekly prescription audit of psychiatric medications
7. Substantial attendance for v-CSD module
8. Evaluation sessions for Tele-OCT at end of training & subsequently every 3-4 months (at least 3 evaluations)
9. Delivery of at least One public initiative
10. Designing at least One public education material

Outcome –

1. Total number of patients consulted (at the end of 10 weeks) – 7771
2. Total number of Psychiatric patients consulted (at the end of 10 weeks) – 794
3. First time psychiatric consultations (at the end of 10 weeks) – 794
4. Follow up psychiatric consultations (at the end of 10 weeks) – 166
5. Diagnosis of Common Mental Disorders – 68%
6. Diagnosis of Substance Use Disorders – 24%

Total CVC till –