Tuesday, 22 December 2020

Biopsychosocial Model of Healthcare and doctor-patient relationship

The biopsychosocial model of healthcare emphasizes the following paradigms of doctor-patient relationship

  • Psychosocial assessment,
  • Use of communication skills,
  • Informational care,
  • Counseling,
  • Crises intervention, and
  • Extension of care to the family.



"The biopsychosocial model is an interdisciplinary model that looks at the interconnection between biology, psychology, and socio-environmental factors. The model specifically examines how these aspects play a role in topics ranging from health and disease models to human development. George L. Engel developed this model in 1977 and is the first of its kind to employ this type of multifaceted thinking. The biopsychosocial model has received criticism about its limitations but continues to carry influence in the fields of psychology, health, medicine, and human development."

Source: Biopsychosocial model - https://en.wikipedia.org

Monday, 21 December 2020

Mental Health Professionals As ‘Silent Frontline Healthcare Workers’: Perspectives from Three South Asian Countries

Mental Health Professionals As ‘Silent Frontline Healthcare Workers’: Perspectives from Three South Asian Countries

Sheikh Shoib1, Anoop Krishna Guppta2, Waleed Ahmad3, Shijo John Joseph4, Samrat Singh Bhandari4


Mental health professionals across the globe foresaw the mental health impact of the coronavirus disease 2019 (COVID-19) pandemic. They have faced a scarcity of trained professionals, rising morbidities, lack of protective gear, shortage of psychotropic drugs, and poor rapport building because of masking and social distancing. Amidst all, they have responded with approaches that focus on continuing mental health services to the patients already in care, educating the vulnerable people to help them cope with these stressors, and providing counselling services to patients and families affected by the pandemic.


The unprecedented impact of the coronavirus disease 2019 (COVID-19) pandemic has caused a jolt to various realms of life and various groups of people globally. There is a plethora of mental health and psychosocial issues associated with COVID-19. The psychological repercussions of the pandemic in the general population and amongst health professionals may last a long time compared to the acute medical crisis. The enduring outcomes of this pandemic are not yet fully estimated. Early screening of mental health and timely action can go a long way in improving the quality of people affected.[1,2] Mental health professionals across the globe foresaw the mental health impact of such an extraordinary crisis and have responded with approaches that focus on continuing mental health services to the patients already in care, educating the vulnerable people to help them cope with these stressors, and providing counselling services to patients and families affected by the pandemic.

Examples from all over the globe have proven that mental healthcare workers have been on the frontline but, peculiarly, deal with the crisis times. Among other regions in Italy, in Lombardi, Mental health workers provided mental health services to the citizens most severely struck by the pandemic on priority, and providers ensured continuous provision. [3] The psychiatry service in Spain formulated a contingency plan reorganising human resources, closing some units and shifting to telepsychiatry practice, alongside two programmes specifically focusing on the homeless.[4] Comparable changes have been described and suggested in the United States[5] and France[6] to strengthen mental healthcare delivery during challenging times. The United Kingdom Academy of Medical Sciences and Mental Health Charity took the initiative in the early weeks. They suggested the acute need for quality research to discover the vulnerable groups and the effects of COVID-19 on the brain’s functioning.[7] China provided telemental health services, including supervision, training, and psychological services (counselling and psychoeducation) to the people highly susceptible to the infection.[8] In Australia, officials increased the funded services and appointed consultants and specialists, whereas they did not focus on facilitating the people in mental health services.[9] In Malaysia, online counselling services and psychological first-aid were provided to the people throughout the pandemic by utilising reactive support systems.[10]

The authors have, with this, thrown some light on their perspectives on the contributions of mental health professionals as frontline healthcare workers in India, Pakistan, and Nepal.


A report from the World Health Organization (WHO) mentions the Government’s total expenditure on mental health in India as 1.30 % of the overall government health expenditure. The country has only 0.29 psychiatrists per 100,000 people.[11] There is undeniably a shortfall in the quantity and quality of mental health services and their distribution in the country. Another publication estimates the number of psychiatrists in India currently as about 9000 and the number of psychiatry graduates per year as about 700. Based on these estimates, India has 0.75 psychiatrists per 100,000 population, against the preferable number of at least three psychiatrists per 100,000. With 3 psychiatrists per 100,000 population as the preferable number, the study mentions that the number of psychiatrists required to reach the desired ratio in India is 36,000. The country is currently short of 27,000 psychiatrists based on the current population.[12] According to a survey conducted by the Indian Psychiatric Society (IPS), there has been an increase in cases of mental health disorders in India by 20% within a week of the commencement of the nationwide lockdown. The country can anticipate a major mental health crisis resulting from unemployment/loss of jobs, alcohol use issues, financial adversity, intimate partner violence, and monetary liabilities in the subsequent months. The at-risk population comprises around 150 million persons with existing psychological issues, survivors of COVID-19, frontline healthcare workers, youngsters, differently-abled persons, female adults, those working in unorganised sectors/immigrant workers, and older adults. The current need is to construct a community-based capacity to manage local issues long after the acute stage of the pandemic.[13]

Considering the potential of relapse of illness, if psychotropic medications are not made available to patients due to a lack of new prescriptions, society has asked to relax the norms so that patients can get their refills with old prescriptions or through online prescriptions till the crisis is over.[14] The various state branches under the aegis of IPS have made available a list of over 650 psychiatrists who have volunteered to meet the need of the affected population. This voluntary telepsychiatry service will provide psychological support to patients with pre-existing psychiatric conditions and healthcare workers involved in the care of COVID-19 patients.[15]

To assist, educate, and advise psychiatrists towards providing telepsychiatry services as a routine in their clinical practice, IPS and the National Institute of Mental Health and Neuro Sciences (NIMHANS) have brought out an operational guide aimed at practising psychiatrists in India as well as low and middle-income countries (LAMIC). This guide covers legal, technology, electronic case documentation, consultation, online prescription, teletherapy aspects, basic minimum standards for documentation, and proformas for ready reference and use by the patients/their relatives/nominated representatives, and the psychiatrists.[16] With practice guidelines and standard operating procedures available, telepsychiatry seems well set for gaining wider acceptance and adoption in India.


In Pakistan, mental health service providers have responded similarly and have faced special challenges. There is a shortage of mental health professionals, with only a few hundred fully trained psychiatrists and almost non-existent psychotherapeutic services. The current pandemic has worsened the situation even further. Psychiatrists and other mental health professionals have responded with various programmes to mitigate the impact of COVID-19 on the mental health of the citizens and the mental health services. Almost all hospitals across Pakistan provide free telepsychiatry services to patients in their respective areas. Similarly, the Pakistan Psychiatric Society has been active in supporting the nation’s mental health, carrying out social media awareness campaigns and making suggestions to the Government of Pakistan to take steps in this direction.[17] The Aga Khan University Hospital, Karachi, launched a mental health programme for children and adolescents to help and train parents to do therapies at home and enable them to deliver rehabilitation to their children in such needs.[18] Likewise, an Online Mental Health Rapid Response Team started providing counselling to patients from remote areas of Pakistan.[19]

Because of the lack of reliable internet connectivity across the country, especially in rural areas, and low education rates, providing internet-based services has not been without its own problem. The consensus among psychiatrists is that patients have not been seeking telepsychiatry services as expected. Similarly, the response of the Government of Pakistan has been lukewarm.


The Nepalese society believes that a doctor should always work selflessly despite the pain. Health professionals in Nepal have already been facing anxiety and depression.[20] Lack of personal protective gear, inadequate hospital infrastructure, stigma towards healthcare workers, and lack of governmental preparedness have worsened the already prevalent burnout in a resource-deprived health system.[21-24]

Mental healthcare workers (MHW) face additional hindrances. Uses of masks and social distancing in psychiatry have only blunted the interview and therapeutic effects due to poor rapport and slowed communication.[25] MHWs have been working in a situation where a psychiatric pandemic is looming over. They are known and expected to spend more time than other professionals due to extensive history, psychotherapy, and counselling. They are expected to listen patiently and lend tissue to weeping patients daily during a pandemic or later. Thus, limited contact or exposure is impractical.

Most of the psychiatrists in Nepal are known to serve through satellite clinics. They have not been able to continue that since the Government implemented the country-wide lockdown on March 24, 2020.[26] In the absence of consultation, old cases have worsened, and an increased suicide rate during the pandemic.[21] The unavailability of medicines in rural areas has added to the misery. Local pharmacists tend not to provide psychotropic drugs without a prescription. Nepal has only 0.36 psychiatrists per 100,000 population.[27] Amidst this, they have been working without complaining. Additionally, they have used online social platforms and telepsychiatry to serve the needy. Most of the service they offer is for free. The Psychiatrists’ Association of Nepal has provided free helpline numbers. Local psychiatrists have volunteered, and each has received up to 30 calls per day! Some have been posting educational videos, while others are attending webinars and discussions on social media intending to alleviate anxiety and combat depression in the general population. Several pages and blogs have been created over the last few months, and the only reward expected is someone being benefited. This has been useful in LAMIC before.[28]

In conclusion, the silently working Nepalese psychiatrists are likely to have increased work after the lockdown is lifted shortly. We suggest task shifting as a handy tool to serve Nepalese remotely located on the rugged landscape. We need to train local community workers and paramedics to assist the overworked MHWs.


Hopefully, perspectives from these three South Asian countries will take the readers through a roller coaster ride of the role of mental health professionals on the frontline. It highlights the lack of mental health professionals to face the impending psychiatric pandemic. The common hindrances faced by India, Pakistan, and Nepal are poor social connectivity, possible scarcity of psychotropic drugs, and failed outreach clinics. The complex landscapes, especially in the northern part of these three countries, have added to the misery. However, the silver lining that appears to be is telepsychiatry that can make it possible to reach the socially and geographically distanced population (Table 1).

It is also imperative to focus on survivors and healthcare professionals following the pandemic in alleviating the burden of distress in humans. Peer support can alleviate this anguish, encouraging social connections and improving physical safety. Social distancing need not be emotional distancing. Also, there cannot be a better time than now to promote Mental Health Gap Action Plan (mhGAP). Thus, psychiatrists can train local practitioners and primary care physicians to treat and counsel local patients under supervision. This is likely to alleviate mounting stress for mental healthcare workers. Last but not least, the health of MHWs needs to be prioritised by the respective governments to sustain the health system during the psychiatric pandemic that is likely to follow.

About the Authors

1Jawahar Lal Nehru Memorial Hospital, Srinagar, Jammu and Kashmir, India, 2National Medical College, Birgunj, Nepal, 3Department of Psychiatry and Behavioural Sciences, Peshawar Medical College, Mercy Teaching Hospital, Peshawar, Pakistan, 4Department of Psychiatry, Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim, India

Saturday, 19 December 2020

NICE Guidance on Electroconvulsive Therapy

NICE recommends to use electroconvulsive therapy (ECT) only to attain quick and short-term improvement of severe symptoms if an adequate trial of other options has not been effective and/or when the condition is considered to be potentially life-threatening, in individuals with:

  • catatonia
  • a prolonged or severe manic episode.

Indication to an individual must be based a documented assessment of the risks and potential benefits to the individual.

Exercise caution when considering electroconvulsive therapy during pregnancy, in older people, and in children and young people.

Valid consent should be obtained in all cases where the individual can grant or refuse consent. The decision to use electroconvulsive therapy should be made jointly by the individual and the clinician(s) responsible for treatment, based on an informed discussion after full information about the risks and potential benefits, without pressure or coercion, the involvement of patient advocates and/or carers is strongly encouraged.

If informed consent is not possible advance directives should be taken fully into account.

Clinical status should be assessed following each electroconvulsive therapy session and treatment should be stopped when a response has been achieved, or sooner if there is evidence of adverse effects.

Cognitive function should be monitored on an ongoing basis, and at a minimum at the end of each course of treatment.

Repeat Course

Consider a repeat course under the circumstances indicated for patients who previously responded. In patients who have not previously responded, a repeat trial should be undertaken only after all options have been considered and following discussion with individual/carer/advocate.


Do not recommend to patients with schizophrenia.


For patients with depression, see use electroconvulsive therapy as recommended in the NICE guidance on the treatment of depression.

What are the components of the Positive behavior support (PBS)

Components of the Positive behavior support (PBS)

  1. System change
  2. Environmental alterations
  3. Skill intrusion—teaching the student alternative behaviors
  4. Behavioral consequences

What is functional communicative training?

Functional communicative training:

Teaching children to ask for what he/she wants through language instead of problem behavior.

Wednesday, 16 December 2020

What is the approximate salary package in the psychiatric department for a junior doctor?

Is it different from the ED salary packge for a junior SHO level?
My current packge is 42,969 plus 50% banding = 64,453 per annum in emergency duty, junior level non-trainee post.
Will it decrease if I move to a non-trainee SHO (speciality house officer) post in the same trust in psychiatry?

£64,000 is a good salary for a junior doctor.
The salary packages depend on level of responsibility and frequency of oncalls.
All jobs advertised will have a range & given your previous experience you can ask them to give you higher side of the range

It will definitely go down but you will have more time and more work life balance,—more valuable than money.

I assume your salary is so high as there is so much unsocialable hours. I imagine base salary will be the same but total less as just some twilights, night and weekends- normal day will be 9-5. It should say pay in the job description

Tuesday, 15 December 2020

Can you apply for the MTI UK Scheme before passing MRCPsych?

You do not need to pass MRCPsych paper-A or Paper B before you apply for the MTI. You can apply to the program before passing any part of the MRCPsych exams. The following are your requirements to enter the MTI scheme. 

  1. GMC-recognized primary medical qualification from an internationally accepted medical institution. 
  2. An acceptable internship (or equivalent) of 12 months. 
  3. Three years of experience working in Psychiatry in the last five years. 
  4. Working in psychiatry for the last year. 
  5. A score of 7.5 in IELTS academic or grade b on OET taken in the last 18 months.  
  6. You have received or will work towards a postgraduate qualification in psychiatry.

What is the discrete trial format?

The discrete trial format:

It is one to one, Short and clear instructions, Planned, uses prompting and prompt fading, reinforcement.

Monday, 14 December 2020

What was the 1970s psychoanalytic approach to children with autism?

The 1970s psychoanalytic approach:

Applied Behavior Analysis (ABA), based on operant-conditioning, target behaviors (excess of unwanted and or deficits of wanted) are modified with reinforcement approximations (shaping).

Applied behavior analysis, also called behavioral engineering,
applying empirical approaches based upon the principles of respondent and operant conditioning to change behavior of social significance. It is the applied form of behavior analysis; the other two forms are radical behaviorism and the experimental analysis of behavior. (Wikipedia)

1960s Psychoanalytic Approach to Children with Autism

The 1960s psychoanalytic approach to children with autism:

Base on Lovaas- socialization study

Building social behavior in children with autism by use of electric shock. Method- use of identical twins: Tell them to come here and shock them until they move toward the experimenter. They based applied behavior analysis on it, supported by decades of research behind the Lovaas approach and more if you include the research into Skinner's theories, on which they base it.

Predictors of response

  1. Early: better the outcome in younger children. 
  2. Intensive more sessions per week. 
  3. Duration: longer duration of therapy. 
  4. With Parents: Children accompanied by parents in therapy do better.

What are the psychoanalytic approaches to the treatment of patients with autism?

Holding therapy (Tinbergen 1983):
A failure to bond Parent holds child to cause the autistic defense to crumble.

Humanistic play therapy (Axline 1965): Encouraged the expression of feelings through play and unconditional positive regard.

OPTIONS (Kaufman 1976) Parents spent every waking hour with child follow child lead

Sunday, 13 December 2020

Factors that Obstruct Effective Communication

Factors that Obstruct Effective Communication

The following factors can interfere with effective communication during clinical assessment. 
  • Lack of exclusivity, for example, assessment on the bedside inside a unit of 20 patients. 
  • Anxiety by a doctor, because of which divides their attention and concentrating, not the assessment is difficult. 
  • Awkward seating that makes it difficult to relax while assessing a patient. 
  • Lack of attention to the nonverbal cues
  • Offensive remarks.
  • Frequent interruptions. 
  • Selective listening.
  • Daydreaming. 

What are the techniques of active reading and learning?

  1. Read the summary to get an idea
  2. Study the table of contents
  3. Read all the bold faced excerpts and boxed summary
  4. Leaf through the entire chapter
  5. Identify the most important and unfamiliar words
  6. Highlight the key points
  7. Develop deeper understanding
  8. Compare to your previous concepts

What are the characteristics of a physician according to the holistic medicine?

Belief in potential of healing act
Capacity to listen and empathies
Respect and dignity of humans
Tolerance to difference of opinion
Gentle spirit
Ability to mix creative thinking
Never give up.

What are the different types of doctor patient relationship?

Vertical model
Teacher student model
Mutual participation model
Informational care model

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