The Indian Journal Psychiatry (IJP) is delighted to present the Indian Psychiatric Society (IPS) Clinical Practice Guidelines (CPGs) for psychiatric emergencies and brain stimulation techniques. These guidelines cover two very important aspects of psychiatric practice – emergencies and brain stimulation techniques. These CPGs have been developed through due process, have involved experts from different parts of India, who have read through the literature, considered unique system and cultural setting of practice, and then provided recommendations. These CPGs have significant relevance for clinical practice in the country for both trainees and those who are currently in practice. However, these should not be considered as a substitute for clinical knowledge. The clinicians can use these guidelines keeping the working conditions in mind and can modify the same as per the needs of the patients and the treatment settings.
The first larger set of topics, psychiatric emergencies, is something which all practicing psychiatrists have to deal with on a fairly regular basis. Emergency is indeed a situation where the patient is vulnerable and where a quicker triaging and decision-making process is engaged to stabilize the situation or address the immediate concern. These emergencies demand our acute and astute attention, while dealing with a patient (and sometimes, others) in distress who requires urgent psychiatric care. Decisions have to be made cognizant of the acuity of the condition as well as constraints of space, information, resources, and pressure from colleagues and family members. The present CPGs cover a gamut of different emergency scenarios where a psychiatrist may need to provide opinion or take charge to manage the situation.
Of late, emergency setting has been a place when medical professionals, including psychiatrists, feel vulnerable. Violence against doctors is a sad reality in present day medical practice, and emergency setting is a place where often tempers run high. Sometimes, psychiatrists are victims of aggression of the patient and in a few occasions victims of the aggression of the family members. Multi-pronged approaches may need to be implemented to reduce the violence. The CPGs in the present supplement do lay out and emphasize the measures psychiatrists should take while managing patients with aggression and violence. Nonetheless, additional systemic measures are needed to cater to the risk of violence.
Suicide is an extremely important clinical consideration for psychiatrists. Mental health professionals play a very important role in suicide prevention and providing care of patients with suicidality. The recently unveiled national suicide prevention strategy provides a direction with implementable methods to reduce suicides by at least 10%. These strategies classified as short term, medium term, and long term provide a roadmap of how suicides can be addressed in a vast and varied country like India. The CPGs in the present supplement on suicidal behavior presenting to the emergency complement the strategy by providing guidance on how a psychiatrist can manage the patient when he/she is brought to the emergency services.
The present volume of CPGs also caters to discussing breaking bad news. Often, breaking bad news is not easy and may lead to discomfiture for the patient and the psychiatrist as well. A nuanced consideration of the situation, ascertaining available information with the patient, expression of empathy while providing information, and graded disclosure, can help to make the delivery of bad news less scathing. Perhaps there is a greater need for honing soft skills to improve the satisfaction with the care process.
Substance intoxication is a common presentation in the emergency setting, and often, there is a tussle between the physicians and psychiatrists about their role in the management of substance-related disorders presenting to the emergency setting. The CPGs on this topic will provide guidance to the mental health professionals about the assessment and management of the same.
Other topics that have been covered in this volume of CPGs include assessment and management of aggression and assultativeness, anxiety disorders and panic disorder, dissociative disorders, borderline personality disorder, and crisis intervention in the emergency setting. Specific CPGs have also been formulated to assess and manage special populations, that is, children and adolescents, and elderly presenting to the emergency setting.
Another aspect that these CPGs address is the mental health of the medical professionals. Fortunately, there is a growing recognition of the need to take care of mental health of medical community. Mental illnesses are viewed seriously, rather than being swept under the carpet or caricatured. As medical professionals face unique barriers for help seeking (including denial of illnesses, confidentiality concerns, self-medication, etc.), psychiatrists have to make their services available somewhat little differently to such medical professionals. Addressing and removing these barriers to care access may help medical professionals to seek care more frequently. Keeping the tenet ‘doctor! Heal thyself’ in mind, a healthy medical workforce would be able to take care of their patients better.
This volume of CPGs also caters to brain stimulation techniques. Some modes of brain stimulation and neuromodulation techniques such as electroconvulsive therapy (ECT) have been entrenched in practice since a long time. Newer modes of brain stimulation such as repetitive transcranial magnetic stimulation and transcranial direct current stimulation have been seeing growing research and clinical application in the recent times. There has been a need for guidance to the clinicians on better utilization of these brain stimulation techniques. The CPGs discuss these brain stimulation techniques in significant depth.
The development of the guidelines has been cognizant of the research gaps in some of the areas, especially those relating to contextual aspects of clinical practice of psychiatry. There is a need to enhance collaborative and cross-national research on gaps. The IPS has taken a lead by promoting and funding collaborative multi-centric research on locally relevant clinical questions. Projects are selected through a vetting process and promote more participatory research across diverse settings. However, still there are many unanswered questions, which if researched may provide guidance in our clinical setting. For example, how to better use family members in care of suicidal and violent patients, pharmacodynamic and pharmacokinetics of medications used for the management of acutely violent patients, process deconstructs and acceptance of diverse approaches of breaking bad news, efficacy of training and recognition for substance intoxication, patient acceptance of ECT vis-à-vis other neurostimulation measures, and others. Future research pursuits may help to provide answers to these questions.
The CPGs also have a scope of reaching out effectively to a larger audience. Effective training modules can be developed by the CPG team to train residents and other interested psychiatrists on the recently released CPGs. Multiple complementary methods can be used to train, for example, didactic lectures, quizzes, and interactive discussion sessions. A wider reach can also be performed through social media. Since attention has become the most valuable commodity in today’s times, the salient and actionable points of CPGs may be disseminated through online posts and feeds, possibly taking help of Twitter and Instagram.
As medical literature is ever changing and the best practices evolve, one should caution against casting CPGs in stone. A timely update of the CPG is warranted as newer discoveries are made. The readers need to reflect upon how the CPG relates to their practice and the individual patient at hand. The ‘guidance’ from the CPG is valuable but should be cognizant of the individual circumstances. The IJP as the repository ensures that the CPG is accessible to psychiatrists all over India and also to the world. The CPGs of IPS also have considerable value for other lower- and middle-income countries which have similar social outlook and availability of healthcare infrastructure. The efforts of the contributors to the CPGs are lauded, and hopefully, these would benefit the practitioners by clarifying their clinical queries.