text:
- Study protocol
- Open Access
Rationale and design: telepsychology service delivery for depressed elderly veterans
Trials volume 10, Article number: 22 (2009)
Older adults who live in rural areas experience significant disparities in health status and access to mental health care. "Telepsychology," (also referred to as "telepsychiatry," or "telemental health") represents a potential strategy towards addressing this longstanding problem. Older adults may benefit from telepsychology due to its: (1) utility to address existing problematic access to care for rural residents; (2) capacity to reduce stigma associated with traditional mental health care; and (3) utility to overcome significant age-related problems in ambulation and transportation. Moreover, preliminary evidence indicates that telepsychiatry programs are often less expensive for patients, and reduce travel time, travel costs, and time off from work. Thus, telepsychology may provide a cost-efficient solution to access-to-care problems in rural areas.
We describe an ongoing four-year prospective, randomized clinical trial comparing the effectiveness of an empirically supported treatment for major depressive disorder, Behavioral Activation, delivered either via in-home videoconferencing technology ("Telepsychology") or traditional face-to-face services ("Same-Room"). Our hypothesis is that in-homeTelepsychology service delivery will be equally effective as the traditional mode (Same-Room). Two-hundred twenty-four (224) male and female elderly participants will be administered protocol-driven individual Behavioral Activation therapy for depression over an 8-week period; and subjects will be followed for 12-months to ascertain longer-term effects of the treatment on three outcomes domains: (1) clinical outcomes (symptom severity, social functioning); (2) process variables (patient satisfaction, treatment credibility, attendance, adherence, dropout); and (3) economic outcomes (cost and resource use).
Results from the proposed study will provide important insight into whether telepsychology service delivery is as effective as the traditional mode of service delivery, defined in terms of clinical, process, and economic outcomes, for elderly patients with depression residing in rural areas without adequate access to mental health services.
National Institutes of Health Clinical Trials Registry (ClinicalTrials.gov identifier# NCT00324701).
People who live in rural areas experience significant disparities in health status and access to care compared to their urban counterparts [1, 2]. Access to appropriate mental health care services represents a significant problem in many rural and remote areas and as the ageing population expands, this problem will intensify over the next several decades without innovative solutions [1–4]. There is growing awareness that specifically tailored treatment and service delivery strategies are frequently needed for different populations of adult consumers of mental health services [3, 5]. Access to appropriate mental health care services represents a significant problem in many rural and remote areas and this problem will intensify over the next several decades without innovative solutions . In the mental health field, "telepsychology," (or "telepsychiatry" or "telemental health") represents a strategy for potentially addressing this longstanding access to care problem [6–8].
The strengths of telemental health include well-documented patient and provider satisfaction for a range of services [9–15]; strong support for the reliability of clinical assessments (eg, neuropsychological testing, clinical interviews, and mental status exams) relative to face-to-face assessments [16–20]; and evidence that medical patients would choose to receive it if it was available and would improve their access to care . In addition, research has documented the effectiveness of telepsychiatry to treat specific mental health diagnoses such as depression [22–24] and anxiety disorders [25–27], as well as its effectiveness with specific populations including incarcerated patients [28, 29], children and adolescents , rural populations [13, 31, 32] and older adults [16, 33–35]. The weaknesses identified in the research literature include a paucity of rigorous cost and efficacy studies, particularly for specific populations, and lack of research into the legal, ethical and regulatory issues inherent in this application of technology to clinical practice [6, 7, 36].
The use of telemedicine to address urgent patient care needs for older adults has been identified as the first two of five priority areas for future development by the Department of Veterans Affairs (VA) . Although there is widespread use of telepsychology to provide clinical services within and outside of the VA , there is insufficient research to determine if telepsychology service delivery is as acceptable or effective as traditional service delivery for older adults. In addition it remains unknown whether it is cost-effective for elderly veterans with depression residing in rural areas, without access to specialty geropsychiatric services. Thus, research that addresses the efficacy of this mode of service delivery is urgently needed.
This paper describes the rationale, study aims and objectives, and research design and methods of an ongoing four-year prospective, randomized clinical trial comparing the effectiveness of Behavioral Activation treatment for geriatric major depression delivered via in-home videoconferencing technology ("Telepsychology") compared to traditional face-to-face delivery ("Same-Room"), to test the hypothesis that in-home "Telepsychology" service delivery will be equally effective as the traditional mode (Same-Room).
The population of older adults is particularly well-suited for telepsychology for several reasons: (1) Over the next two decades there will be a large increase in the rural elderly population, and access to care is already a significant problem for many elderly adults with major depressive disorder (MDD) ; (2) telepsychology may be preferred by older adults, who avoid traditional mental health care due to embarrassment or stigma [39–43]; and (3) telepsychology may address significant age-related problems in ambulation and transportation [3, 44]. Indeed, medically disabled older adults with ambulation difficulties, and those isolated older adults in rural areas, are among those at greatest risk of psychopathology, yet currently are the least likely to be able to obtain treatment . Finally, results from a recent randomized trial also found telepsychiatry to be efficacious in the treatment of mild cognitive deficits among elderly persons .
Study Aims & Objectives
The objective of the study is to test the hypothesis that in-home video-conferencing technology ("Telepsychology") will be as effective as the more traditional mode of service delivery ("Same-Room") for treating older adult veterans suffering from major depressive disorder (MDD). This objective will be accomplished by (1) Using an established, highly effective and well-tolerated behavioral treatment for depression (i.e. Behavioral Activation Treatment for Depression (BATD) [45–47]; (2) Employing a randomized between groups experimental design; (3) Examining standardized, repeated dependent measures of: (a) clinical outcomes, such as symptom severity, social functioning, and medical status; (b) process variables, such as patient satisfaction, treatment adherence, and treatment dropout rates; and (c) economic outcomes; and (4) conducting analyses to examine for outcome differences between African-American and Caucasian patients.
The primary research questions of the proposed study are:
Is in-home telepsychology for major depressive disorder in older adults as effective as same-room treatment on clinical and process outcomes?
Is in-home telepsychology for major depressive disorder in older adults cost-effective?
The study is a 2 group randomized controlled trial with randomization of individual participants, blinded outcomes assessments at baseline, mid-treatment (4-weeks), post-treatment (8-weeks), 3-months, and 12-months, and concurrent economic evaluation.
Location and Setting
The assessments and interventions will be conducted at the primary care and mental health clinics of the Ralph H. Johnson Veterans Affairs Medical Center (VAMC) located in downtown Charleston, South Carolina. The Ralph H. Johnson VAMC is a primary, secondary, and tertiary referral medical center providing acute medical, surgical, and psychiatry inpatient care as well as primary care and specialized outpatient services. Currently, there are 98 acute care beds and 28 nursing home care unit beds for a total of 126 operational beds. The primary service area extends from north of Myrtle Beach, SC, down to the surrounding counties of Savannah (Georgia, USA). For the most recent fiscal year (FY 2007), there were 41,645 unique patients, 4,000 discharges, 475,714 total outpatient visits, and 2,968 OEF/OIF enrollees and users. The Ralph H. Johnson VA Medical Center is a part of VA Southeast Network VISN 7 which includes facilities in Charleston, SC, Columbia, SC, Atlanta, GA, Augusta, GA, Dublin, GA, Birmingham, AL, Tuscaloosa, AL, and Central Alabama (Montgomery and Tuskegee campuses). The facility also has four Community Based Outpatient Clinics (CBOCs) in (1) Beaufort, SC – 53 miles to VAMC; (2) Goose Creek, SC – 17 miles to VAMC; (3) Myrtle Beach, SC – 83 miles to VAMC; and (4) Savannah, GA – 84 miles to VAMC.
Ethics and Trial Registration
The study is funded by grant #IIR 04-421 from the Veterans Health Administration Health Services Research and Development program. The trial is approved by the joint Institutional Review Board (IRB) of the Ralph H. Johnson VAMC and the Medical University of South Carolina (HR#16402). The trial is registered on the United States National Institutes of Health Clinical Trials Registry (ClinicalTrials.gov identifier# NCT00324701), available online at: http://clinicaltrials.gov/ct2/show/NCT00324701
Trial Population and Recruitment
Subjects will be 224 older male and female veterans (age 60 or older) presenting for services at VA primary care clinics and meeting DSM-IV  criteria for MDD. Actively psychotic or demented persons, individuals with both suicidal ideation and clear intent, and individuals meeting criteria for substance dependence will be excluded from participation; however, in order to maximize generalization of results, presence of other forms of psychopathology (eg, anxiety disorders) will not be a basis for exclusion. Participants who are incapable of giving informed consent due to mental incapacity or extreme distress will be excluded from the study. Because the inclusion of minorities in research on psychiatric disorders is important, about 40% of our sample will be African American, which is representative of the population of South Carolina.
We will use two complementary approaches to identify eligible study subjects. The first method will consist of systematic identification of patients with MDD. After obtaining IRB approval for a partial waiver of HIPAA, we will use clinic-billing records over the previous 12-month period to identify subjects with ICD-9 codes consistent with a diagnosis of MDD. The physicians of eligible patients will be notified of their patients' potential eligibility and asked permission to enroll their patients in this study. After consent is obtained from the physicians, letters of invitation on clinic letterhead signed by the patient's physician will be mailed to patients from the study clinics. The letter will provide information about the study, explain the study requirements, and clarify that only subjects that meet certain criteria will be eligible to participate in the study. The letter will include an addressed and stamped post-card that subjects can mail back to indicate interest or lack of interest in participating in the study. In addition, the letter will provide a telephone number that interested subjects can call to receive detailed information about the study. In the letter, subjects will also be informed that they will receive a follow-up call in two weeks unless they mail back the post card or call to decline being contacted. Subjects that mail back the post card and express interest or call the provided telephone number will receive detailed information about the study. Subjects who agree to participate will be asked to provide written consent and will be scheduled for the initial screening assessment.
The second method will consist of referrals from physicians, other clinic staff such as nurses, or patients themselves in response to recruitment flyers for the study. The Principal Investigator (PI) will share the goals of the study and inclusion/exclusion criteria with physicians and clinic staff during clinic administrative meetings. Physicians and clinic staff will be asked to refer appropriate subjects to the study research assistants. In addition, IRB approved recruitment flyers will be posted in prominent locations in the study clinics.
Regardless of recruitment pathway, research staff will obtain written informed consent, complete a screening for dementia and psychosis, and assure that participants meet DSM-IV  criteria for MDD. Those candidates meeting MDD criteria will then complete the remainder of the assessment battery (Tables 1 and 2).
The study coordinator will verify all eligibility criteria prior to randomization. The procedure and risks will be explained to the patient and the consent form signed as per standard clinical practice. All subjects will be randomly assigned to one of two groups – Telepsychology (n = 112) and Same Room (n = 112). The randomization sequence will be generated by the senior biostatistician and provided in individual sealed envelopes to the data/statistical analyst who will be responsible for randomization. This information will remain confidential and not shared with the study sites in accordance with the CONSORT guidelines . The study coordinator will call the data/statistical analyst to get subject randomization assignment. Once a randomization assignment is provided, the patient is entered into the study and will be included in the intention to treat analysis (Figure 1).
Intervention and Control Groups
All subjects will receive the same individual mental health intervention for an 8-week period. Sessions will occur approximately once each week during this period, and each session will last for about 60 minutes. The intervention group (Telepsychology) will receive therapy via videophone while the control group (Same Room) will receive face-to-face therapy. All patients will receive 8 sessions of BATD. One of the strengths of the BATD protocol is that it is designed to be very straightforward, easily learned by therapists and patients, and can be implemented over an 8-session period. Initial sessions are used to build patient rapport and provide a rationale for activation-based treatment. Subsequent sessions are used to assess factors that might be maintaining depressed behavior (eg, determining if a deficit of reinforcing activities or a preponderance of punishing activities exists); assess functional aspects of the behavior itself (eg, is the depressed person receiving significant social reinforcement for being depressed); initiate efforts to increase the likelihood of engaging in reinforcing behaviors; and reduce the availability of unintended reinforcement for depressed behavior. Next, a systematic approach to behavioral activation is implemented. This is simply a process to increase the rate of enjoyable (ie, going to dinner with a friend) and functional (ie, grocery shopping) behaviors, with this increase resulting in a decrease in depression. Using a daily calendar, patients begin with a weekly self-monitoring exercise that serves as a baseline assessment of daily activities, and orients them to the quality and quantity of his or her activities on a daily basis. Following the introductory and assessment stages of BATD, emphasis in sessions two and three shifts towards the identification of goals within key life areas including relationships, employment, recreational activities, physical/health issues, and spirituality. From these goals, the individual will select specific behaviors that will help achieve these objectives. For example, the life area of family relationships may include the goal of rebuilding a relationship with a particular family member, which can be accomplished with specific behaviors such as calling the family member twice per week. To help facilitate engagement in the desired behaviors, each activity is placed within an activity hierarchy and rank-ordered from "easiest" to "most difficult" to accomplish. Patients then use a daily calendar to plan, in advance, the next week wherein they schedule a variety of activities, including both 'fun' (such as something they enjoy doing) or 'functional' (such as getting some undesirable chore out of the way so they do not have to worry about it any longer). The planning calendar serves as an activity log (in instances where patients do not follow the planned activity, they are instructed to update the calendar to reflect what they actually did). Behavioral Checkouts, or specific reviews of completed activities and concurrent moods are completed with therapists in session to monitor progress over the course of treatment as the patient graduates to different levels of the hierarchy of activities.
The therapist and patient collaboratively ensure that the behaviors that they are planning fit well within the life area and goals in that area as previously established. At the beginning of each session, the behavioral checkout occurs in which adherence to the planned calendar of activities is reviewed, and ensuing mood states are discussed. Specific behaviors and contextual parameters, including time of occurrence and duration of activity, are determined on the basis of the patient's level of success or difficulty with activities for the prior week. As an additional incentive for patients to complete the behaviors on the behavioral checkouts, patients are asked to identify and schedule weekly rewards, arranged to become available only after they have completed the planned activities a particular week. The treatment is flexible and we ensure that all activities (eg, pleasant activities lists) are age, gender, and culture appropriate.
Upon completion of the active treatment program described above, subjects from both conditions (Telepsychology, Same-Room) will be followed for 12 months. The outcome assessment battery will be administered to all subjects at the end of this follow-up period. Those who develop acute problems during follow-up will either be provided additional treatment by the project staff or will be referred to other appropriate treatment providers. In order to prevent distortions in the follow-up data, information on patients who receive further treatment will be analyzed separately.
Treatment sessions for the Telepsychology condition will be conducted using in-home videoconferencing technology. We will use an analogue videophone (KMEA TV500SP, Figure 2) that operates via plain old telephone service (POTS). Apart from the video screen, this equipment appears and functions much like a basic touch-tone telephone. It is a "plug-and-use" product, with built-in camera, full duplex speakerphone, 4-inch LCD color screen (270 K pixels) with real-time motion display (18 frames per second), and oversized touch-tone buttons for easy use by all patients. This equipment is simple to use. If necessary, project or clinic staff will be available to visit participants in their homes to help set up the equipment. We will track the type and amount of assistance required across sessions in order to help anticipate future difficulties with in-home use.
Study Instruments and Data Collection Schedule
Self-report measures will be used to evaluate clinical outcome at baseline, mid-treatment (4-weeks), post-treatment (8-weeks), 3-months, and 12-month follow-up. Process outcomes will be evaluated at 4-weeks, 8-weeks, 3-months, and 12-months. Resource Utilization surveys will be administered at baseline, and then 3 and 12 month follow-up. Endpoint psychiatric interviews (ie, Structured Clinical Interview for DSM-IV, [SCID]) ; will be administered at baseline and 12-months by raters blind to subject condition. Structured interviews will be audiotaped, and 20% will be rated by an independent to ensure interrater reliability. The complete assessment takes about 120 minutes. Study assessments will be administered by either the Research Coordinator. Assessment clinicians will not deliver treatment. Their training will include instruction, assigned readings, modeling, role-playing, and feedback.
Therapist Training and Supervision
The same counselors will conduct the individual BATD treatment for both conditions (Telepsychology, Same-Room). At the start of the project, treatment providers will undergo a 12-hour training program with the clinical psychologist/project consultant and the developer of the BATD treatment manual. During the project, therapists will follow the BATD treatment manual, and will undergo weekly peer supervision with an experienced clinical psychologist on the team. Thus, a highly experienced and expert team of mental health care providers will implement the treatment for the subjects in this study. We have used a similar training approach in our other studies.
Treatment Integrity and Adherence
A quantitative measure of protocol adherence will be obtained using a checklist of the specific procedures scheduled to be followed in the BATD treatment manual. To ensure treatment adherence, all sessions will be audiotaped, and 20% of these will be rated for competence and adherence by co-investigators. To evaluate adherence to treatment protocol, rating forms that use a 7-point Likert scale were developed and assess how well the therapists accomplished relevant behavioral tasks for each session. Two raters, blind to treatment condition, will rate tapes independently to allow for computation of inter-rater reliability. Our rating forms are modeled after the therapist rating forms used in other studies of cognitive-behavioral treatments, including our own treatment outcome studies that successfully demonstrated therapist fidelity to a manualized cognitive behavioral intervention delivered via "telepsychology" . This will allow us to study any differences between conditions on non-specific factors, such as therapist empathy and rapport.
Clinical Outcome Measures
The primary clinical outcome measure is the proportion (%) of patients who respond to treatment. Treatment Responder status will be determined using each of the dependent measures of depression (ie, Geriatric Depression Scale (GDS) ; Beck Depression Inventory (BDI) ; and SCID . For the BDI and GDS, treatment responders will be those that demonstrate, at 12-month follow-up, improvement of at least 50% on the total score. For the SCID, treatment responders will be those who are no longer diagnosed with MDD. Dichotomous classifications for the GDS and the BDI will be achieved by defining treatment response as at least a 50% improvement from baseline to post-treatment level (percent change from baseline: [baseline-post]/baseline ≥ 50%). We will report analyses involving each measure of treatment response separately, but will take the a priori position that, in the case where results based on each of these analyses do not converge, overall conclusions regarding treatment response will be based on the two measures that concur. Thus, our indicator of treatment response will be in terms of each measure, as well as in terms of the converging data from at least two different measures.
The primary process outcome is score on the Charleston Psychiatric Outpatient Satisfaction Scale (CPOSS),  measured at the end of the 12-month follow-up period. The CPOSS is a 16-item measure with each item having a Likert-type format (total score is sum of the 16 items with range 16–80). Non-inferiority of patient satisfaction at the end of the 12-month follow-up period for the two modes of delivery will be evaluated via the one-sided non-inferiority 90% confidence interval approach to estimate the difference in end of study mean scores on the CPOSS for the Telepsychology and Same-Room conditions. The magnitude of the difference in satisfaction levels, as estimated by the confidence interval will provide useful clinical information and will allow a clinical judgment relative to the clinical non-inferiority of the of the two modes of delivery.
Economic Outcome Measures
The economic analysis will determine the cost and potential cost savings of Telepsychology. Comprehensive information will be gathered on 1) telepsychology-related capital expenditures, and 2) patient-related resource utilization over 12 months for all patients in the project. This will allow us to estimate the combined spectrum of investment expenditures and direct in-hospital cost of Telepsychology as well as cumulative health costs over 12 months. In addition, a Markov-type economic model , determining transition probabilities between different health states, will be developed to predict flow of funds and event rates over a 12-month period for Telepsychology participants based on outcomes.
Sample Size Determination and Power Analysis
The primary response variable for sample size calculation is the proportion (%) of patients who respond to treatment. Treatment response is defined as at least a 50% improvement from baseline to post-treatment level on the GDS [percent change from baseline: (baseline-post)/baseline ≥ 50%]. Demonstration of non-inferiority among treatments differs from that of establishing superiority. For a non-inferiority trial, the null hypothesis states that two treatments are non-equivalent, that is they differ by at least a clinically relevant amount, Δ. [55–62]. The approach will be formulated in terms of the one-sided non-inferiority problem [55, 60, 61, 63] because it is of interest only to test that the treatment response (% responders) for the Telepsychology mode of delivery is not too low compared to that for the standard Same-Room mode of delivery. Note that, for non-inferiority trials, the consequence of a false positive (ie, claiming the novel therapy [Telepsychology] is worse than the standard therapy [Same-Room] when it is, in fact, non-inferior) is to keep patients on the standard therapy. Therefore, the Type I error rate, α, can be set higher than in traditional superiority trials (eg 0.1–0.2) .
We estimate that the % treatment responder for Same-Room delivery (P) is 0.70. We assume that a maximum clinically unimportant difference in response proportion (Δ, the non-inferiority effect size) is 0.15 between Telepsychology and the standard Same-Room service delivery (upper limit of one-sided 90% confidence interval must not be greater than Δ = 0.15 for the conditions to be declared equivalent). Using the tables of Machin and Campbell  and assuming Δ = 0.15, one-sided α = 0.10, P = 0.70, and power = 0.85, we estimate that approximately n1 = n2 = 100 subjects per condition are needed for overall treatment effects comparisons. If we further assume that 10% of subjects will not have at least one post baseline measurement (i.e. will not be included in the ITT sample), then 112 subjects must be randomized to each treatment group to yield the required sample size for the primary intent-to-treat analyses (n1 = n2 = 100/group).
For the ITT sample (n1 = n2 = 100/treatment group) we will be able to estimate the individual (main effects) end of treatment means for each of the continuous clinical and process measures with a precision of ± 0.2 standard deviations. For the primary outcome measure ΔΔ1 = Δ(Post)T- Δ(Post)S, which measures the difference in change from baseline (pre to immediate post treatment) for the continuous outcome domain measures for the telepsychology condition compared to change from baseline for the standard (same-room) condition, we will be able to estimate with a precision of ± 0.3 standard deviation units using 95% confidence intervals for the difference in two means (Δ(Post)T, Δ(Post)S), where the appropriate standard deviation is the pooled standard deviation for comparing change from baseline for the telepsychology condition versus the standard condition.
Assuming that 20% of subjects will drop out of the ITT sample (n1 = n2 = 80, assuming equal treatment distribution of dropouts), we will be able to estimate for the completer sample the individual end of treatment means for each of the measures with a precision of ± 0.2 standard deviations, and the difference in change from baseline (pre to immediate post treatment) for the outcome domain measures with a precision of ± 0.3 standard deviation units.
Both the standard deviation and the distribution of costs are presently unknown for the type of patients who will be enrolled in Telepsychology. Thus, it is difficult to obtain a meaningful estimate of the power to detect a difference in CE from any arbitrary value. We propose to determine costs and apply to our economic model after the completion of the study, and then use the bootstrap technique to obtain a 90% Confidence Interval (CI) around the estimated costs. The bootstrap technique is appropriate because, as noted, the distribution of costs for these types of patients is presently unknown.
Primary Clinical Outcome
Testing the non-inferiority of the Telepsychology mode of delivery to the standard Same-Room mode in terms of % responders can be carried out through either a confidence interval approach or through a modified hypothesis testing procedure [55–62]. For both approaches, a conclusion that the two modes of delivery are similar in clinical efficacy (non-inferior) requires that the response proportion (% responders) for the standard delivery (Same-Room) cannot exceed by more than Δ the response proportion for the novel delivery (Telepsychology). We assume Δ = 0.15 between the novel delivery and the standard delivery (one-sided non-inferiority). With the confidence interval approach, the upper limit of the one-sided 90% confidence limit for the difference in % responders for the novel delivery (Telepsychology) and the standard delivery (Same-Room) must be 0.15 (Δ) or less to accept the hypothesis of a non-inferior novel treatment. Statistically, this translates into testing a non-zero difference between the treatments, where noninferiority is established by demonstrating that the difference between treatments is less than the maximum clinically unimportant difference in response proportions, Δ[55–57, 59, 61, 62]. The hypothesis testing approach to evaluating equivalency in % responders, with an appropriately adjusted test statistic as described by Dunnett and Gent  and Farrington and Manning  will also be used.
In addition to comparing unadjusted % responders between the modes of delivery conditions, it also is of interest to compare % responders, adjusted for putative confounding variables. Possible covariables to be considered for inclusion in these analyses include initial disease severity as measured by baseline GDS or BDI score, use of psychiatric medication, number of other co-morbid conditions, and relevant others as identified though the preliminary descriptive analyses. Two approaches will be used to evaluate non-inferiority of adjusted % responders for the two delivery conditions. The method of Gart and Nam  and Nam , which involves calculation of a non-inferiority test statistic within strata of potential confounding variables, formulates a score test for a null hypothesis of a common specified clinically relevant non-zero difference in % responders between two treatments for multiple 2 × 2 tables. Because the above procedure may be limited by the number of covariables (number of strata) that can be used, we will carry out a second set of analyses using a multivariable logistic regression model to obtain estimates of adjusted % responding for each treatment delivery condition for a specified set of values for the covariables, and then will apply the methods described above (one-sided confidence intervals and non-inferiority hypothesis testing) to evaluate non-inferiority of the two interventions. The response variable for these analyses is the dichotomous outcome, responder/non-responder to treatment, with missing data from premature exits treated as non-responders. The primary independent variable is treatment condition.
The one-sided non-inferiority 90% confidence interval approach (as described above) to evaluate noninferiority using the difference in change from baseline mean scores for the continuous clinical measures; GDS , BDI , BAI , SF-36 ; for the Telepsychology and Same-Room conditions will be used. The magnitude of the difference in the means (effect sizes), as estimated by the confidence intervals will provide useful clinical information and will allow a clinical judgment relative to the clinical non-inferiority of the two modes of delivery. The hypothesis testing approach to evaluating noninferiority, as described by Dunnett and Gent  and Farrington and Manning , will also be used.
In additional analyses, using the intent-to-treat sample and the baseline (week 0), mid- (week 4) and post- (week 8) active-treatment (randomized) phase values for continuous clinical variables (GDS, BAI, BDI, SF-36, patient ratings, functional status indicators), we will use random regression models (RRM) analyses (or equivalently, hierarchical linear model [HLM] or mixed effects models) to compare the Telepsychology and Same-Room conditions over the 8-week active phase time tracjectory. These analyses will use scores for each outcome as the dependent variable and delivery mode (treatment) and time (time by treatment) as the primary independent variables. The random regression approach estimates individual change in outcome for each subject in addition to estimating average change in outcome within each treatment population. Specifically, random regression models allow for measurement of subjects at different time points, missing data, and time varying or invariant covariates [68–74]. Further, longitudinal methods for binary outcomes [75–77] will be used to compare the Telepsychology and Same-Room conditions for the dichotomous outcome measure (MDD response status measured at weeks 4 and 8). Methods for categorical or ordinal outcomes [78–82] will also be applied where appropriate.
Exploratory multivariable logistic regression, assuming drop-outs are nonresponders, will be used to determine the set of predictor variables associated with treatment response (dichotomous outcome: treatment responder/nonresponder as described under primary analyses). In additional exploratory analyses, RRM analysis will be used to evaluate the effect of putative confounding or prognostic variables on continuous or binary clinical outcomes following the 8-week treatment course, and the possible effect modification (interaction) of these variables on the relationship between treatment status (delivery mode) and clinical outcome. Interaction between treatment status variables and covariates will be evaluated by inclusion of treatment by covariate interaction terms in the model. In a final set of analyses, we will compare the single end of study measure (change from baseline) for the outcome variable using a multivariable regression approach with treatment status as the primary independent variable, with missing values imputed using the method of Little and Rubin . Analyses will be repeated for each of the clinical measures, both with and without a Bonferroni correction  for the multiple outcome variables. In other words, both the unadjusted and Bonferroni-corrected p-values will be obtained to evaluate sensitivity of conclusions to the "multiple comparisons" effect.
A Markov-type economic model will be used to predict flow of funds and event rates over a 3-month and 12-month period for populations with depression based on outcomes and effectiveness data. The model will use actual event data reported by participants through survey at follow-up. The reason for including all costs is that it is sometimes difficult to distinguish depression-related from non-depression events. However, we will attempt to separate hospitalizations and office visits associated with a patient's depression problems from non-depression episodes of care. Another reason for including all costs is that depression is comorbid with many other conditions and the benefit of treatment may go beyond mental health costs. Thus, we will measure total cost savings and, based on patient response, separate depression-related costs from the cost offset. Capital costs will be annualized and depreciated over the life of the equipment, thus calculations for a 12-month period should be straightforward. Potential costs savings of Telepsychology will be based on sensitivity analysis of the fluctuations in the proportion of those appropriately treated with traditional Same-Room mental health care service delivery, compared to the actual proportion from those in the Telepsychology analysis.
Patient-oriented resource utilization data will be linked to participant's clinical data and a set of standard cost weights developed from archival VA billing data sources from patients with depression. The resources reported by the study participants (including medications) will be converted to dollar values using standard cost weights estimated from DSS administrative data. Average cost per day and average cost per admission will be calculated. Outpatient costs will include the average cost per clinic visit. Cost weights will be applied to the survey responses. To gain further insight into the variation in the resource utilization and costs of Telepsychology, sensitivity analyses will be performed. Sensitivity analysis involves systematically altering our assumptions about the costs and health effects of Telepsychology and noting the effect on the resulting cost/savings estimates. Two types of sensitivity analyses will be performed. The first set of calculations will be one-way sensitivity analyses. In one-way sensitivity analysis, the assumption about each parameter (eg, cost of telepsychology hardware) is varied over a reasonable range of values with all other parameters fixed. Finally, we will develop favorable and unfavorable scenarios for Telepsychology based on various assumptions including, but not limited to capital costs of telepsychology, technology "downtimes," and clinical outcomes. Because the specifics of these scenarios will depend on the nature of our findings, we cannot describe fully these analyses a priori. Nonetheless, these scenarios will reflect our understanding of the variation surrounding the cost estimates and the correlations among those parameters.
Cost data will be displayed in tables to highlight the extent to which costs cluster around videoconferencing technology, as well as patient-related utilization such as initial hospitalizations, outpatient visits, non-healthcare patient costs, medications and readmission(s). Costs will also be displayed graphically in a cumulative fashion, with cost on the horizontal axis and percent of patients with a specified or lower cost on the vertical axis. Finally costs will be displayed over time, with time on the x axis and mean cost on the y axis. Means and standard deviations of costs will be presented for each component of cost. "Trimmed" means and standard deviations of costs will be presented when 10% largest values and 10% smallest values are ignored. This way the summary statistics are less influenced by a small number of extreme outliers. Another possibility is to consider median as a measure of location and inter-quartile range as a measure of variance. However the usual or trimmed means and standard deviations seem more appropriate for this analysis because health care providers and payers may be concerned more about average cost, not median cost.
Study recruitment commenced in April 2007, with all follow-up assessments associated with the study expected to be completed by June 2010. As of October 2008, 171 participants have been screened and 111 have been randomized. Of the number randomized, 80 have completed Week 4 assessments, 72 have completed Week 8 assessments, 39 have completed Month 3 assessments, and 6 are due to complete Month 12 assessments.
Addressing a significant knowledge gap, this study is a prospective, randomized evaluation of clinical, process, and cost outcomes for a mental health intervention. The study will test the hypothesis that in-home Telepsychology service delivery will be equally effective as a traditional mode (Same-Room). If this study demonstrates telepsychology efficacy is equivalent to Same-Room service delivery, future research and program development will focus on bringing a wide range of specialized mental health services to the homes of veterans and community based outpatient clinics (eg, CBOCs, Veteran Centers) via videoconferencing technology. If Telepsychology non-inferiority and cost-effectiveness can be empirically established, research that examines a range of important system issues, including effectiveness outcomes and service delivery strategies to maximize the accessibility of mental health services for rural veterans can proceed. We anticipate that future research projects would include examination of telepsychology applications for providing individual and group mental health care to people with a range of other mental illnesses. Furthermore, we will also be able to evaluate the association between process and outcome measures in this study, which will have implications for future telepsychiatry efforts, as well as more general treatment outcome efforts with older veteran populations. Thus, while meeting the VA's mission to provide quality health care to all veterans, this project represents an important step in a programmatic line of research, including planned future VA HSR&D applications in mental health service delivery and care coordination to rural and underserved populations.
Beck's Anxiety Index
Behavioral Activation Treatment forDepression
Beck's Depression Index
Community BasedOutpatient Clinic
Consolidated Standards of ReportingTrials
Charleston Psychiatric Outpatient Satisfaction Scale
Diagnostic and Statistical Manual of Mental Disorders, 4th Edition
Decision Support System
Health Services Research and Development
Health Insurance Portability and Accountability Act
International Classification of Diseases, Ninth Revision
Intention to Treat
Institutional Review Board
Operation Enduring Freedom
Plain Old Telephone Service
Structured Clinical Interviews for DSMDisorders
Medical Outcomes Study Short Form – 36
Department of Veterans Affairs
Veteran Affairs Medical Center
Veteran Integrated Service Network.
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The study was funded by grant #IIR 04-421 from the Veterans Health Administration Health Services Research and Development program.
CL is the developer of the behavioral activation treatment for depression (BATD) used in this study. The other authors declare that they have no competing interests.
LE, CF, RA, RK, PM and CL conceived of the study, obtained funding for the study, participated in its design and coordination and helped to draft the manuscript. LR drafted the manuscript. All authors read and approved the final manuscript.
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Egede, L.E., Frueh, C.B., Richardson, L.K. et al. Rationale and design: telepsychology service delivery for depressed elderly veterans. Trials 10, 22 (2009). https://doi.org/10.1186/1745-6215-10-22
- Major Depressive Disorder
- Veteran Affair
- Beck Depression Inventory
- Major Depressive Disorder
- Geriatric Depression Scale

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A. The Contracting State and the New York Convention
1. Name of Contracting State (also specify jurisdiction(s), if relevant)
2. Date of entry into force of the New York Convention
11 October 1960.
(Sources: Foreign Awards (Recognition and Enforcement) Act, 1961 (Act 45 of 1961), as published in Gazette of India, 1961, Part II Extraordinary, Statement of Objects and Reasons, p. 219 & Preamble; see also <www.uncitral.org/uncitral/en/uncitral_texts/arbitration/ NYConventon_status.html>.)
3. Has any reservation been made under Art. I(3) of the New York Convention regarding:
Yes. India will apply the Convention only to recognition and enforcement of awards made in the territory of another Contracting State which has been notified by the Central Government as a reciprocating territory. For a foreign award in a foreign territory to be enforceable as a New York Convention award in India, that territory must be notified by the Central Government as a reciprocating territory separately through a notification in the Gazette of India. Signature of the New York Convention is not enough for such territory or country to qualify as a reciprocating territory.
The list of 'reciprocating territories' notified by the Government of India in the Gazette of India, for the purposes of s. 44 of the Arbitration and Conciliation Act 1996 ('1996 Act') comprises the following 46 States: Austria, Belgium, Botswana, Bulgaria, Central African Republic, Chile, Cuba, Czechoslovak Socialist Republic, Denmark, Ecuador, The Arab Republic of Egypt, Finland, France, German Democratic Republic, Federal Republic of Germany, Ghana, Greece, Hong Kong, Hungary, Italy, Republic of Ireland, Japan, Republic of Korea, Kuwait, Malagasy Republic, Malaysia, Mexico, Morocco, The Netherlands, Nigeria, Norway, Philippines, Poland, Romania, San Marino, Singapore, Spain, Sweden, Switzerland, Syrian Arab Republic, United Republic of Tanzania, Thailand, Trinidad and Tobago, Tunisia, UK, the United States of America and USSR.
(b) commercial relationships?
Yes. India will apply the Convention only to differences arising out of legal relationships, whether contractual or not, that are considered commercial under the national law.
(Source: 1996 Act, s. 44.)
4. In addition to arbitral awards made in the territory of another State, the New York Convention (Art. I(1)) also applies to arbitral awards not considered as domestic awards in the State where recognition and enforcement are sought. Are there any awards rendered in your country that are not considered as domestic awards such that the New York Convention and the answers to this Questionnaire are applicable to them?
No. An award rendered in India pursuant to an international commercial arbitration held in India will be a domestic award for the purposes of the 1996 Act.
B. National sources of law
5. What specific sources of law are applicable to recognition and enforcement of foreign awards (e.g. statutes, regulations, codes, directives, other legal instruments)?
The 1996 Act (Act 26 of 1996), Part II, entitled 'Enforcement of Certain Foreign Awards'. Chapters I & II thereof apply to 'New York Convention Awards' and 'Geneva Convention Awards' respectively. Certain states/state high courts have prescribed procedural rules in relation, inter alia, to enforcement of foreign awards. These include: (i) Andhra Pradesh Arbitration Rules, 2000 (Roc. No. 203/SO-1/2000, published in A.P. Gazette, R.S. to Part II (Ext.) dated 15 Dec. 2000; (ii) Rules of the High Court of Judicature at Bombay (No. 1614/1996); (iii) Himachal Pradesh Arbitration Rules, 2000 (Notification No. HHC/Rules-22 (29) 84 dated 25 May 2000 published in the Himachal Pradesh Rajpatra, Ext., dated 23 June 2000, with effect from 26 May 2000; (iv) Karnataka Arbitration Rules, 2001 (Notification No. RPS, 1/1999/HCLC, Bangalore dated 30 July 2001, published in Karnataka Gazette, dated 18 Oct. 2001); (v) High Court of Madhya Pradesh Arbitration Rules, 1997 (No. C-966-III-15-28-41 dated 25 Feb. 1997).
C. Limitation periods (time limits)
(a) Is there a limitation period (time limit) applicable to the commencement of legal proceedings for recognition and enforcement of foreign awards?
(b) If yes, what is the applicable limitation period (time limit) and when does it start running?
The limitation period for recognition and enforcement of foreign awards in a 'court' is 3 years.
(Sources: Limitation Act, 1963 (Act 36 of 1963), Schedule, Art. 137; Noy Vallesina Engineering SPAA Corporation v. Jindal Drugs Limited, 2006 (3) Arb. LR 510 (Bombay High Court).)
The limitation period for making an application for recognition and enforcement of a foreign award would start to run from the date the right to apply for such recognition and enforcement accrues, i.e. date on which the foreign award in question becomes final and binding between the parties in the jurisdiction where it was made.
(Sources: Limitation Act, 1963 (Act 36 of 1963), Schedule, Art. 137. Noy Vallesina Engineering SPAA Corporation v. Jindal Drugs Limited, 2006 (3) Arb. LR 510 (Bombay High Court).)
D. National courts and court proceedings
7. What authority or court has jurisdiction over recognition and enforcement of foreign awards?
The relevant civil court is the principal civil court of original jurisdiction in a district, including the high court which, in exercising ordinary original civil jurisdiction, would have jurisdiction over the subject matter if a suit had been brought, but not any lower civil court or court of small causes.
(Source: 1996 Act, explanation s. 47.)
Explanatory note: India is a republic comprising 28 states and 7 centrally administered territories/ union territories. Each state has its own courts comprising courts of first instance and courts of appeal, with final recourse to the Supreme Court of India in New Delhi.
(Sources: Constitution of India, 1950, Preamble; Arts. 245 and 246, read with Seventh Schedule; Part V, Ch. IV (Arts. 124-147); Part VI, Ch. V (Arts. 214-231) & Ch. VI (Arts. 233-237; Art. 51(c), Art. 73(1)(b), Art. 253 read with Entry 14 of List I of Seventh Schedule; see official website of Government of India/National Portal of India: www.india.gov.in/knowindia/states_uts.php.)
8. What requirements, if any, must be met for the authority or court to accept jurisdiction over recognition and enforcement of foreign awards (e.g. domicile or assets of respondent in the jurisdiction, etc.)?
An action for recognition and enforcement of a foreign award has to be brought in a court that would have jurisdiction over the subject matter of the award in the event of a civil suit. Consequently, the relevant provisions of the Code of Civil Procedure, 1908 (Act 5 of 1908) dealing with 'execution of decrees' (ss. 36-74, read with Order XXI) would be applicable to the recognition and enforcement of a foreign award.
Accordingly, in order for a civil court in any state to have jurisdiction to entertain a petition for enforcement of a foreign award, the defendant should be domiciled or, if the award is for recovery of money, should have assets within the jurisdiction of that court.
9. Is the first decision granting or denying recognition and enforcement obtained through ex parte or inter partes proceedings?
In India, the general practice is not to decide ex parte a petition seeking enforcement of a foreign award.
(a) Is the first decision granting or denying recognition and enforcement subject to any form of appeal or recourse?
No automatic right of appeal lies from a first decision granting recognition and enforcement of a foreign award. However, a special leave petition to the Supreme Court of India (seeking permission to appeal the first instance decision) can be filed against a first decision granting recognition & enforcement.
An appeal lies from a first decision rejecting recognition and enforcement of a foreign award.
(Sources: 1996 Act, s. 50 (1)(b); Fuerst Day Lawson Ltd v. Jindal Exports Ltd (2011) 8 SCC 333.)
(b) How many levels of appeal or recourse are available against this decision?
In the case of a first decision granting enforcement of a foreign award, only a special leave petition can be filed to the Supreme Court of India.
In the case of a first decision rejecting enforcement of a foreign award, effectively two levels of appeal are available: (i) an appeal under the 1996 Act and (ii) an appeal against the appellate order to the Supreme Court of India by way of a special leave petition (seeking permission to appeal the appellate decision).
(Sources: 1996 Act, s. 50(2); Constitution, Art. 136.)
11. What is the earliest stage in legal proceedings for enforcement of foreign arbitral awards at which a party can obtain execution against assets (i.e. party actually obtains possession of assets as opposed to simply freezing assets)?
The judgment recognizing a foreign award may be executed against the assets immediately after the court order recognizing the foreign award is served on the judgment debtor. If enforcement is granted, it is possible for a court to grant ex parte execution, if certain conditions are satisfied (ordinarily the court is more likely not to grant ex parte execution). A party filing a special leave to appeal against the judgment may request the Supreme Court to stay execution of the judgment pending appeal. If the stay requested by the party wishing to appeal is granted, execution is suspended until the appeal is disposed of or the stay granted by the court is vacated. As a condition for such stay, the court would ordinarily order that part of the sum due under the award (usually 50% of the amount due under the foreign award) be deposited.
E. Evidence required
(a) What evidence must be supplied for recognition and enforcement of foreign awards (e.g. arbitral award, contract containing arbitration clause, affidavits, witness statements, etc.)?
The person/entity applying for recognition and enforcement of a foreign award must supply the court with: (i) the original award or a copy thereof, duly authenticated in the manner required by the law of the country in which it was made; (ii) the original arbitration agreement or a duly certified copy thereof; (iii) other evidence as may be necessary to prove that the award is a foreign award; (iv) a certified copy of the English translation of the arbitral award and the arbitration agreement (if applicable).
(Source: 1996 Act, s. 47(1).)
The Delhi High Court in its recent decision in Glencore Grain Rotterdam B.V. v. Shivnath Rai Harnarain (India) Co., C.S. (O.S.) 541 of 1998 held that the above-mentioned documents shall form prima facie evidence to prove that the award is a genuine foreign award, and that the applicant who is applying for enforcement of a foreign award is not required to produce any further evidence. (See also CETACO SA v. Bombay Export International, 2000 (3) Arb. LR 69 (Bom).)
(b) Is it necessary to provide the entire document or only certain parts (e.g. entire contract or only arbitration clause)?
The arbitral award for which recognition and enforcement is sought must be provided in its entirety. The contract containing the arbitration agreement should be provided in full as a matter of practical convenience, although a strict reading of the relevant section requires only the arbitration agreement to be produced in full.
(c) Are originals or duly certified copies required?
Authenticated originals or duly certified copies are admissible.
(d) How many originals or duly certified copies are required?
The court requires only one duly authenticated original or duly certified copy of each of the award and the arbitration agreement. Other copies of these documents, e.g. for the court record or for service upon counsel for the judgment debtor, may be duly certified by counsel for the applicant/petitioner.
(e) Does the authority or court keep the originals that are filed?
(a) Is it necessary to provide a translation of the documents supplied?
Yes, if the award and arbitration agreement are not in English.
(Source: 1996 Act, s. 47(2).)
(b) If yes, into what language?
(c) Is it necessary for the translations to be certified and, if yes, by whom (official or sworn translator, diplomatic or consular agent (of which country?) or some other person)?
Yes. The translation must be duly certified as correct by a diplomatic or consular agent of the country to which the party seeking recognition and enforcement belongs, or certified as correct in such other manner as may be sufficient according to the law in force in India.
(d) Is it necessary to provide a full translation of the documents or only a translation of certain parts (e.g. entire award or only part setting forth the decisions; entire contract or only arbitration clause)?
A full translation must be provided.
F. Stay of enforcement
(a) Can the authority or court stay legal proceedings for recognition and enforcement pending the outcome of an application to set aside or suspend the foreign award before the competent authority referred to in Art. V(1)(e) of the New York Convention?
(Source: 1996 Act, s. 48(3).)
(b) On what other grounds, if any, can the authority or court stay legal proceedings for recognition and enforcement (e.g. forum non conveniens)?
No other grounds are specified in the 1996 Act.
(Source: 1996 Act, s. 48.)
(c) Is the granting of a stay of legal proceedings for recognition and enforcement conditional on the provision of security?
No. However, the court may, on the application of the party claiming enforcement of the award, order the other party to furnish suitable security.
(a) Do the documents filed in legal proceedings for recognition and enforcement form part of the public record? If yes, can any steps be taken to preserve the confidentiality of such documents?
Yes. A motion can be brought seeking an order of the court to preserve the confidentiality of documents. However, Indian courts are generally averse to granting such orders.
(Source: Indian Evidence Act, 1872 (Act 1 of 1872), s. 74(1).)
(b) If there are hearings on recognition and enforcement, are such hearings confidential? If not, can steps be taken to maintain the confidentiality of the legal proceedings?
No. However, if thought fit, the presiding judge may, at any stage of an inquiry into or trial of any particular case, order that the public generally, or any particular person, shall not have access to or remain in the room or building used by the court.
(Sources: Code of Civil Procedure, 1908, s. 153B; Naresh Shridhar Mirajkar and Ors. v. State of Maharashtra and Anr., AIR 1967 SC 1 (9-Judge Bench); Narottamdas v. State of Gujarat, 1971 GLR 894.)
(c) Are judgments on recognition and enforcement published? If yes, can steps be taken to remove the names of the parties or avoid publication of confidential information (such as business or State secrets)?
(Sources: Code of Civil Procedure, 1908, Order XX, Rule 1(1); Indian Evidence Act, 1872 (Act 1 of 1872), s. 74(1).)
A motion can be brought seeking an order of the court to preserve the confidentiality of any information in the court record. However, Indian courts are generally averse to granting such orders.
(Sources: Indian Official Secrets Act, 1923 (Act 19 of 1923), s. 14; Naresh Shridhar Mirajkar and Ors. v. State of Maharashtra and Anr., AIR 1967 SC 1 (9-Judge Bench); Narottamdas v. State of Gujarat, 1971 GLR 894).)
H. Other issues
16. When, if ever, can a party obtain recognition and enforcement of interim or partial foreign awards?
So long as an interim or partial award is enforceable according to the law under which it was made, it may be enforced in India like any final foreign award. Additionally, s. 2(1)(c) of the 1996 Act defines an 'arbitral award' as including an interim award. Although this section is in Part I of the 1996 Act, which deals with 'domestic awards', the same is applicable to 'foreign awards', so the definition of a 'foreign award' in s. 44 would also include an 'interim award'. This was the position of the Supreme Court of India in Bhatia International v. Bulk Trading S.A. and Anr., (2002) 4 SCC 105, where it was held that the 1996 Act is one consolidated and integrated Act, that general provisions applicable to all arbitrations are not repeated in all Chapters and Parts, and that the same applies to all Chapters and Parts unless the Act expressly states that this is not so or, in respect of a matter, there is a separate provision in a separate Chapter or Part. S. 44 does not specify that the definition of 'foreign award' contained therein does not include an 'interim award', so it would also include an 'interim award'. However, although the decision of the Supreme Court in Bhatia International has been overruled in Bharat Aluminium Co. v. Kaiser Aluminum Technical Services Inc. (2012) 9 SCC 552, the overruling is prospective only and hence applies to arbitration agreements entered into after 6 Sept. 2012. Interim and partial awards should, in principle, be equally enforceable as 'foreign awards' provided the conditions of s. 44 of the Act are otherwise satisfied.
17. When, if ever, can a party obtain recognition and enforcement of non-monetary relief in foreign arbitral awards (e.g. an order requiring a party to deliver up share certificates or other property)?
A party can obtain recognition and enforcement of non-monetary relief in foreign awards so long as the relief can be granted through arbitration under the substantive law applicable to the arbitration agreement and that the award was made pursuant to an arbitration agreement in a commercial relationship. Enforceable non-monetary relief includes: (i) decree for specific performance for the transfer or delivery of movable property including shares; (ii) decree for execution of a document or endorsement of a negotiable instrument; (iii) decree for recovery or delivery of immovable property; (iv) declaratory relief.
(Source: Code of Civil Procedure, 1908, Order XXI, rr. 31, 34 and 35.)
18. When, if ever, can a party obtain recognition and enforcement of only part of the relief granted in foreign awards?
The 1996 Act does not specify whether a party can obtain recognition and enforcement of only part of the relief granted in a foreign award. However, where part of a foreign award deals with a dispute not contemplated by or not falling within the terms of the arbitration agreement, or the award contains decisions on matters beyond the scope of the agreement, and such irregular provisions can be severed from the remainder of the foreign award, then the court may recognize and enforce only the remainder of the award.
(Source: 1996 Act, s. 48 (1)(c).)
19. When, if ever, can a party obtain recognition and enforcement of foreign awards which have been set aside by the competent authority referred to in Art. V(1)(e) of the New York Convention?
A foreign award which has been set aside by a competent authority of the country in which or under the laws of which it was made cannot be recognized and enforced by the courts in India, and enforcement of such an award may be refused, at the request of the party against whom it is invoked, if that party furnishes to the court sufficient proof in this regard. Although the statute uses the phrase 'may be refused', drawn from the New York Convention, Indian courts are in practice more likely to hold that no award remains in existence to be enforced (although this may not be the correct view). The issue has not so far been considered by the courts.
(Source: 1996 Act, s. 48 (1)(e).)
20. Are there any other procedural or practical requirements relating to recognition and enforcement of foreign awards which are worth mentioning (e.g. unusually high court costs, filing fees, stamp duties, obligation to post security as a condition for seeking recognition and enforcement, obligation to identify the assets that will be the object of enforcement, etc.)?
The party seeking recognition and enforcement of a foreign award may have to pay court fees in accordance with the relevant provisions of the Court Fees Act, as applicable in the state where enforcement and execution are sought. Court fees vary from state to state depending on the amount of monetary relief sought and are usually ad valorem ranging from 1% to 10% and sometimes more. It is possible, although would not seem to be a requirement under the Indian Stamp Act and state amendments thereto, that some states would impose a stamp duty at the applicable rate when the award is brought into that state. The issue does not appear to have yet been raised in or decided by the Supreme Court of India. The rate of stamp duty varies: in some states it is nominal while in others it is ad valorem ranging from 0.1% to 2-3%.

domain: law


text:
AAP MP Raghav Chadha dodges question on Parineeti, duo were spotted together at restaurant
The AAP MP though got little uncomfortable with ‘Parineeti question’ but tired to brush it aside with a smile.
New Delhi: Aam Aadmi Party (AAP) lawmaker Raghav Chadha, recently spotted with Bollywood actress Parineeti Chopra at a Mumbai restaurant, skirted questions on the dating rumours.
Raghav Chadha, the youngest AAP Rajya Sabha MP from Punjab, was pursued by a reporter outside the Parliament and questioned about alleged affair between them.
The AAP MP though got little uncomfortable with ‘Parineeti question’ but tired to brush it aside with a smile. The reporter asked him whether he was going to marry Parineeti Chopra, to which Raghav said, “Please ask questions on politics, not on Parineeti.”
When the reporter insisted that he speaks up on alleged affair with Bollywood actress and why was he seen with the actress, the AAP MP again sought to evade the cameras and moved on.
For the unversed, the AAP MP was seen with actress Parineeti Chopra at a restaurant in Mumbai recently and the duo even posed for the paparazzis. As the photos & videos landed on social media, it sparked wide speculations of something personal brewing between the two.
According to reports, the actor & politician went for outdoor meal twice, once for lunch & then for dinner.
Raghav & Parineeti went for dinner at a restaurant on Wednesday, with both wearing white shirts while the next day, they again visited a restaurant for lunch.
While they exited the restaurant after lunch, they were clicked by shutterbugs. Both left in the same car and Parineeti also got pictures clicked before getting into the car.
Parineeti Chopra & Raghav Chadha stepped out for lunch in style! #zoomtv #parineetichopra #raghavchadha #entertainment #zoompapz #bollywood pic.twitter.com/YAP0cIuJMr
— @zoomtv (@ZoomTV) March 23, 2023
For the unversed, Raghav Chadha is AAP MP and also the youngest Member of Parliament. Being a native of Delhi, he studied at London School of Economics (LSE).
Parineeti is an acclaimed Bollywood actress and cousin of Priyanka Chopra. She also studied in UK at Manchester Business School. She debuted in the Hindi film industry with Yash Raj Films and first starred in movie Ladies Vs Ricky Bahl (2011) opposite Ranveer Singh.

domain: celebrity


text:
There is many color in the world, but the soft pink is the most famous color for girls. Therefore we pick some soft pink color bedroom design to give learn how famous is soft pink girl bedroom. Previosly we pick impressive colorfull teen room and now time for pink color describe. Pink color is timeless theme for girls bedrooms. For many people it is a symbol of tenderness and youth. This color is associated with fairy-tale princess or Barbie and almost every girl dreams about a charming pink bedroom. Pink color could perfectly fit as traditional bedrooms with classical furniture and amazing curves as contemporary, more severe ones.
Combining this color with others you could get a various awesome designs. For example white and pink furniture looks very beautiful but if you want more bright bedroom then you might more like a combination of pink and green colors. Below you could see very interesting ideas to create the best pink kids bedroom. There are different examples of girls rooms which would be liked by as young as adult girls among them.
Take a Look at the picture.
One of the famous Internets telephony application Skype’s bring one of its office interiors to public. Skype north american headquarters which set themselves side by side with their opponent’s in the Bay area, Palo Alto California. When the office interiors project is began and planning, there was discovered about the site had more to contribute than was originally thought. The site was very friendly for with industrial style design, with the hidden high ceilings that can increasing the scope for inventiveness. This office interiors is not like the Google Office at Pittsburgh which used a old biscuit factory to rebuild their office.
Today the one of the most unique home design, the small cube home we presents to our reader. This small cube home are consisting of an combine from interior and exterior design. The interior and exterior of this small cube home have a relationship as a proposal of architecture of a new relationship between internal and external. The site of this small cube home was very not irregular shape as common house, the planar shapes of the rooms in the two cubes of “inside house” and “outside house” are irregular shapes. Like Clean Nature Based Winter Sport Resort by RYRA which adapted igloo house plans.
On this 2011 spring Cerasa, an italian company released their modern bathroom decor based on luxury bathroom style. Spring 2011 bathroom was many people search on our site, and now we share this luxury modern bathroom ideas on many part. Luxury bathroom was our dream, when we take a bath on this kind of bathroom of course our feel gona relax and comfy. No one we get that all without planning to get some luxury bathroom on their demand. On this part not only expose how luxurious this bathroom, but it’s furniture too.
BluBleu as famous bathroom designer today presents its beautiful bathtubs design for this 2011. All of this beautiful bathtubs is begin to visualize bathrooms as areas for indulgence and living, the concepts they put forward tend to reflect this philosophy. Many of this beautiful bathtubs is a bathtub refinising, which finished with awesome colorful design. This bathtubs is exellent when attached on a house apartment like Modern Semi Open Floor Plan House Apartment by Stadshem. With freestanding, cast iron, clawfoot etc to make beautiful colorful design.
Related Home Decor & Design Ideas for school soft board border at HomeDesignDecorations.com
Luxury wood and stone based spring home is one of the best choice to design and decor our home. Luxury wood and stone based spring home below inspired us how to design and modeling a spring home.
Designed by Simonsen and Czechura they was began as a small carpentry in 1994 which specializing in interiors design, but now they design stylish scandinavian kitchen. This stylish Scandinavian kitchen was developed a reputation for designing and producing kitchens with very simple lines, even in classic designs. Stylish Scandinavian kitchen are made with modern equipment [...]
When people thinking about inner city living they must has never looked so good at it. But today we presents one of the best modern home designs in a inner city living with its beautiful panorama and entertaining spaces. Modern home is usually offers the owner with lots of easily features, this next Brisbane architectural [...]
Developed by ONY Architecture, the Sawyer Loft an apartment interior which have 1,500 square foot space in the leather district of Boston. The goal of this apartment interior project is to renovation the kitchen, an addition of an office/guest bedroom, creating a multi-functional storage wall, and general improvements to the space. The minimalist apartment interior [...]
This modern classy home interior was one of the amazing loft interior which located on the top floor of a very attractive building on one of the most desired addresses in Stockholm. The classic style on the modern classy home interior was used because the building was built in 1885 so the 300 square meter [...]
One of the most beautiful apartment interior concept is bring by Stadshem with modern cocktail apartment ideas, they presents a fresh cocktail apartment with high ceilings and patio. This modern cocktail apartment building is located in Sweden which its designer come from. Exciting and bright accommodation with high ceilings and open floor plan. The association [...]
For people who like swimming at the private pool on their vacation mountain resort, this place was the perfect one to enjoy your whole vacation day featuring with infinity private pool which mean each room does have a single pool. This mountain resort is located in St. Lucia, called Jade Mountain Resort. This resort place [...]
Awesome vacation house of hello kitty, located in Taiwan and built by a designer who is very fannatic with hello kitty character.
This hemeroscopium house is a unusual modern home design. Designed by Ensamble Studios, this unusual modern home push the limit of home designing. When people design a home with contemporary design style, this modern home did not follow that line, it makes new line of home design which unusual for common home designer. This modern [...]
Lot of staircases design in the world, but why this one is the most amazing staircases design. The reason is this is a floating staircases design and packed with amazing designs for your home ideas.

domain: design


Graphite Mining include mining of graphite and its compounds that is used in refractory materials, chemical industries, nuclear industries, electrical applications, and mechanical applications. Graphite is one of three forms of crystalline carbon; the other two are diamond and fullerenes. Graphite occurs naturally in metamorphic rocks such as marble, schist, and gneiss.
Graphite Global Market Size
The global graphite mining market was valued at $1.42 billion in 2017. Asia Pacific was the largest geographic region accounting for $0.54 billion or 38% of the global market. USA was the largest country accounting for $0.27 billion or 19.01% of the global graphite mining market.
Graphite Global Market Trend
Companies involved in graphite mining are increasingly using autonomous vehicles to increase productivity, reduce cost and increase safety. Autonomous vehicles increase efficiency by minimizing delays, reducing operating costs and eliminate mistakes by improving the accuracy and repeatability. For instance, Rio Tinto, BHP Billiton, and Fortescue Metals Group are deploying autonomous vehicles in their operations, using driverless trucks to haul ore.
The companies covered are Graphite India Limited, Mason Graphite, SGL Carbon SE, GrafTech International Holdings Inc, and Triton Minerals Ltd.
The countries covered are USA, China, Germany, Brazil, Japan, UK, Spain, Russia, France, Australia, Italy, India and rest of the world.
Graphite Global Market Segmentation
The graphite market is segmented into Natural Graphite; and Synthetic Graphite.
Natural Graphite Mining include mining of graphite and its compounds that is used in refractory materials, chemical industries, nuclear industries, electrical applications, and mechanical applications.
Synthetic graphite industry is primarily engaged in making the Synthetic graphite by the high temperature processing of amorphous carbon materials.


text:
Some people swear by “It’s a Wonderful Life” or “Die Hard” or “Holiday Inn” or “The Polar Express.” But there is a segment of the population that can’t endure Christmas without “Love Actually.” A screening Nov. 29 at Wadsworth Atheneum scratches that annual itch.
Richard Curtis’ 2003 comedic drama tells eight stories of love at Christmastime in London. Laura Linney and Rodrigo Santoro love each other but are too shy to say so. Prime Minister Hugh Grant is hot for a servant, Martine McCutcheon. Colin Firth and Lucia Moniz don’t speak the same language, but he is besotted with her. Emma Thompson and Alan Rickman are having a rough patch in their marriage.
Thomas Sangster, age 11, has a crush on Olivia Olson, and asks advice from his father, Liam Neeson. Keira Knightley has a yen for her husband’s best friend, Andrew Lincoln. Martin Freeman and Joanna Page are actors making a porn movie who want an old-fashioned romance. The movie’s sole bromance is portrayed by fading rocker Bill Nighy and Gregor Fisher, his devoted manager and drinking buddy.
Showtime is 8 p.m. Admission is $10, $9 seniors and students, $7 members. The theater is at the 29 Atheneum Square North entrance to the Hartford museum. thewadsworth.org.

domain: entertainment


Editor's Note: The following is reprinted with the permission of the Council on Foreign Relations.
Long lines of voters turned out across Egypt to cast their ballots in the country's first parliamentary election since the fall of Hosni Mubarak (NYT). The historic vote comes as a revitalized protest movement has clashed with the ruling military council in recent days, demanding an immediate handover to a civilian government.
The governing Supreme Council of Armed Forces has rejected protester calls to cede its leadership in the near term, saying it would follow through on its road map for transferring authority (al-Jazeera). The military never set a precise date for handing over power to civilian administration, only pledging that presidential elections would be held before the end of June 2012.
Analysts expect the new parliament to have strong Islamist representation led by the Muslim Brotherhood (BBC). Forty-one protesters have been killed and more than two thousand have been wounded in violence leading up to the election.
Egypt's military appeared to be pursuing a divide-and-rule approach to defuse mass protests ahead of today's planned polls, but this may backfire, says CFR's Steven A. Cook.
With fresh political violence erupting ahead of elections, Shibley Telhami points to new polling data showing Egyptians are concerned that the military is attempting to undo the gains of the revolution.
This Backgrounder notes the divide in views over whether the Muslim Brotherhood will choose a path of moderation or extremism.
Arab League Sanctions Syria
The Arab League approved economic sanctions against the government of embattled President Bashar al-Assad (NYT)–an unprecedented move by the regional bloc against a member state. The decision follows Syria's failure to abide by the terms of an Arab League peace treaty agreed to earlier this month.
Investigation into Borneo Bridge Collapse
Indonesian President Susilo Bambang Yudhoyono has ordered an investigation into the collapse of the Mahakam II Bridge (al-Jazeera) in Borneo on Saturday. The cause of the tragedy, which killed at least eleven people, was not immediately clear.
CHINA: Beijing proposed increased military relations with Myanmar (Reuters) just days ahead of a scheduled visit from U.S. Secretary of State Hillary Clinton. In recent weeks, Chinese officials have claimed the U.S. diplomatic push in the Asia-Pacific region is an attempt to encircle China.
CFR's Josh Kurlantzick discusses the improving U.S-Myanmar relations, and suggests the Obama administration watch several markers to see that reform in the country is continuing.
SOUTH AND CENTRAL ASIA
Fears over Souring U.S.-Pakistan Relations
A NATO airstrike that killed twenty-four Pakistani soldiers in a border region on Saturday has further heightened tensions between the United States and Islamabad (BBC). While NATO apologized for the attack, public anger in Pakistan is fueling calls for the country to sever all ties with Washington.
AFGHANISTAN: The Pakistani government has halted military supplies destined for U.S.-led forces in Afghanistan following a deadly NATO airstrike (Bloomberg). Islamabad shut down the border for ten days in 2010, and the Pentagon has been looking for alternate routes since.
Congo Holds Historic Vote
The Democratic Republic of Congo is holding its second presidential and parliamentary election since the country emerged from war in 2003. Incumbent Joseph Kabila is one of eleven presidential contenders competing in an election beset by logistical problems (CNN).
MOROCCO: Morocco's Justice and Development Party, a moderate Islamist political group, dominated the country's parliamentary elections (AP), another indication that religious-based groups are profiting most from the Arab Spring's democratic changes.
Guyana to Elect New Government
Voters in Guyana (BBC) are set to elect a new government in a poll pitting the People's Progressive Party against long-time rival the People's National Congress. National politics have been largely split along ethnic lines since independence from Britain in 1966.
UNITED STATES: Police in Los Angeles are set to begin arresting Occupy LA protestors (LAT) who violated a 4 a.m. deadline to leave parts of the downtown area. Hundreds of Occupy activists gathered at City Hall after the deadline passed.
The international Occupy movement faces crackdowns in several cities, but continues to spur public discourse over economic inequality. But there is sharp debate over how to translate protest into policy changes.
OECD Cautions on Eurozone Contagion
OECD Chief Economist Pier Carlo Padoan said European leaders must provide "credible and large enough firepower" to curb the sell-off in the eurozone sovereign debt market (FT) or risk a severe recession. The organization representing the world's richest countries cut its half-yearly forecasts and said growth in Europe was approaching stall speed.
The eurozone, once seen as a crowning achievement in the decades-long path of European integration, is buffeted by a sovereign debt crisis of nations whose membership in the currency union has been poorly policed.
BELGIUM: Belgian lawmakers struck a deal on a budget for 2012, prompting hopes the country can form a coalition government and end a seventeen-month old political stalemate (DeutscheWelle). Belgium has had a "caretaker" government since June 13, 2010, when parliamentary elections produced an impasse between the country's Dutch and French speakers.