INTRODUCTION
“We are responsible for what we are, and whatever we wish ourselves to be, we have
the power to make ourselves. If what we are now has been the result of our own past
actions, it certainly follows that whatever we wish to be in future can be produced
by our present actions; so we have to know how to act.”
- Swami Vivekananda
With all its alluring contrasts and remarkable features, India has a grand heritage
of 34,000 years. Down the traditional lane, it has evolved into a pluralistic, multilingual,
and multiethnic society. It is quite striking that while India is the second-most
populous country, it has the largest democracy in the world. The second fastest growing
economy and the third largest military force are also her golden quills. Seventy-four
per cent of the 1.14 billion population of India live in rural areas. India has 28
states, seven union territories, 612 districts, and 6, 38,365 villages. The fact that
there are 22 official languages in a single country is ample evidence for the heterogeneous
nature of the society it represents. Having a literacy rate of about 64.8%, India
has 80 million internet users. With all this, I do not mean to say that India is not
without its lacunae. Even while India is the world's twelfth largest economy, we cannot
close our eyes to the grim truth that 22% of the population exists below the poverty
line.[1–3]
With regard to the academic scene, India is proud to have 289 institutions providing
undergraduate medical training (196 MCI recognized, 77 MCI permitted, and 16 in the
“danger zone”). The postgraduate training in psychiatry includes Doctor of Medicine
(MD) (83 centers, 159 seats), Diploma in Psychological Medicine (DPM) (46 centers,
107 seats), and Diplomate of National Board (22 centers, 36 seats). Strikingly, 25%
of the medical colleges in India do not have a Psychiatry Department.[4–6] Apparently,
there are only around 4000 psychiatrists in India to serve the five crore mentally
ill population currently.
MENTAL HEALTH SCENARIO IN INDIA
Obviously, in a vast country like India, the threat posed by the psychiatric and behavioral
disorders is just inexplicable. A meta-analysis of 13 epidemiological studies consisting
of 33,572 persons reported a total morbidity of 58.2 per 1000. Another meta-analysis
of 15 epidemiological studies reported a total morbidity of 73 per 1000.The saddest
aspect is that the bulk of the affected falls in the 15 to 45 year age group. The
existing facilities in the country fall short of the required norms, which makes the
situation still worse. The number of psychiatric beds in the country is only about
0.2 per 1, 00,000 population and there are only two psychiatrists per 10 lakh population.
The major share of psychiatric facilities lies with the government sector (especially
mental hospitals), which is centered on certain areas of particular states. The psychiatric
services have not yet been integrated into the primary health care system and this
leaves large populations in dire need of such facilities, with no hope of effective
treatment. Therefore, they seek help from the private sector and there are no clear
policies regarding treatment of the mentally ill in the private sector. A significant
population in India cannot afford private hospital care and the insurance system in
the country is in its infancy. The rehabilitation of psychiatric patients is also
given little importance in the existing mental health framework. The integration of
psychiatric services to primary care needs a public–private partnership to enable
comprehensive mental health care.[7–10]
INDIAN PSYCHIATRIC SOCIETY EVOLUTION
Our society sprouted from the Indian Association for mental hygiene founded in 1929
by Berkeley Hill. In 1935, the Indian division of the Royal Medico-Psychological Association
(RM-PA) was formed, due to the efforts of Dr. Banarasi Das. Thanks to the efforts
of Dr. Nagendra Nath De, Major R. B. Davis, and Brigadier T. A. Munro, the association
gained its new name, the Indian Psychiatric Society (IPS) on 7 January, 1947. The
rules and regulations were framed by the eminent Psychiatrists of that period (Dhunjibhoy,
Rosie, Kenton, Llyodo, Masani, Shah, Johnson, Govindaswamy, and Kak). The first annual
meeting held on 2 January, 1948, at Patna, was presided by N.N. De.[11
12] The society has grown into a group of 2000 Fellows (right of franchise) and many
ordinary members. The activities of IPS are also delegated to state branches coming
under five zones. The objectives of the society are very comprehensive.[13]
Promote and advance the subject of Psychiatry and allied sciences in all their different
branches.
Promote the improvement of the mental health of people and mental health education.
Promote prevention, control, treatment, and relief of all psychiatric disabilities.
Formulate and advice on the standards of education and training for medical and auxiliary
personnel in psychiatry, and recommend adequate teaching facilities for the purpose.
Promote research in the field of psychiatry and mental health. Propagate the principles
of psychiatry and current development in psychiatric thought.
Deal with any matters relating to mental health concerning the country and conduct
all other things as are cognate to the subjects of the Indian Psychiatric Society.
Safeguard the interest of Psychiatrists and fellow professionals in India.
Promote the ethical standards in the practice of psychiatry in India.
It is worthwhile to introspect on our achievements and deficits.
The achievements include academic updates as part of professional development, in
the form of publications like Indian Disability Evaluation and Assessment scale (IDEAS)
and Clinical Practice Guidelines, and the Indian Journal of Psychiatry. Some efforts
have been carried out in mental health literacy and community service strategies.
Although psychiatrists are involved in NMHP (National Mental Health Program) and DMHP
(District Mental Health Program), the society's involvement as a stakeholder is still
not appreciated. The same is true for other mental health policies and programs.
IPS should
Be a stakeholder in mental health policy matters.
Have its publications on mental health issues.
Try to get its journal indexed in international databases.
Actively involve in the initiative to have a Mental Health Website by the Health Ministry.
Address social issues, conduct mental health literacy programs, and open free mental
health service outlets in an organized and planned manner, if possible.
Have an advocacy team to facilitate the link between the society and officialdom,
in matters such as undergraduate psychiatric training, decriminalization of ‘attempted
suicide,’ and ‘homosexuality’, better functioning of DMHP, and refining the Mental
Health Act.
THE VISION
1. Reaching the unreached
The rural population, comprising of about 74%, is beset with multiple disadvantages.
High population growth rate, agrarian form of economy, primitive agricultural practices,
illiteracy, ignorance, unemployment, underemployment, caste-based politics, urban
rural divide, social iniquity, and discrimination, account for 22.15% of the population
that remain below the poverty line. “State of the World Population 2007” report comments
on the rapid shift of rural population to the cities by 2008. This ‘pseudo-urbanization’
may lead to shortage of resources in cities leading to ‘urban poverty’. Relationship
between poverty and poor mental health has been well studied and stated. The World
Health Organization report on mental health states ‘Mental disorders occur in persons
of all genders, ages, and backgrounds. No group is immune to mental disorders, but
the risk is higher among the poor, homeless, unemployed, and persons with low education’.
Poverty, unemployment, poor education, and poor nutrition may pave the way for maladaptive
behavior, depressive illness, and broken families. The vicious cycle of poverty breeding
mental dysfunction may culminate in substance use, domestic violence, and antisocial
behavior. The pathological family atmosphere may cast a negative impact on a child's
mental health.[14–16]
Ignorance, illiteracy, ‘myth understanding’, poor access to psychiatric services,
and fractured community care / support necessitate the need for mental health literacy,
Psychoeducation, proper immunization, improved nutritional care, and better mental
health service delivery in the rural population. This may be facilitated by IPS in
collaboration with NRHM (National Rural Health Mission) and DMHP.
2. Rehabilitation
Psychiatric rehabilitation facilities do not satisfy even the adequate requirements
in many states across India. There is a polarization toward South India, especially
Kerala, Karnataka, and Tamil Nadu, in the psychosocial rehabilitation map. Training
facilities exist at NIMHANS, Richmond Fellowship Society of India at Bangalore, and
SCARF at Chennai. Many NGOs are involved in rehabilitation practices, especially in
substance use disorders, human immunodeficiency virus (HIV), dementia, and schizophrenia.
However, IPS has not done enough in this area except for formulation of IDEAS.
It is quite appropriate and appreciable to have a status report on the psychiatric
rehabilitation facilities, and initiate skill development in psychiatric rehabilitation
under the umbrella of IPS.
3. Research
The research output from India concentrates mainly on epidemiology and service delivery.
The database on drug abuse research has been mainly from AIIMS (New Delhi) and NIMHANS
(Bangalore). Psychiatric genetic research is another domain, again from New Delhi
and Bangalore. Biological psychiatry research initiated from Lucknow has now shifted,
mainly to Bangalore. The priorities in research on mental health have been outlined
elsewhere.[17–18] Research publications in the international database during the last
decade mainly reflect on the studies generated from selected teaching institutions
in India — NIMHANS (Bangalore), PGI (Chandigarh), AIIMS (New Delhi), RML hospital
(New Delhi), KGMC (Lucknow), IHBAS (New Delhi), and CIP (Ranchi). CMC (Vellore) deserves
a special mention for its collaboration with the Cochrane Database.
There are efforts being made to conduct and pursue research in other teaching institutions
and private psychiatric centers. However, the limiting factors include,
Lack of proper training in research methodology.
Lack of motivation.
Lack of infrastructure.
Lack of skill in writing a research article.
Lack of funding.
Central budget allocation for training and research — 2008-2009
Center
Budget Allocation (in crores)
AIIMS
452
PGI
183
JIPMER
128
Lady Hardinge Medical College and Smt. Sucheta Kripalani Hospital, New Delhi
99
NIMHANS
68
RML
10.8
Others
10.9
Central budget allocation for research — 2008-2009
Center/Activity
Budget allocation (in crores)
ICMR
356 (How much for mental health research?)
Promotion, coordination and development of basic, applied, and clinical research
50
Inter-sectorial coordination in medical, biomedical, and health research
19
Advanced training in research in medicine and health
5.5
International cooperation in medical and health research
10
Matters relating to epidemics, natural calamities, and development of tools to prevent
outbreaks
5
Matters relating to scientific societies and associations, charitable and religious
endowments in medicine, and health research areas
2
Other health research schemes
1
Provision for projects/schemes of North, Eastern Areas, and Sikkim
40
Hospitals and dispensaries have separate allocation for development plans
A bird's eye view on the Central Budget allocation under the Health Ministry[19
20] can reveal why major teaching institutions have been able to churn out research
data.
It would be worthwhile to look at the budget allocation for research, and propose
a research agenda for mental health.
However, the state-run institutions depend upon research grants from their respective
state governments. The allocation for mental health research might be negligible or
almost nil, partly due to the myopic vision of the mental health planners in the ministry
or due to “masterly inactivity” of the state psychiatric associations. There is a
provision from the Central Ministry for upgrading selected institutions to the ‘AIIMS
Model’ with an allocation of 490 crore rupees. If properly planned and executed, the
barren land for research in mental health may hopefully become fertile in the near
future.[19]
IPS should focus on this issue and try to facilitate research in psychiatry. The possible
methods include,
Research methodology training to selected psychiatrists.
Advocacy to reallocate and channelize research grants. A core group should screen
the proposals and the advocacy committee of IPS should try to impress the ministry
and ICMR (Indian Council of Medical Research) to take appropriate steps. NMHP has
58 crores as its share, whereas, NRHM having 10786.25 crores as budget allocation,
encompasses the National Drug De-addiction Control Program (11 crores) and Information
Education and Communication (171.7 crores). The core group may try to include mental
health related programs under NRHM, such as,
Orientation in skills in drafting a research article.
Young researchers group under IPS may have a positive impact.
The networking of the international association may render assistance to mental health
research in India.
4. Women' issues
Forty-eight per cent of the Indian population is constituted by women. Although Indian
history depicts equal rights for women in ancient India, the medieval period denied
equal rights. The Indian constitution has many provisions for the welfare of women
as can be learnt from article 14 (equality), article 15 (1) (no discrimination by
the State), article 16 (equality of opportunity), article 39 (equal pay), article
51 (A) (e) (dignity of women), and article 42 (maternity relief). The Dowry Prohibition
Act of 1961, National Policy for the Empowerment of Women in 2001, and The Protection
of Women from Domestic Violence Act of 2005 (which came into force in October, 2006),
are geared toward the welfare of women. Despite all this, discrimination and oppression
are rampant, especially in rural areas. Less than 10% of the households are matriarchal.
It has been predicted that the growth rate of crimes against women might surpass the
population growth rate by 2010. Poverty, illiteracy, malnutrition, infections, and
improper maternity care in rural areas might be the reason for the high rate of maternal
mortality in India (second highest in the world).[21
22]
A meta-analysis of 13 epidemiological studies from the different regions of India
revealed an overall prevalence rate of mental disorders in women of 64.8 per 1000.[8]
Women are twice prone to develop depression compared to men. Poverty and malnutrition
may have a direct link in causing depression during pregnancy and the post partum
period. The hormonal milieu of the female gender may render vulnerability to emotional
disorders and may influence the pharmacokinetics of drugs. Women's mental health issues
have been discussed elsewhere.[8
21
22]
5. Physical illness in mentally ill
Several large studies show that psychiatric patients suffer a high rate of co-morbid
medical illnesses. Co-morbid depression in the medically ill is often undiagnosed
and untreated, leading to increased morbidity. Lack of proper training, defective
perception of the psychological impact on physical disorders, improper rationalization
about the somatic symptoms of depression, and a tunnel vision of medical pathology
may culminate in the physician's non-recognition of the psychopathology. Co-morbid
psychopathology may contribute to the therapeutic nonadherence to medical regimen.
The drug—drug interaction may pose a therapeutic dilemma.[23]
Let me now focus on two specific issues relevant to the Indian context — Diabetes
and HIV.
With a 40 million diabetic population, India has earned recognition as the diabetic
capital of the world. The characteristics of higher glycemic response to all food
items, secreting more insulin in response to glucose, and the Asian Indian Phenotype
(increased insulin resistance, greater abdominal adiposity, lower adiponectin, and
higher high-sensitivity C-reactive protein levels) demonstrate a higher vulnerability
to develop type II diabetes, with a projected 70 million by 2025.[24–28]
A meta-analysis of 42 studies has shown clinically relevant depression in 31% of diabetics.
Diabetics are twice as likely to have depression. Co-morbid depression may affect
glycemic control and diabetes self-care behavior. Depression may also add to disability
and decreased Quality of Life (QOL). Medication nonadherence can lead to increased
morbidity and mortality. The relationship between depression and diabetes may be summarized
as follows:[27
28]
Depression is a risk factor in the development of Type II diabetes mellitus (DM).
Depression increases the risk of coronary heart disease (CHD) in established DM.
Depression is associated with hyperglycemia and other metabolic abnormalities.
Depression is associated with other physical precipitants of heart disease.
Treatment of depression may reduce the risks of DM and its complications.
About half of the Indian population consists of adults in the sexually active age
group. The National Family Health Survey conducted between 2005 and 2006, has measured
HIV prevalence among the general adult population of India. The revised prevalence
estimate in July 2007, suggests that around 2.5 million people in India are living
with HIV. The HIV prevalence in female sex workers in India is around 5%, mainly accounted
for in Maharashtra and Nagaland. HIV prevalence is high in intravenous drug users
(IDU).The rates are as high as 64% in certain cities. Manipur ranks first, with six
times the prevalence of Maharashtra and 20 times that of Tamilnadu. Concurrent hepatitis
C/B, tuberculosis, anemia, and cellulitis complicate the management of HIV in IDU.[29–31]
The psychiatric disorders in HIV may range from adjustment disorders, depression,
and anxiety states to acquired immune deficiency syndrome (AIDS) dementia. Rates of
depression in Indian HIV cases range from 10 – 40%, higher than the rate reported
elsewhere. However, the rates of AIDS dementia are pretty low (1 – 2%).[29]
Research in psychiatric disorders in HIV will be an area where young researchers in
Psychiatry have to focus.
6. Nonpharmacological treatment
Training in the nonpharmacological management of psychiatric disorders is abysmally
poor in India. Although very few teaching institutions impart the knowhow of cognitive
behavior techniques and basic psychotherapeutic skills, a majority of the practitioners
employ ‘common sense’ psychotherapy. The upswing of psychopharmacological research
has provided a generation of ‘pill pushers,’ relegating the very essence of a good
doctor – patient relationship and nonpharmacological management principles. It has
to be remembered that a ‘psychological mattress’ is essential for a ‘pharmacological
pillow’.
The time is ripe to initiate skill development in cognitive behavior therapy (CBT)
and other nonpharmacological management strategies.
7. Child psychiatry
It is estimated that as many as one in five children and adolescents may have identifiable
mental health disorders requiring treatment. Mental health disorders in children and
adolescents are caused by biology, environment, or a combination of the two. A hostile,
threatening or uncomfortable environment provides the breeding ground for many negative
perceptions with resultant emotional and behavioral disturbances. Families and communities,
working together, can help children and adolescents with mental disorders. A broad
range of services is often required to meet the needs of these young people and their
families.
Child psychiatry training in India is available only in very few centers. Most of
the postgraduate training centers do not address psychological/psychiatric issues
in a desired format, thanks to the lack of proper training in that specialty. The
cry for a super specialty in child psychiatry did not impress the authorities. However,
the NIMHANS model of child psychiatry specialization is a welcome step.
There is an urgent need to pool the available child psychiatrists of India and to
initiate time-bound, focused, training workshops.
8. Geriatric psychiatry
The elderly population in our country will increase from 7.6 million in 2001 to 137
million by 2021. The feelings of loneliness along with the natural age-related decline
in physical and physiological functioning are catalysts to psychological disturbances.
Services catered to the comprehensive array of psychological, cognitive, and physical
problems of the elderly have to be provided. The only reliable morbidity data is on
dementia and its estimated prevalence is 33.9 per 1000 in the rural and 33.6 per 1000
in the urban population, above 60 years. Of late, 10/66 dementia research groups have
contributed to our understanding of the prevalence, caregiver burden, and service
delivery of dementia subjects. The Departments of Geriatric Mental Health at Lucknow,
NIMHANS at Bangalore, BYL Nair Hospital at Mumbai, and a private psychiatric center
at Varanasi have to be congratulated in their efforts on geriatric care.[32–35]
The geriatric specialty wing of IPS should organize a focused workshop, to help psychiatrists
in the identification, assessment, and care of the elderly.
9. Addiction psychiatry
The World Health Organization (WHO) estimates suggest that there are 60 to 70 million
alcoholics in India, of which 50% are “hazardous drinkers” and require treatment.
The age of initiation to alcohol has come down from 19 years in 1986 to 13.5 years
in 2006. Studies have revealed that the revenue generated from the industry (216 billion)
is less than the revenue lost due to alcohol-related health problems (244 billion).
In a report for WHO, a multicenter collaborative study — ‘Injury and Alcohol’ — at
NIMHANS Bangalore, found that the proportion of injuries 'linked' to alcohol use was
58.9% of all injuries. Alcohol-related injuries include road accidents (46%0, violence
(24%), falls, (24%) and others (6%).[36
37]
Kerala leads in per capita consumption of liquor at a whopping 8.3 liters [pushing
Punjab to second place (7.9 liters)] as against four liters in the rest of the country.
Kerala has been emerging as one of the largest consumers of alcohol in the world.
The sale of Indian Made Foreign Liquor (IMFL) in Kerala has jumped to Rs 3,669.49
crore during 2007 – 2008, from a mere Rs 81.42 crore in 1987 – 1988. The state had
received revenue of Rs 2,914.28 crore from the KSBC (Kerala State Beverages Corporation)
alone as its share, besides crores of rupees from bar licenses. Kerala, the most literate
of Indian states, often quoted as ‘Gods own country’ ranks high in suicide rates,
accidents, and alcoholism. One really wonders whether ‘God's own country’ will be
swallowed by the devil's advocate — alcoholism.[36
38
39]
Addiction to heroin (1 million), abuse of cannabis / cannabis products, psychotropics,
and other ‘over-the-counter’ (OTC) drugs delineate unbridled regulation at sale outlets,
with inefficient legal measures.
The addiction specialty section, I hope, will pay more attention in training psychiatrists
on substance use disorders, educate the society on the evils of drug abuse, and advice
the policy planners.
10. Undergraduate psychiatry
It is a paradox that the undergraduate (graduate) medical curriculum has lesser provision
(hours of training) for psychiatry than the nursing curriculum. Despite repeated efforts
to provide more thrust on Psychiatry in graduate medical education, the status quo
remains, so as to contradict the WHO definition of health. With the current training,
medical graduates trained in “body medicine” will be miserable in identifying common
mental disorders. The medical council of India (MCI) has to intervene urgently to
include psychiatric training (doctor – patient relationship, identification of common
psychiatric problems, co-morbidity of psychiatric disorders in physical illness, somatic
symptoms and their relevance, and basic nonpharmacological and pharmacological principles).
If not, the efforts of empowering primary care providers will be a disaster. Undergraduate
psychiatric training will also minimize irrational psychotropic use and ‘doctor-shopping’
of hapless subjects, with unexplained physical symptoms.
The IPS task force, on advocacy, should take immediate steps to ‘psychoeducate’ the
agencies concerned.
11. Disaster management
India has been traditionally vulnerable to natural disasters on account of its unique
geo-climatic conditions. About 60% of the landmass is prone to earthquakes of various
intensities; over 40 million hectares is prone to floods; about 8% of the total area
is prone to cyclones, and 68% of the area is susceptible to drought. United Nations
General Assembly, in 1989, declared the decade 1990 – 2000 as the International Decade
for Natural Disaster Reduction. Major natural disasters include the super cyclone
in Orissa, the earthquake in Lathur and Gujarat, and the tsunami in Tamil Nadu.[40]
In recent times, many man-made disasters, as a part of terrorism, have driven the
Indian society to a state of panic. The bomb blasts in Mumbai, Hyderabad, Jaipur,
Delhi, Bangalore, and Guwahati have inflicted considerable psychological trauma.
In 2003 the Home Ministry has launched an India Disaster Resource Network (IDRN) and
released a Status Report on Disaster Management in India in 2004. There was a suggestion
for introducing emergency health management in the MBBS curriculum and in-service
training of Hospital Managers and professionals. However, the involvement of psychiatric
professionals either in crisis management or in managing psychological sequelae is
not highlighted.
IPS has already got a taskforce on disaster management. The society has to be involved
in disaster management programs of the country.
NETWORKING WITH OTHER ORGANIZATIONS
In this century of the world becoming smaller and smaller with a pledge of “brain
circulation in psychiatry” (instead of brain drain and brain gain) it is important
to have networking with like-minded organizations, national and international, for
better psychiatric care. This will also facilitate faculty exchanges and research
collaborations.[41]
IPS is a member of the WPA (World Psychiatric Association) and the South Asian Association
for Regional Cooperation (SAARC) psychiatric federation. The SAARC psychiatric federation
comes under the Asian Federation of Psychiatric Association (AFPA). IPS has links
with the Indo-American Psychiatric Association, Indo-Australian Psychiatric Association,
British Indian Psychiatric association, and Indo-Canadian Psychiatric Association.
The South Asian Forum International (SAFI), is another organization involved in training
and service delivery, representing 18 countries.
The collaboration and the goodwill of these bodies should be encouraged for the benefit
of Indian Psychiatry. The Royal College of Psychiatrists can assist in teaching and
training, in collaboration with IPS.
I hope the networking will open new avenues of teaching and research in India.
“You are where you are today because you stand on somebody's shoulders. And wherever
you are heading, you cannot get there by yourself. If you stand on the shoulders of
others, you have a reciprocal responsibility to live your life so that others may
stand on your shoulders. It's the quid pro quo of life. We exist temporarily through
what we take, but we live forever through what we give”
- Vernon Jordan
CONCLUSION
I have tried to outline certain areas that need special attention by the psychiatric
fraternity. I shall try to initiate the process with your cooperation, but it is up
to you all to carry forward the mission in the years to follow. Let us hope that IPS
will take the leadership in mental health matters of India.
“When looking at the future, the “what” is far more predictable than the “when.” And
the “how” will always feel different than predicted.”
- Thomas Frey