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(Adapted from the keynote address
delivered at the joint inaugural session of the CME (Military Psychiatry) and
the National Consultation on Mental Health Manpower Augmentation Strategies,
Armed Forces Medical College, Pune, 21 Aug 2004)
At the very outset, permit me to
enter a caveat: I represent a minority point of view in Indian psychiatry,
as well as in the medical profession. Nevertheless, I believe, this point
of view, howsoever unpopular, needs to be articulated. In this I draw
sustenance from the 19th century Danish philosopher, Soren Kierkegaard,
who viewed the minority as stronger, in a sociopolitical context uncannily
similar to India today!
Given the background of my long
association with the Armed Forces Medical Services, I hope this august audience
will forgive what some might regard as a lapse into intellectual nepotism. There
is, however, a message somewhere in this mundane, nuts-and-bolts beginning.
Vacuous pomposity, reflected in seemingly profound but actually meaningless
phrases like “view beyond psychopharmacology”, is not on my agenda. Instead, I
propose to deal with unfashionable and, perhaps, uncomfortable issues which, in
my subjective, wholly empirical view, merit informed debate, but which hardly
ever find place in our professional conferences. In short, these are
issues which bother me.
Ethical issues
Medical practice in the country is largely
unregulated and, what is
more
worrying, conducted in an ethical vacuum. Despite a
statutory Code of
Medical Ethics, formally notified through the Gazette
of India1, the
Medical
Council of India (MCI) and the corresponding state
councils have a
singularly sterile track-record in respect of
enforcement. The Indian
Medical Association (IMA) has demeaned itself to a
mere pressure-group,
hostage to its own internal intrigues/electoral scams
and given to
using
shoddy trade-union tactics. The situation with
regard to the Indian
Psychiatric Society (IPS) and the India Association
of Private
Psychiatry
(IAPP) is little better. Not too long ago we were
witness to the sad
spectacle of an IPS president threatening a
pharmaceutical firm with
boycott
of their products if one of their lady medical
representatives did not
withdraw her criminal complaint alleging molestation
by a senior
psychiatrist, who had been jailed on the basis of the
said FIR and the
subsequent police investigation. To compound
matters, the IPS chief
deemed
it fit to e-mail copies of his aforesaid letter to
all members, little
realizing that his ill-conceived action constituted a
prima-facie
offense
(attempt to intimidate a witness) under the Indian
Penal Code (IPC).
More
recently, the Tehelka expose of the despicable
conduct of a
psychiatrist at
the Agra Institute of Mental Health, who was caught
on camera taking a
bribe
to declare a woman “insane” in order to help her
husband obtain a
divorce,
has brought the entire profession into disrepute,
kindling memories of
the
infamous Anamika Chawla case2,3. While the UP
Government moved swiftly
to
suspend the errant psychiatrist within hours of the
telecast and the
National Human Rights Commission (NHRC) issued notice
to the
Institute’s
director, the IPS and the IAPP maintained a deafening
silence. The
psychiatrist concerned, who absconded to escape the
clutches of the
law, has
not even been suspended from the membership of these
associations,
which are
expected to be the conscience-keepers of the
profession. These generic
issues should arouse the collective consciousness of
the psychiatric
fraternity, and result in definitive action aimed at
creating a
credible
machinery to deal with such situations in the
future. There is no
substitute for peer-enforced discipline and
community-initiatives in
this
area are long overdue.
Ethical considerations impact the practice
of psychiatry in other,
more
secular, ways as well. Well meaning relations often
seek advice in
respect
of a patient who is obviously suffering from a major
mental disorder,
but
who is not prepared to see a psychiatrist. The
obvious course of
action in
such a situation, hospitalization through a
magisterial reception-order
under the Mental Health Act 1987, Section 20, is
often unpalatable for
the
relations and invariably leads to eventual alienation
of the patient
from
his or her family. This legalistic approach also
fractures the
therapeutic
alliance and nurtures a me and them paradigm, with
disastrous
consequences
for subsequent compliance/maintenance therapy.
Confronted with the
choice
between coercive treatment or no treatment, relations
readily opt for
the
covert administration of safe drugs like risperidone,
without the
patient’s
knowledge, subject to the proviso that the individual
will be brought
into
formal/overt therapy as soon as possible. This
grey-period usually
does not
extend beyond a week and, in my experience, the
outcome is invariably
positive. From the strictly scientific and legal
perspective, however,
there
is much that can be said against such unorthodox in-abstentia
treatment
without the patient’s consent, or even knowledge. To
Srinivasan and
Thara
must go the credit for bringing this sensitive issue
out of the closet
into
the open through a well-argued paper4, published in
an international
peer-reviewed journal. This ignited a lively
debate. The dialogue
needs to
be carried further in various professional fora,
with the active
involvement of lawyers, human-rights groups, women’s
organizations,
patients, carers and other social activists. It is
desirable that
consensus
guidelines and safeguards are evolved to address such
situations in an
equitable and humane manner, always keeping in view
the possibility of
misuse. The recent Agra fake medical certificate
case, referred to
earlier,
adds urgency to this issue.
The third dimension of medical ethics
relates to research and
academic
psychiatry. There are grave and well founded / widely
shared misgivings
about pharmaceutical industry supported research /
drug- trials and
sponsored academic / professional events 5,6,7. Healy
has articulated
these
concerns in a seminal paper, aptly titled: “Is
academic psychiatry for
sale?”8. Apart from direct distortions, suppression
of unfavorable
research
outcomes has virtually become routine in the
pharmaceutical industry.
The
unholy pharma-psychiatry nexus manifests in myriad
ways. Conferences
and
CME programmers have been subverted and the same set
of committed
researchers, many of whom are in full-time, or near
full-time, private
practice and do not even have an academic fig-leaf to
cover their naked
avarice, criss-cross the country, presenting research
papers to promote
their pharma-patrons’ products. For practitioners,
depending on the
volume
of business provided by them, the industry funds
family-junkets to
professional conventions, thereby promoting a
pernicious brand of
conference
tourism. This probably poses the gravest
threat to our
professional
integrity/image and it needs to be addressed
urgently. Three remedial
measures are suggested:
-
In accordance with statutory provisions1 ,
drugs should be
prescribed
only by their generic/pharmacological names. No brand
names should be
used.
There is no scientific evidence to suggest the
superiority of one brand
over
another9.
-
Pharmaceutical industry-supported research
should be funded in a
transparent manner, funds should be routed through
the institution
where
such research is conducted and the relevant
information should be
available
in the public domain, e.g., on the websites of the
company as well as
the
institution concerned. All such research should be
subject to mandatory
watch-dog audit, either through a structured
peer-group mechanism or
through
an independent agency like the ICMR.
-
Conferences and other academic events
should be funded in a
transparent
manner and the advertisements restricted to a
dedicated brochure,
wherein
full fiscal details must be disclosed. The academic
sanctity of the
conference venue should not be desecrated by
pharmaceutical company
banners
or stalls offering freebies. Equipment-vendors and
medical publishers
may be
allotted stalls to display/sell their wares in an
appropriate manner.
All
promotional print-material may be placed in the
delegate-kit and no
sponsored sight-seeing trips should be permitted.
Vulgar ostentation
should
be avoided and, in keeping with internationally
accepted norms, only a
working-lunch and tea/coffee may be provided. The
delegate-fee will be
sufficient to meet the costs of such a business-like
event. The revenue
generated from advertisements and stall-rentals may
be utilized to
support
academic and research activities, post-graduate
fellowships and
training
programmes for primary care physicians. A vibrant
protestant movement
is
required to rid our calling of the many evils which
have virtually made
us
vassals of the pharmaceutical industry and which have
reduced our
annual
conferences to tamashas, infested with touts and
other pests. Our
conduct in
this regard must align with the oft repeated
professions of being
members of
a noble profession.
Who should treat psychiatric illness?
Moving now to another vital issue,
concerning the pathway to mental
health care, there is need for a focused debate,
informed by sound
clinical
and public health principles rather than emotive
considerations of
myopic
self-interest, we must accept the fact that a vast
majority of mental
disorders will be treated by primary care physicians
and may never
reach the
psychiatrist. This reality was succinctly
articulated by W Mayer
Gross,
over half a century ago, in the preface to his
classic text-book of
psychiatry: “The fact that the psychiatric aspect of
medical illness
can
never be ignored is not an argument for referring
every patient to the
psychiatrist but for equipping with psychiatric
knowledge every
physician
who has to handle patients”. Recognizing the
importance of
psychological
factors in medical practice and that many of these
are competently
managed
by physicians, a joint working group of the Royal
College of Physicians
and
the Royal College of Psychiatrists has evolved
pragmatic guidelines on
when
to treat and, more importantly, when not to treat and
refer to a
psychiatrist10. A number of well-designed studies
have examined the
epidemiology of mental disorders in primary care
settings and the
factors
determining specialist referrals as well as the
quality of care11, 12,
13.
While doubts do persist,14 the principles underlying
the concept of
integrating mental health care with primary health
care are essentially
sound and do not pose a threat to psychiatry. 15
Indian data generally
support this view, while highlighting some of the
grey areas16,17,18.
In a
pioneering effort, Chisholm et al19 have, while
quantifying the burden
of
mental morbidity in four rural communities, attempted
a cost-evaluation
of
primary care mental health outcomes in low income
countries. They
conclude
that: “Between 12% and 39% of the four screened
populations had a
diagnosable mental disorder. In three of the four
localities there
were
improvements over time in symptoms, disability and
quality of life,
while
total economic costs were reduced.”
The message is clear. Devolving mental
health care to the primary
care
physicians, in the public and private sector alike,
is the only
feasible
strategy for meeting the mental health needs of our
vast population,
given
the paucity and uneven distribution of psychiatrists
and other mental
health
professionals in the country. This major public
health challenge needs
to
be tackled on a war footing, making it incumbent upon
every academic
department of psychiatry/GHPU/state or city unit of
the IPS and IAPA to
conduct formal skill-based training programmes for
physicians/general
practitioners (GPs) on a regular basis, with the
collaboration of the
IMA and the Association of Physicians of India (API) Several models have
been field-tested in the country and the results have been encouraging.20, 21,
22 While self-financing appears feasible, additional fiscal support
may be obtained from the government/WHO. Weekend modules, spread over 6-8
weeks, may be more acceptable to private practitioners, while 6-day full-time
modules can be designed for those in service. The Armed Forces should take
the lead in this regard and every military psychiatric centre must formulate a
training calendar, under consultation with the formation headquarters.
Moving medical officers within the formation for such short training programmes
will not require sanction from higher authorities. Provision may be made
for brief (2-3 days) refresher modules, a year after the initial training.
This will also help in evaluating outcomes and obtaining feed-back.
Psychiatric education
The need for the psychiatric training of
primary care physicians
arises
mainly because of the abysmal state of the teaching
of psychiatry at
the
undergraduate level.23, 24, 25,26 Despite sustained
efforts over the
past
five decades, the time allotted to psychiatry in the
MBBS curriculum
has
actually declined, while the plea to make it an
examination subject has
fallen on deaf ears. In Sep 2001, a detailed
proposal for radical
changes,
including the teaching of behavioural sciences during
the pre-clinical
phase,27, 28 in the medical curriculum, aimed at
equipping the medical
graduate with the necessary psychiatric skills, was
mooted by the
Directorate General of Health Services. After
approval by the Ministry
of
Health and Family Welfare, it was forwarded to the
MCI in early 2002.
It is
understood that some of these proposed changes have
been introduced by
the
MCI, but a great deal more remains to be done. In
the meanwhile,
rather
than waiting indefinitely for the mountain to come to
the prophet,
efforts
should be focused on making qualitative improvements
in teaching
methodology,24,25,29 thereby making the subject more
interesting,
relevant
and jargon-free. It will be futile on our part to
deny that even the
existing slot allotted to psychiatry is not optimally
utilized and
undergraduates are often put off by our
sanctimonious, mysticised
approach.
There has been phenomenal expansion of
post-graduate psychiatric
training
facilities in the country since independence. Little
has been done,
however, to render these courses relevant to the
Indian reality, or to
ensure quality assurance. Adherence to western
models of care, lack of
a
social orientation and total neglect of the public
health dimension are
some
of the grey areas which merit urgent attention of
medical educators and
mental health administrators/planners alike. Pending
the long overdue
revision and reorientation of the MD curriculum, a
beginning can be
made by
inviting guest-faculty to cover these areas and by
allotting
theses/dissertation topics relevant to social and
public health aspects
of
mental health. The wide variation in standards with
regard to
selection,
teaching and examinations must end, if necessary by
entrusting overall
superintendence of these areas to a national entity,
like the National
Board
of Examiners. The Diploma in Psychological Medicine
(DPM) should be
revived
to meet the huge mental health manpower-gap, with 50%
of the seats
being
reserved for in-service candidates nominated by the
central/state
governments. This may be made obligatory for every
centre recognized
or
seeking recognition for MD (Psychiatry).
Training for a career in teaching or research
It is a fallacy to believe that the mere
possession of an MD degree
equips a person for a full-time academic or research
career. That such
has
been the case in the past is not a valid reason for
continuing with the
practice, given the present, globally competitive
context. One of the
main
reasons for our insipid teaching techniques and
uninspiring research is
the
lack of appropriate training. Bridge courses of a
year’s duration
should be
introduced for training in contemporary teaching
technology and
research
methodology. The KL Wig Centre for Medical Education
& Technology at
the
All India Institute of Medical Sciences (AIIMS), New Delhi could serve as a
useful model. Linkages should be established with other institutions with
the necessary expertise and experience in these specialized areas. This will
provide the vitally needed qualitative thrust to psychiatric teaching and
research.
Conclusion
Indian psychiatry is at the cross-roads.
It is tempting to use
this,
rather melodramatic but nonetheless fashionable,
phrase to exit the
tedium
of this rambling narrative. The only problem is that
we have been
stuck at
these cross-roads for the past fifty years. The
story of Indian
psychiatry
is littered with noble intentions, good beginnings,
encouraging
outcomes
and, then, complete inertia! This is also the story
of the National
Mental
Health Programme (NMHP): begun in 1982 with
pioneering fervor and
justifiable fanfare, as the first such
national-level initiative
anywhere
in the world, it ran out of steam even before a
single district had
been
covered. In fact it is the story of India, of
literally thousands of
schemes which failed to take-off, of hundreds more
which are launched
each
year as populist rituals, destined only to remain on
paper. As VS
Naipaul
wrote in his 1963 travelogue, An Area of Darkness,
India is a land of
many
beginnings but few culminations. This is the final
and most important
issue
facing Indian psychiatry: do we mean business, or is
this yet another
charade?
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