ROLE OF INDIAN RESEARCH ROLE OF INDIAN RESEARCH AMONG SOUTH ASIAN REGION AMONG SOUTH ASIAN REGION

IN THE DEVELOPMENT OF IN THE DEVELOPMENT OF PSYCHIATRYPSYCHIATRY

J.K. TRIVEDI Professor

ARVIND KENDURKAR

Resident

Department of Psychiatry, K.G. Medical University

Lucknow

SOUTH ASIAN REGION: AN SOUTH ASIAN REGION: AN OVERVIEWOVERVIEW

• Region extending from Hindukush to Sri Lanka Region extending from Hindukush to Sri Lanka to tip of Bangladesh and even beyond.to tip of Bangladesh and even beyond.

• South Asian region gives an unique South Asian region gives an unique representation to world population in terms of representation to world population in terms of varied cultural beliefs, different psychosocial varied cultural beliefs, different psychosocial implications on diseases, variable ethnic & implications on diseases, variable ethnic & racial factors and typical patterns of racial factors and typical patterns of environments .environments .

• The region represents nearly 1/4The region represents nearly 1/4thth of the total of the total world population i.e. about 1.5 billion out of world population i.e. about 1.5 billion out of the 6 billion on earth are living in this area. the 6 billion on earth are living in this area.

• The geo political situation among the The geo political situation among the countries of the region are in the process of countries of the region are in the process of maturation towards better public maturation towards better public representation in the functioning. representation in the functioning.

SOUTHERN & EASTERN PART OF ASIA

MENTAL HEALTH SCENARIO IN THE MENTAL HEALTH SCENARIO IN THE REGIONREGION

• Estimating a prevalence of 10 – 12 percent Estimating a prevalence of 10 – 12 percent of psychiatric illnesses, total number of of psychiatric illnesses, total number of mentally ill people in the region turn out to mentally ill people in the region turn out to be 150 – 200 million. be 150 – 200 million.

• Total number of trained psychiatrists in Total number of trained psychiatrists in the region are about 3500 – 4500 i.e. the region are about 3500 – 4500 i.e. nearly three psychiatrists for a million and nearly three psychiatrists for a million and one psychiatrist for nearly 5000 mentally one psychiatrist for nearly 5000 mentally ill . ill .

OBSTACLES IN THE PATHWAY OBSTACLES IN THE PATHWAY

• The stigma and ignorance towards the The stigma and ignorance towards the concept of mental illnesses are widespread.concept of mental illnesses are widespread.

• This limits the mental health delivery system This limits the mental health delivery system as well as further research in the field by as well as further research in the field by putting a question mark on the concept of putting a question mark on the concept of psychiatric illnesses.psychiatric illnesses.

• The concept of medicine in South Asian The concept of medicine in South Asian region has to compete equally with region has to compete equally with traditional system of medicine, as well as traditional system of medicine, as well as with the supernatural beliefs prevalent in this with the supernatural beliefs prevalent in this region. region.

OBSTACLES IN THE PATHWAY OBSTACLES IN THE PATHWAY ((Contd.)Contd.)

• The traditional system of Ayurveda in India, Sri The traditional system of Ayurveda in India, Sri Lanka; Unani medicine in India, Pakistan & Lanka; Unani medicine in India, Pakistan & Bangladesh are being supported by local Bangladesh are being supported by local governments for further research. This division governments for further research. This division of resources is further, taking its toll in the areas of resources is further, taking its toll in the areas of health and especially in the mental health, of health and especially in the mental health, which still lies in a virtually neglected condition.which still lies in a virtually neglected condition.

• Poor collaboration among various health Poor collaboration among various health agencies in the region due to political barriers agencies in the region due to political barriers amongst the countries further add on to the amongst the countries further add on to the problems.problems.

• The social division on the basis of the casteism The social division on the basis of the casteism prevails even among the medical fraternity prevails even among the medical fraternity where psychiatry and other allied branches where psychiatry and other allied branches represents the “Dalit” among other “Pandit” represents the “Dalit” among other “Pandit” medical branches. medical branches.

INDIA AMONG SOUTH ASIAN INDIA AMONG SOUTH ASIAN COUNTRIESCOUNTRIES• The country with 1.1 billion population has The country with 1.1 billion population has

nearly 100 million in need of mental health nearly 100 million in need of mental health care.care.

• Nearly 3500 trained psychiatrists i.e. 1 Nearly 3500 trained psychiatrists i.e. 1 psychiatrist on every 4 million population are psychiatrist on every 4 million population are rendering the health care services.rendering the health care services.

• The concentration in urban,metropolitan or big The concentration in urban,metropolitan or big cities has led to a widely heterogeneous picture cities has led to a widely heterogeneous picture in terms of available mental health services.in terms of available mental health services.

• Few leading psychiatric institutions in different Few leading psychiatric institutions in different parts of the country are ,however ,giving their parts of the country are ,however ,giving their valuable contributions in terms of mental valuable contributions in terms of mental health care as well as research output. health care as well as research output.

INDIA AMONG SOUTH ASIAN COUNTRIESINDIA AMONG SOUTH ASIAN COUNTRIES

Regional distribution of Articles

WHO

3%

Latin America

4%

J apan

25%

Israel

12%Africa

11%

Asia

13%

China

14%

Eastern Europe

4%

India

14%

Among western literature Indian research has Among western literature Indian research has prominently figured out, yet the representation is prominently figured out, yet the representation is less than 1% of the total publicationsless than 1% of the total publications

(Patel et. al. 2001)(Patel et. al. 2001)

0.80%

5.20%

94%

India

Rest of World

US & Western Europe

NEEDS AND REQUIREMENTS OF NEEDS AND REQUIREMENTS OF MENTAL HEALTH STUDIES IN THE MENTAL HEALTH STUDIES IN THE

REGIONREGION• The wide socio-cultural variability has its The wide socio-cultural variability has its

influence on the understanding and adaptation of influence on the understanding and adaptation of illness in the region.illness in the region.

• Mere adaptation of western studies might not Mere adaptation of western studies might not totally serve the purpose, as these countries are totally serve the purpose, as these countries are strongly enrooted in cultural and religious beliefs. strongly enrooted in cultural and religious beliefs.

• The ethnic and genetic influence on treatment, The ethnic and genetic influence on treatment, the social acceptability of the type of the social acceptability of the type of management and the concept of illness per se in management and the concept of illness per se in the society needs to be considered before the society needs to be considered before drawing an outline for a mental health delivery drawing an outline for a mental health delivery system system

PROMINENT INDIAN RESEARCH IN THE PROMINENT INDIAN RESEARCH IN THE REGIONREGION

• Indian research has revealed some of the novel Indian research has revealed some of the novel ideas that have enriched the subjectideas that have enriched the subject

• The first international step was by inclusion of The first international step was by inclusion of India among 9 countries in International Pilot India among 9 countries in International Pilot Study of Schizophrenia (WHO, 1960). This study Study of Schizophrenia (WHO, 1960). This study revealed that schizophrenic patients in revealed that schizophrenic patients in developing countries have less severe course developing countries have less severe course and better outcome than patients in developed and better outcome than patients in developed countries with comparable initial clinical countries with comparable initial clinical pictures (WHO, 1973, 1979).pictures (WHO, 1973, 1979).

PROMINENT INDIAN RESEARCH IN THE PROMINENT INDIAN RESEARCH IN THE REGION REGION (Contd.)(Contd.)

• To find out the basis for the results, To find out the basis for the results, Determinants of Outcome of Severe mental Determinants of Outcome of Severe mental disorder study (DOS Med) was carried out in 10 disorder study (DOS Med) was carried out in 10 countries, where developing countries were countries, where developing countries were represented by India, Sri Lanka & Nigeria.represented by India, Sri Lanka & Nigeria.

• This study further supported the findings with This study further supported the findings with better outcome of schizophrenia among better outcome of schizophrenia among developing than developed nations . It also developing than developed nations . It also revealed the presence of large number of revealed the presence of large number of patients having an entity of “Acute Psychosis” - patients having an entity of “Acute Psychosis” - a finding which was included under a finding which was included under schizophrenia till then.schizophrenia till then.

PROMINENT INDIAN RESEARCH PROMINENT INDIAN RESEARCH IN THE REGION IN THE REGION (Contd.)(Contd.)

• A concept of “Non affective acute remitting A concept of “Non affective acute remitting psychosis” was adopted and it was found to psychosis” was adopted and it was found to be present 10 times more frequently in be present 10 times more frequently in developing countries developing countries (Susser & Wanderling, 1994).(Susser & Wanderling, 1994).

• This led to a cross cultural study of acute This led to a cross cultural study of acute psychosis by WHO in 6 centres including India psychosis by WHO in 6 centres including India across the world. This study clarified the rubric across the world. This study clarified the rubric of acute psychosis with largely benign course, of acute psychosis with largely benign course, favorable outcome with rapid resolution in favorable outcome with rapid resolution in large number of cases. This study paved the large number of cases. This study paved the way for official inclusion of a new category of way for official inclusion of a new category of ‘‘acute psychosis’acute psychosis’ under ICD-10. under ICD-10.

AREAS OF SPECIAL INTEREST IN THE AREAS OF SPECIAL INTEREST IN THE COUNTRYCOUNTRY• The presence of larger number of patients and The presence of larger number of patients and

availability of mental health workers with favorable availability of mental health workers with favorable clinical and research aptitude has helped in clinical and research aptitude has helped in developing a wide clinical database of almost all developing a wide clinical database of almost all psychiatric illnesses ,even with a great many psychiatric illnesses ,even with a great many constraints.constraints.

EPIDEMIOLOGICAL STUDIESEPIDEMIOLOGICAL STUDIES• Post independence , epidemiological studies have Post independence , epidemiological studies have

been carried out in almost all the regions of the been carried out in almost all the regions of the nation.These have helped in assessing the extent and nation.These have helped in assessing the extent and nature of the problem,thus enabling the planning of nature of the problem,thus enabling the planning of mental health services.mental health services.

• Long term predictability of major psychiatric illnesses Long term predictability of major psychiatric illnesses such as schizophrenia, mood disorders etc. have also such as schizophrenia, mood disorders etc. have also been studied.been studied.

AREAS OF SPECIAL INTEREST IN AREAS OF SPECIAL INTEREST IN THE COUNTRY THE COUNTRY (Contd.)(Contd.)

PHENOMENOLOGICAL STUDIESPHENOMENOLOGICAL STUDIES• These have helped in understanding the illness These have helped in understanding the illness

behavior and how different it is from the rest. behavior and how different it is from the rest. For eg. Depression in this country is associated For eg. Depression in this country is associated with more somatic symptoms and less guilt with more somatic symptoms and less guilt than in western studies than in western studies

• Incorporation of obsessive compulsive disorder Incorporation of obsessive compulsive disorder as part of culturally acceptable belief – Suchibai as part of culturally acceptable belief – Suchibai phenomenon in some parts of the country; Dhat phenomenon in some parts of the country; Dhat syndrome as a somatic manifestation of syndrome as a somatic manifestation of psychosexual problems. psychosexual problems.

• Culture bound syndromes have been studied by Culture bound syndromes have been studied by many workers many workers (Dhat – Behere and Nataraj 1984, (Dhat – Behere and Nataraj 1984, Koro- Chakraborty 1983)Koro- Chakraborty 1983)

AREAS OF SPECIAL INTEREST IN AREAS OF SPECIAL INTEREST IN THE COUNTRY THE COUNTRY (Contd.)(Contd.)

DRUG TRIALSDRUG TRIALS• It is important to identify socio-cultural determinants of

psychotropic drug response for the Indian populace.• Climatic conditions, nutritional status and social standards have their own influence.• Recent trials on drugs like Mirtazepine, iv Valproate reflect

the status of ongoing research . ELECTROCONVULSIVE THERAPYELECTROCONVULSIVE THERAPY• One of the most widely studied area of therapy .One of the most widely studied area of therapy .• Studied almost in all indications of its use.Studied almost in all indications of its use.• Proper guidelines for its use in treating Proper guidelines for its use in treating

psychiatrically ill patients in the country have also psychiatrically ill patients in the country have also been proposed. (Gangadhar et al., 1990, 1992; been proposed. (Gangadhar et al., 1990, 1992; Andrade et al. 1990) Andrade et al. 1990)

AREAS OF SPECIAL INTEREST IN AREAS OF SPECIAL INTEREST IN THE COUNTRY THE COUNTRY (Contd.)(Contd.)

PSYCHOLOGICAL STUDIESPSYCHOLOGICAL STUDIES

• The major concern has been focused on The major concern has been focused on adapting a local version of internationally adapting a local version of internationally accepted tools so that they could be employed accepted tools so that they could be employed on the local population. on the local population.

- Hindi adaptation of PSE - Hindi adaptation of PSE (Wig et al., 1982)(Wig et al., 1982)

- Hindi adaptation of Beck Depression Inventory- Hindi adaptation of Beck Depression Inventory

(Ajmany & Nandi, 1973)(Ajmany & Nandi, 1973)

- Hindi adaptation of general health - Hindi adaptation of general health questionnairequestionnaire

(Gautam et al., 1988)(Gautam et al., 1988)

AREAS OF SPECIAL INTEREST IN AREAS OF SPECIAL INTEREST IN THE COUNTRY THE COUNTRY (Contd.)(Contd.)

PARALLEL AREAS OF RESEARCHPARALLEL AREAS OF RESEARCH• In line with western studies parallel studies In line with western studies parallel studies

are being carried out in Indian setting in are being carried out in Indian setting in some of the major areas :some of the major areas :

Child and adolescent psychiatryChild and adolescent psychiatry - - Earlier studies mostly dealt with the psychological

aspects of childhood disorders whereas now the studies emphasize on a variety of childhood disorders.

Biological psychiatryBiological psychiatry - This is a comparatively new area of - This is a comparatively new area of research and few studies have been carried research and few studies have been carried out in the areas of suicide, mood disorders, out in the areas of suicide, mood disorders, schizophrenia etc. schizophrenia etc.

AREAS OF SPECIAL INTEREST IN AREAS OF SPECIAL INTEREST IN THE COUNTRY THE COUNTRY (Contd.)(Contd.)

PARALLEL AREAS OF RESEARCHPARALLEL AREAS OF RESEARCH Genetic studiesGenetic studies

- High cost involved in these studies have - High cost involved in these studies have limitedlimited

their number.their number.- Prominent ones are schizophrenia proband- Prominent ones are schizophrenia proband

(Sethi et al., 1978; Kapoor et al., 1992),(Sethi et al., 1978; Kapoor et al., 1992), Genomic imprinting in bipolar affectiveGenomic imprinting in bipolar affective disorders (Kapoor et al., 2000)disorders (Kapoor et al., 2000) Immunological studiesImmunological studies

- - Immunological markers in diseases like Immunological markers in diseases like schizophrenia & obsessive compulsive disorderschizophrenia & obsessive compulsive disorder

Geriatric psychiatryGeriatric psychiatry- Increasing life expectancy in the region has - Increasing life expectancy in the region has highlighted the importance of studies in this highlighted the importance of studies in this areaarea

FUTURE AREAS OF RESEARCHFUTURE AREAS OF RESEARCH

• Ethnic variations need to be studied for Ethnic variations need to be studied for development of ‘Transcultural development of ‘Transcultural pharmacotherapy’. pharmacotherapy’.

• Psychotherapeutic interventions need to be Psychotherapeutic interventions need to be adapted to local needs and beliefs, for example adapted to local needs and beliefs, for example Asians accept ‘problem solving’ better than Asians accept ‘problem solving’ better than psychodynamic approach (D’Zurilla & Nezu psychodynamic approach (D’Zurilla & Nezu 1999). 1999).

• The locally held view of psychiatric illnesses and The locally held view of psychiatric illnesses and various culture bound syndromes need to be various culture bound syndromes need to be further explored in order to destigmatise the further explored in order to destigmatise the mental health problems. mental health problems.

TOWARDS BETTER MENTAL HEALTH TOWARDS BETTER MENTAL HEALTH CARE CARE

• The most striking need of the region is The most striking need of the region is development of a community based mental development of a community based mental health care delivery system.health care delivery system.

• In India a step in this direction has already In India a step in this direction has already been taken in the form of National Mental been taken in the form of National Mental Health Program and District Mental Health Health Program and District Mental Health Program.Program.

• Other nations of the South Asian region can Other nations of the South Asian region can also incorporate (if already not done) such also incorporate (if already not done) such programs in their government policies for programs in their government policies for the betterment of Mental Health services.the betterment of Mental Health services.

NATIONAL MENTAL HEALTH PROGRAM NATIONAL MENTAL HEALTH PROGRAM

• NMHP was accepted for implementation in 1982 (Ministry of health and family welfare,2000)

MAIN OBJECTIVESMAIN OBJECTIVES • Prevention and treatment of mental disorders and their associated disabilities, and to promote community participation in the organization of services.• Use of mental health technology to improve general health services.• Application of mental health principles in gross national development to improve quality of life.

National Mental Health Program National Mental Health Program (Contd..)(Contd..)

• Diffusion of mental health skills to the periphery of the health service system.• Appropriate allotment of tasks in mental health care for different levels of health personnel.• Balanced territorial distribution of resources.• Integration of basic mental health care into general health services.• Linkage to community development.• Improve mental health training.• Train parents and ICDS personnel in the management of mentally retarded children.

District Mental Health Program District Mental Health Program

• Launched in 1996-97; is being implemented and a total of 22 districts.

OBJECTIVESOBJECTIVES• Training courses for all the health personnel of the district.• A program officer for mental health to be appointed in the district health and family welfare office.• Essential psychotropic drugs to be made available at all the health centers in the district.• Development of a simple recording and reporting system to assess the progress of the program.

TOWARDS BETTER MENTAL HEALTH TOWARDS BETTER MENTAL HEALTH CARECARE• The Indian Government in its 10The Indian Government in its 10thth five year plan has five year plan has

sanctioned Rs. 190 crores to National Mental Health sanctioned Rs. 190 crores to National Mental Health programprogram

• Details of the scheme of National Mental Health Details of the scheme of National Mental Health Program are as follows:Program are as follows:

- - District Mental Health Program – Rs. 63.27 croresDistrict Mental Health Program – Rs. 63.27 crores

- Improvement in Mental Hospitals – Rs. 74.23 crores- Improvement in Mental Hospitals – Rs. 74.23 crores

- Strengthening of Medical Colleges/General hospitals- Strengthening of Medical Colleges/General hospitals

– – Rs. 37.50 croresRs. 37.50 crores

- I.E.C activity – Rs. 10.00 crores- I.E.C activity – Rs. 10.00 crores

- Research and training – Rs. 5.00 crore- Research and training – Rs. 5.00 crore

• It has also been planned to incorporate 29 more new It has also been planned to incorporate 29 more new districts into the existing District Mental Health districts into the existing District Mental Health ProgramProgram

CONCLUSIONCONCLUSION• Original research based on fresh ideas with

special relevance to regional context is needed.

• Looking back, past years have been immensely fruitful, however challenge is to give Indian Psychiatry a distinctive face of its own ,and to keep in pace with the recent research from the West .

• Newer advancements and researches come to be understood in the developing countries and

thereby remove the darkness on etiological factors for mental illnesses.

• Educational & cultural exchanges among South Asian countries will help in removing stigma & discredit associated with illnesses.

CONCLUSION CONCLUSION (Contd.)(Contd.)

o Indian Psychiatric Society ,the largestIndian Psychiatric Society ,the largest ensemble of psychiatrist of South Asian ensemble of psychiatrist of South Asian region should strive for a common platform region should strive for a common platform for mental health care and research which for mental health care and research which will help in better management of meager will help in better management of meager resources in the region.resources in the region.

…. Last but not the least one cannot forget …. Last but not the least one cannot forget the contribution from this region to the rest the contribution from this region to the rest of the world- the importance of of the world- the importance of family ,religion spirituality,meditation ,yogafamily ,religion spirituality,meditation ,yoga- - towards the better mental health.towards the better mental health.