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The Royal College of Psychiatrists Improving the lives of people with mental illness

One psychiatrist per 200,000 people

C.S.I. Rainy Multi Speciality Hospital in Chennai

The population in India has expanded to 1.21 billion according to the recent Census report 20111 making it the second largest population in the world next to China. Mental disorders are still under recognised and untreated in India. Psychiatry is an emerging field in India2. The prevalence of ‘serious mental disorders’ in India is 6.5% which is nearly 70 million people3. Anecdotal reports suggests that the total number of psychiatrists could be between 3,500 and 5,000 which translate to one psychiatrist to 200,000 to 300,000 people. Consequently, the need for psychiatrists is enormous. The existing training infrastructure produces about 320 psychiatrists, 50 clinical psychologists and 185 mental health nurses per year4.  This suggests that the current figure of psychiatrists should double in 10 years, but this does not seem to happen!


"It was very interesting to see a range of mental disorders in a very different cultural context. In India the families are closely- knit;  a patient comes in with 4 - 5 carers or relatives."


My first day at the C.S.I Rainy Hospital

January, 2012; Chennai, India: I got an opportunity to attend the psychiatric outpatient clinic in C.S.I. Rainy Multi Speciality Hospital in Chennai (formerly ‘Madras’), India. This hospital has an interesting history relating to its establishment. It was founded in 1888 by the Church of Scotland as a Medical Dispensary and due to the efforts of Miss. Christina Rainy the hospital buildings came into being5. The medical work was pioneered by Dr Alexandrina Mcphail, between 1888 and 1928, who established an institution primarily to provide medical care to women and children. Both these pioneers were Missionaries from the Church of Scotland. Over the years, the institution has grown under the leadership of Overseas and Indian Doctors. The department of psychiatry has been growing over the years.

On the first day of my first visit, outside this psychiatric clinic, there stood a large crowd of patients and their relatives waiting their turn to meet the psychiatric team. Among them was a young girl restrained by three or four people. She suddenly screamed and rolled on the floor and squirmed and shouted ‘It’s coming’ (later, I came to know that she was referring to the demons coming into her body). Her hair was untied and her sari tied up shabbily; poor self care was apparent. She was surrounded by a group of onlookers. At this point, the nurse came out of the clinic and called that particular patient and her five (!) carers followed her inside the clinic room.

This was my first day at the C.S.I. Rainy Hospital.  It was very interesting to see a range of mental disorders in a very different cultural context. In India the families are closely- knit as we can see from the above description, a patient comes in with 4- 5 cares or relatives. They take care of the patient round the clock.

Mental illness in India is gradually escaping from the clutches of stigma, but still it seems miles away before it is completely free. The family members of the patient feel embarrassed to talk about the illness explicitly.  In fact, they try to cover up the facts about the illness for months or even years until either they could no longer contain the patient’s symptoms or they are burnt out.


They also try alternative medicines and keep visiting the religious gurus. Finally, they arrive at the out-patient clinic when all their alternate avenues have closed down.

In this scenario, this patient presented with dissociative disorders (trance and possession disorder). She was brought in with the help of five carers. When she was asked to sit down, she sat down calmly. Her screaming had gone. She pulled away the hair from her face. She was quiet for a moment or two. When I asked her what had happened to her, she said the devil was torturing her. She said ‘It’ sometimes comes into her body and then she wouldn’t remember what was happening. At this time, she screamed again saying ‘It’s coming again’… she made a loud noise and tried to get up and run but was restrained by her relatives.  She then started to behave as if she were ‘controlled by the demons’. Her relatives reported the appearance of these symptoms immediately following the death of her father. They said that these attacks lasted for a few minutes only and she got several of such attacks in a day. Such presentations are very common at this clinic.

I will update this blog with few more interesting cases shortly.


"Mental illness in India is gradually escaping from the clutches of stigma, but still it seems miles away before it is completely free."


To sum up, it was a fascinating experience to see how the team operates successfully under pressure (when large number of patients turn up to be seen). One of the reasons could be that the team is not burdened by tiresome notes and record- keeping. This may well be due to the use of the patients' paper notes and lack of IT systems to record things. These notes are used for patients' reviews only. The litigation by a patient or their carers is virtually non existent!

Also the team has a very flexible approach and is able to cater to the patients' needs for longer hours. There are no waiting lists for new appointments and anyone can register and see the team on the same day.


References:

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Comments

Re: One psychiatrist per 200,0
Dear Jeshoor,
It was an interesting insight on how the treatment works in India. Just a quick question. How is the treatment funded? Are the costs borne by patients or the local government?
Thank you.

Kind regards,
Alefiya
Re: One psychiatrist per 200,0
Impressed by the contents of the article on alcohol misuse in Tamil Nadu, I write as a concerned Tamil psychiatrist, to thank you for focussing on a taboo, but highly relevant subject. The TN government earns a vast amount of revenue from sale of alcohol and has shown little motivation to control the availability of alcohol in the state. the social and family impact of alcohol is devastating. There a few voluntary organisation in Chennai that have been working hard to highlight the issue. Please continue with your good work in TN.

Regards
Thambirajah
Dr. M. S. Thambirajah
Re: One psychiatrist per 200,0
Hi Jeshoor,

Your blog is very interesting and I greatly appreciate your work there (India).

Many Thanks,
Dr. Ramakanth Vemuluri MD, MRCPsych
Diplomate, Academy of Cognitive Therapy
River Region Psychiatry Associates
Winton M Blount Loop
Montgomery
USA

Re: One psychiatrist per 200,0
Response to comments by the consultant psychiatrist, Dr Shanthi Davidar, at CSI Rainy Hospital:

1) The predominant mental health needs of the community as we at Rainy Hospital can see right now are (a) Alcohol related mental health disorders (b) Sexuality related mental health needs eg, extra marital affairs and its effect on spouses, depression, abuses and its psychological effects etc. These two areas are proving to be challenges to pure psychological medical assessment and treatments. Related social concerns like domestic violence associated with marital dysfunction, child abuse etc., are again difficult to be addressed by law alone. It demands a special commitment and an insight into such issues.

Therefore, we are trying to bridge these gaps by concentrating on such deeply personal issues, within such dysfunctional individuals and families, so that there is security in the family. The community can then be a safer place to live in. Tamil Nadu has a special "All Women Police Stations" which cater specifically to the needs of women. Rainy Hospital extends support to and is a local referral agency for these organisations.

These are also Area development committees comprising of lawyers, police, psychiatrists and social workers coordinated and anchored by community service organisations which discuss the special mental health and social needs of the community. Rainy Hospital psychiatry department is part of two such committees.

A word on 'Stigma' - Attending the psychiatric outpatient clinic for assessment or just a referral to the psychiatric department for opinion itself creates panic and stigma among patients. A very common mental illness, depression, is still a major illness unrecognised by people which is leading to loss of quality of life, marital dysfunction, divorce etc. But, it should be said, that a psychiatric and counselling and rehabilitation department (functioning within the multi-speciality hospital) has proved to be a good method of reducing stigmatisation.
2) As to funding, the government health services funds psychiatry services in its own Government run hospitals, a free service (similar to the National Health Service). In places like Rainy, a nominal fee (£1 - £3) is charged for outpatient clinical appointment but an admission process would incur some costs. We have reduced hospitalisation to a large degree by judicious use of medication, good care giver support and regular counselling follow up.
Re: One psychiatrist per 200,0
Response from Dr Jeshoor Jebadurai:

I thank everyone for their valuable comments. Please send your comments and questions which would help me to explore further issues relating to mental health in India and ways of setting up projects in India.

Yes, as Dr Bommu pointed out India spends just 0.83% on mental health where other developed countries spend much more than this. Due to the inadequate infrastructure of mental health systems in India, the Government of India launched the National Mental Health Programme (NMHP) in 1982 and the District Mental Health Programme (DMHP). Though the objectives were written with full enthusiasm, the goals were not achieved unfortunately even after three decades. Even the District Mental Health Programme is not launched in every districts in Tamil Nadu state. It was piloted in Trichy and currently there are plans about launching it in Tirunelveli and other few districts. I will give an example of the current situation in Tirunelveli which is one of the 32 districts of Tamil Nadu state in India. About 3 million population live in Tirunelveli district and 50% of them live in rural areas. About 60 PHCs (Primary Health Centre - a Government run rural health centre) cater only to the physical needs of the patients. No mental health service is provided in any of these PHCs. However, there exists one psychiatric department in the Tirunelveli District Hospital which caters to the mental health needs of about 3 million people which is clearly inadequate.

With such appalling inadequacy in mental health services in India, people with mental health problems resort to 'traditional healers' for reassurance and treatment. Medical malpractice which plays on the ignorance of the rural population is also rampant in many areas of the country. Over many decades, such is the flawed system for managing mental illness in the communities. So it's hard to go against the flow and challenge their concepts about mental illness and stigma attached to it. Therefore, it would require coordinated approach from the mental health professionals all over the world, support from the governmental and non-governmental agencies working within mental health grounds to combat the darkened understanding about mental illness among common people and throw light on the positive approach for mental illnesses.

To conclude with a positive note, the private practice of psychiatry is getting better day by day in India. Distinguished psychiatrists in cities like Chennai, charge reasonable price (£10 to £30) per consultation. Also the appearance of psychiatrists in talk shows, films and writings on secular magazines have been on the increase which help to provide easy accessible information on mental health to the public, improving awareness and also reduces stigmatisation.

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About this blog


Dr Jeshoor Jebadurai


Dr Jeshoor Jebadurai is a Consultant Psychiatrist working in Wales. He is interested in International Psychiatry.

Prior to his move to the UK, he was trained at the Institute of Mental Health, Chennai, India.

He has been travelling to India over the last few years conducting health screening camps in rural parts of South India and raising the awareness about mental health. He is in the process of setting up a mental health unit in India.