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ROLE OF INDIAN RESEARCH AMONG SOUTH ASIAN REGION IN THE DEVELOPMENT OF PSYCHIATRY J. ROLE OF INDIAN RESEARCH AMONG SOUTH ASIAN REGION IN THE DEVELOPMENT OF PSYCHIATRY J. K. TRIVEDI Professor ARVIND KENDURKAR Resident Department of Psychiatry, K. G. Medical University Lucknow

SOUTH ASIAN REGION: AN OVERVIEW • Region extending from Hindukush to Sri Lanka to SOUTH ASIAN REGION: AN OVERVIEW • Region extending from Hindukush to Sri Lanka to • • • tip of Bangladesh and even beyond. South Asian region gives an unique representation to world population in terms of varied cultural beliefs, different psychosocial implications on diseases, variable ethnic & racial factors and typical patterns of environments. The region represents nearly 1/4 th of the total world population i. e. about 1. 5 billion out of the 6 billion on earth are living in this area. The geo political situation among the countries of the region are in the process of maturation towards better public representation in the functioning.

SOUTHERN & EASTERN PART OF ASIA SOUTHERN & EASTERN PART OF ASIA

MENTAL HEALTH SCENARIO IN THE REGION • Estimating a prevalence of 10 – 12 MENTAL HEALTH SCENARIO IN THE REGION • Estimating a prevalence of 10 – 12 percent of psychiatric illnesses, total number of mentally ill people in the region turn out to be 150 – 200 million. • Total number of trained psychiatrists in the region are about 3500 – 4500 i. e. nearly three psychiatrists for a million and one psychiatrist for nearly 5000 mentally ill.

OBSTACLES IN THE PATHWAY • The stigma and ignorance towards the concept of • OBSTACLES IN THE PATHWAY • The stigma and ignorance towards the concept of • • mental illnesses are widespread. This limits the mental health delivery system as well as further research in the field by putting a question mark on the concept of psychiatric illnesses. The concept of medicine in South Asian region has to compete equally with traditional system of medicine, as well as with the supernatural beliefs prevalent in this region.

OBSTACLES IN THE PATHWAY (Contd. ) • The traditional system of Ayurveda in India, OBSTACLES IN THE PATHWAY (Contd. ) • The traditional system of Ayurveda in India, Sri Lanka; • • Unani medicine in India, Pakistan & Bangladesh are being supported by local governments for further research. This division of resources is further, taking its toll in the areas of health and especially in the mental health, which still lies in a virtually neglected condition. Poor collaboration among various health agencies in the region due to political barriers amongst the countries further add on to the problems. The social division on the basis of the casteism prevails even among the medical fraternity where psychiatry and other allied branches represents the “Dalit” among other “Pandit” medical branches.

INDIA AMONG SOUTH ASIAN COUNTRIES • The country with 1. 1 billion population has INDIA AMONG SOUTH ASIAN COUNTRIES • The country with 1. 1 billion population has nearly • • • 100 million in need of mental health care. Nearly 3500 trained psychiatrists i. e. 1 psychiatrist on every 4 million population are rendering the health care services. The concentration in urban, metropolitan or big cities has led to a widely heterogeneous picture in terms of available mental health services. Few leading psychiatric institutions in different parts of the country are , however , giving their valuable contributions in terms of mental health care as well as research output.

INDIA AMONG SOUTH ASIAN COUNTRIES Among western literature Indian research has prominently figured out, INDIA AMONG SOUTH ASIAN COUNTRIES Among western literature Indian research has prominently figured out, yet the representation is less than 1% of the total publications (Patel et. al. 2001)

NEEDS AND REQUIREMENTS OF MENTAL HEALTH STUDIES IN THE REGION • The wide socio-cultural NEEDS AND REQUIREMENTS OF MENTAL HEALTH STUDIES IN THE REGION • The wide socio-cultural variability has its influence • • on the understanding and adaptation of illness in the region. Mere adaptation of western studies might not totally serve the purpose, as these countries are strongly enrooted in cultural and religious beliefs. The ethnic and genetic influence on treatment, the social acceptability of the type of management and the concept of illness per se in the society needs to be considered before drawing an outline for a mental health delivery system

PROMINENT INDIAN RESEARCH IN THE REGION • Indian research has revealed some of the PROMINENT INDIAN RESEARCH IN THE REGION • Indian research has revealed some of the novel ideas that have enriched the subject • The first international step was by inclusion of India among 9 countries in International Pilot Study of Schizophrenia (WHO, 1960). This study revealed that schizophrenic patients in developing countries have less severe course and better outcome than patients in developed countries with comparable initial clinical pictures (WHO, 1973, 1979).

PROMINENT INDIAN RESEARCH IN THE REGION (Contd. ) • To find out the basis PROMINENT INDIAN RESEARCH IN THE REGION (Contd. ) • To find out the basis for the results, Determinants • of Outcome of Severe mental disorder study (DOS Med) was carried out in 10 countries, where developing countries were represented by India, Sri Lanka & Nigeria. This study further supported the findings with better outcome of schizophrenia among developing than developed nations. It also revealed the presence of large number of patients having an entity of “Acute Psychosis” - a finding which was included under schizophrenia till then.

PROMINENT INDIAN RESEARCH IN THE REGION (Contd. ) • A concept of “Non affective PROMINENT INDIAN RESEARCH IN THE REGION (Contd. ) • A concept of “Non affective acute remitting • psychosis” was adopted and it was found to be present 10 times more frequently in developing countries (Susser & Wanderling, 1994). This led to a cross cultural study of acute psychosis by WHO in 6 centres including India across the world. This study clarified the rubric of acute psychosis with largely benign course, favorable outcome with rapid resolution in large number of cases. This study paved the way for official inclusion of a new category of ‘acute psychosis’ under ICD-10.

AREAS OF SPECIAL INTEREST IN THE COUNTRY • The presence of larger number of AREAS OF SPECIAL INTEREST IN THE COUNTRY • The presence of larger number of patients and availability of mental health workers with favorable clinical and research aptitude has helped in developing a wide clinical database of almost all psychiatric illnesses , even with a great many constraints. EPIDEMIOLOGICAL STUDIES • Post independence , epidemiological studies have • been carried out in almost all the regions of the nation. These have helped in assessing the extent and nature of the problem, thus enabling the planning of mental health services. Long term predictability of major psychiatric illnesses such as schizophrenia, mood disorders etc. have also been studied.

AREAS OF SPECIAL INTEREST IN THE COUNTRY (Contd. ) PHENOMENOLOGICAL STUDIES • These have AREAS OF SPECIAL INTEREST IN THE COUNTRY (Contd. ) PHENOMENOLOGICAL STUDIES • These have helped in understanding the illness • • behavior and how different it is from the rest. For eg. Depression in this country is associated with more somatic symptoms and less guilt than in western studies Incorporation of obsessive compulsive disorder as part of culturally acceptable belief – Suchibai phenomenon in some parts of the country; Dhat syndrome as a somatic manifestation of psychosexual problems. Culture bound syndromes have been studied by many workers (Dhat – Behere and Nataraj 1984, Koro- Chakraborty 1983)

AREAS OF SPECIAL INTEREST IN THE COUNTRY (Contd. ) DRUG TRIALS • It is AREAS OF SPECIAL INTEREST IN THE COUNTRY (Contd. ) DRUG 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 THERAPY • One of the most widely studied area of therapy. • Studied almost in all indications of its use. • Proper guidelines for its use in treating psychiatrically ill patients in the country have also been proposed. (Gangadhar et al. , 1990, 1992; Andrade et al. 1990)

AREAS OF SPECIAL INTEREST IN THE COUNTRY (Contd. ) PSYCHOLOGICAL STUDIES • The major AREAS OF SPECIAL INTEREST IN THE COUNTRY (Contd. ) PSYCHOLOGICAL STUDIES • The major concern has been focused on adapting a local version of internationally accepted tools so that they could be employed on the local population. - Hindi adaptation of PSE (Wig et al. , 1982) - Hindi adaptation of Beck Depression Inventory (Ajmany & Nandi, 1973) - Hindi adaptation of general health questionnaire (Gautam et al. , 1988)

AREAS OF SPECIAL INTEREST IN THE COUNTRY (Contd. ) PARALLEL AREAS OF RESEARCH • AREAS OF SPECIAL INTEREST IN THE COUNTRY (Contd. ) PARALLEL AREAS OF RESEARCH • In line with western studies parallel studies are being carried out in Indian setting in some of the major areas : Ø Child 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 psychiatry - This is a comparatively new area of research and few studies have been carried out in the areas of suicide, mood disorders, schizophrenia etc.

AREAS OF SPECIAL INTEREST IN THE COUNTRY (Contd. ) PARALLEL AREAS OF RESEARCH Ø AREAS OF SPECIAL INTEREST IN THE COUNTRY (Contd. ) PARALLEL AREAS OF RESEARCH Ø Genetic studies - High cost involved in these studies have limited their number. - Prominent ones are schizophrenia proband (Sethi et al. , 1978; Kapoor et al. , 1992), Genomic imprinting in bipolar affective disorders (Kapoor et al. , 2000) Ø Immunological studies - Immunological markers in diseases like schizophrenia & obsessive compulsive disorder Ø Geriatric psychiatry - Increasing life expectancy in the region has highlighted the importance of studies in this area

FUTURE AREAS OF RESEARCH • Ethnic variations need to be studied for • • FUTURE AREAS OF RESEARCH • Ethnic variations need to be studied for • • development of ‘Transcultural pharmacotherapy’. Psychotherapeutic interventions need to be adapted to local needs and beliefs, for example Asians accept ‘problem solving’ better than psychodynamic approach (D’Zurilla & Nezu 1999). The locally held view of psychiatric illnesses and various culture bound syndromes need to be further explored in order to destigmatise the mental health problems.

TOWARDS BETTER MENTAL HEALTH CARE • The most striking need of the region is TOWARDS BETTER MENTAL HEALTH CARE • The most striking need of the region is • • development of a community based mental health care delivery system. In India a step in this direction has already been taken in the form of National Mental Health Program and District Mental Health Program. Other nations of the South Asian region can also incorporate (if already not done) such programs in their government policies for the betterment of Mental Health services.

NATIONAL MENTAL HEALTH PROGRAM • NMHP was accepted for implementation in 1982 (Ministry of NATIONAL MENTAL HEALTH PROGRAM • NMHP was accepted for implementation in 1982 (Ministry of health and family welfare, 2000) MAIN 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 (Contd. . ) • Diffusion of mental health skills to National Mental Health Program (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 • Launched in 1996 -97; is being implemented and a District Mental Health Program • Launched in 1996 -97; is being implemented and a total of 22 districts. OBJECTIVES • 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 CARE • The Indian Government in its 10 th five TOWARDS BETTER MENTAL HEALTH CARE • The Indian Government in its 10 th five year plan has • sanctioned Rs. 190 crores to National Mental Health program Details of the scheme of National Mental Health Program are as follows: - District Mental Health Program – Rs. 63. 27 crores - Improvement in Mental Hospitals – Rs. 74. 23 crores - Strengthening of Medical Colleges/General hospitals – Rs. 37. 50 crores - I. E. C activity – Rs. 10. 00 crores - Research and training – Rs. 5. 00 crore • It has also been planned to incorporate 29 more new districts into the existing District Mental Health Program

CONCLUSION • Original research based on fresh ideas with • • • special relevance CONCLUSION • 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 (Contd. ) 1. Indian Psychiatric Society , the largest ensemble of psychiatrist of CONCLUSION (Contd. ) 1. Indian Psychiatric Society , the largest ensemble of psychiatrist of South Asian region should strive for a common platform for mental health care and research which will help in better management of meager resources in the region. …. Last but not the least one cannot forget the contribution from this region to the rest of the world- the importance of family , religion spirituality, meditation , yoga- towards the better mental health.