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Dr. Ram Manohar Lohiya National Law University, Lucknow.


TOPIC:Psychiatric Rehabilitation in India : Issues and Challenges

SUBMITTED TO: Mr. R. K . Yadav Faculty of Law

SUBMITTED BY: Anurag Deepak Verma B.A. LL.B (Hons) 7thSEM Roll No. 25

Elite Mission Hospital.  Other Sections▼ INTRODUCTION “We are responsible for what we are. Having a literacy rate of about 64. Diploma in Psychological Medicine (DPM) (46 centers. With all this. Elite Mission Hospital. Strikingly. 159 seats).com This is an open-access article distributed under the terms of the Creative Commons Attribution License. India has a grand heritage of 34. 77 MCI permitted. If what we are now has been the result of our own past actions. and reproduction in any medium. India has 80 million internet users. India is proud to have 289 institutions providing undergraduate medical training (196 MCI recognized.Swami Vivekananda With all its alluring contrasts and remarkable features. It is quite striking that while India is the second-most populous country. E.[4–6] Apparently. Seventy-four per cent of the 1. Kerala Address for correspondence: Dr. The second fastest growing economy and the third largest military force are also her golden quills. Trissur. I do not mean to say that India is not without its lacunae. which permits unrestricted use. it certainly follows that whatever we wish to be in future can be produced by our present actions. Even while India is the world's twelfth largest economy.Roadmap to Indian Psychiatry E. 25% of the medical colleges in India do not have a Psychiatry Department. Mohandas. Down the traditional lane. multilingual. distribution.8%.000 years. Thrissur.  Other Sections▼ MENTAL HEALTH SCENARIO IN INDIA . 107 seats). and Diplomate of National Board (22 centers. The fact that there are 22 official languages in a single country is ample evidence for the heterogeneous nature of the society it represents. 612 districts.365 villages. so we have to know how to act. it has evolved into a pluralistic.mohandas@gmail. 38. and multiethnic society. we have the power to make ourselves. 36 seats).14 billion population of India live in rural areas. there are only around 4000 psychiatrists in India to serve the five crore mentally ill population currently. Email: e. provided the original work is properly cited. and whatever we wish ourselves to be. E-mail: emohandas53@gmail. seven union territories. The postgraduate training in psychiatry includes Doctor of Medicine (MD) (83 centers. Koorkkenchery. we cannot close our eyes to the grim truth that 22% of the population exists below the poverty line. Chief Consultant. India has 28 states. it has the largest democracy in the world.[1–3] With regard to the academic scene. and 6. Kerala. Koorkkenchery. Mohandas Chief consultant.” . and 16 in the ―danger zone‖). This article has been cited by other articles in

[7–10]  Other Sections▼ INDIAN PSYCHIATRIC SOCIETY EVOLUTION Our society sprouted from the Indian Association for mental hygiene founded in 1929 by Berkeley Hill.2 per 1.[11. The integration of psychiatric services to primary care needs a public–private partnership to enable comprehensive mental health care. the Indian Psychiatric Society (IPS) on 7 January. and relief of all psychiatric disabilities. The major share of psychiatric facilities lies with the government sector (especially mental hospitals). due to the efforts of Dr. 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.000 population and there are only two psychiatrists per 10 lakh population. De. and Kak).2 per 1000. Davis. they seek help from the private sector and there are no clear policies regarding treatment of the mentally ill in the private sector. Govindaswamy. In 1935. A meta-analysis of 13 epidemiological studies consisting of 33. A significant population in India cannot afford private hospital care and the insurance system in the country is in its infancy.[13]    Promote and advance the subject of Psychiatry and allied sciences in all their different branches. The first annual meeting held on 2 January. which makes the situation still worse. Another meta-analysis of 15 epidemiological studies reported a total morbidity of 73 per 1000.572 persons reported a total morbidity of 58. Promote the improvement of the mental health of people and mental health education. Johnson. 1947. with no hope of effective treatment. at Patna. The objectives of the society are very comprehensive.N. Rosie. 00. Promote prevention. Thanks to the efforts of Dr. The rehabilitation of psychiatric patients is also given little importance in the existing mental health framework.12] The society has grown into a group of 2000 Fellows (right of franchise) and many ordinary members. . Therefore. the association gained its new name. Llyodo. which is centered on certain areas of particular states. The rules and regulations were framed by the eminent Psychiatrists of that period (Dhunjibhoy. Nagendra Nath De. the threat posed by the psychiatric and behavioral disorders is just inexplicable. and Brigadier T. the Indian division of the Royal Medico-Psychological Association (RM-PA) was formed. The activities of IPS are also delegated to state branches coming under five zones. 1948. Major R. B. The number of psychiatric beds in the country is only about 0. The existing facilities in the country fall short of the required norms. Kenton. Masani.Obviously. Shah. in a vast country like India. Munro. A.The saddest aspect is that the bulk of the affected falls in the 15 to 45 year age group. treatment. was presided by N. control. Banarasi Das.

Promote the ethical standards in the practice of psychiatry in India. in the form of publications like Indian Disability Evaluation and Assessment scale (IDEAS) and Clinical Practice Guidelines. High population growth rate. Propagate the principles of psychiatry and current development in psychiatric thought. Actively involve in the initiative to have a Mental Health Website by the Health Ministry. Although psychiatrists are involved in NMHP (National Mental Health Program) and DMHP (District Mental Health Program). and the Indian Journal of Psychiatry. in matters such as undergraduate psychiatric training. better functioning of DMHP. Try to get its journal indexed in international databases. Safeguard the interest of Psychiatrists and fellow professionals in India. Reaching the unreached The rural population. if possible. The same is true for other mental health policies and programs. and refining the Mental Health Act. Some efforts have been carried out in mental health literacy and community service strategies. and recommend adequate teaching facilities for the purpose. IPS should 1. comprising of about 74%. Have an advocacy team to facilitate the link between the society and officialdom. It is worthwhile to introspect on our achievements and deficits. Be a stakeholder in mental health policy matters. . is beset with multiple disadvantages. and open free mental health service outlets in an organized and planned manner. 3. Have its publications on mental health issues. 4.     Formulate and advice on the standards of education and training for medical and auxiliary personnel in psychiatry. the society's involvement as a stakeholder is still not appreciated. Promote research in the field of psychiatry and mental health. illiteracy. primitive agricultural practices. conduct mental health literacy programs. Address social issues. 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.‘ and ‗homosexuality‘. 5. 2. The achievements include academic updates as part of professional development.  Other Sections▼ THE VISION 1. agrarian form of economy. decriminalization of ‗attempted suicide. 6.

underemployment. IPS has not done enough in this area except for formulation of IDEAS. illiteracy.[14–16] Ignorance.[17–18] Research publications in the international database during the last . unemployment. Research The research output from India concentrates mainly on epidemiology and service delivery. human immunodeficiency virus (HIV). urban rural divide. depressive illness. Psychiatric genetic research is another domain. homeless. Many NGOs are involved in rehabilitation practices. Poverty. and poor nutrition may pave the way for maladaptive behavior. but the risk is higher among the poor. and backgrounds. Relationship between poverty and poor mental health has been well studied and stated. poor education. No group is immune to mental disorders. Rehabilitation Psychiatric rehabilitation facilities do not satisfy even the adequate requirements in many states across India. dementia. ―State of the World Population 2007‖ report comments on the rapid shift of rural population to the cities by 2008. Training facilities exist at NIMHANS. Psychoeducation. and SCARF at Chennai. This ‗pseudo-urbanization‘ may lead to shortage of resources in cities leading to ‗urban poverty‘. domestic violence. social iniquity. poor access to psychiatric services. and schizophrenia. The vicious cycle of poverty breeding mental dysfunction may culminate in substance use. in the psychosocial rehabilitation map. 3. and fractured community care / support necessitate the need for mental health literacy. and discrimination. and Tamil Nadu. ‗myth understanding‘. The pathological family atmosphere may cast a negative impact on a child's mental health. and persons with low education‘. and broken families. unemployment. There is a polarization toward South India. 2. However. Biological psychiatry research initiated from Lucknow has now shifted.15% of the population that remain below the poverty line. Karnataka. mainly to Bangalore. 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. improved nutritional care. again from New Delhi and Bangalore. The priorities in research on mental health have been outlined elsewhere. Richmond Fellowship Society of India at Bangalore. This may be facilitated by IPS in collaboration with NRHM (National Rural Health Mission) and DMHP. ages. caste-based politics. unemployed. especially in substance use disorders. proper immunization. account for 22. The World Health Organization report on mental health states ‗Mental disorders occur in persons of all genders. The database on drug abuse research has been mainly from AIIMS (New Delhi) and NIMHANS (Bangalore). and antisocial behavior. and better mental health service delivery in the rural population. especially Kerala.ignorance.

However.decade mainly reflect on the studies generated from selected teaching institutions in India — NIMHANS (Bangalore). 5. the limiting factors include. The possible methods include. However. AIIMS (New Delhi). There are efforts being made to conduct and pursue research in other teaching institutions and private psychiatric centers. the state-run institutions depend upon research grants from their respective state governments. Lack of funding. IHBAS (New Delhi). . 1. 4. KGMC (Lucknow). Lack of infrastructure. There is a provision from the Central Ministry for upgrading selected institutions to the ‗AIIMS Model‘ with an allocation of 490 crore rupees. CMC (Vellore) deserves a special mention for its collaboration with the Cochrane Database. Lack of motivation. PGI (Chandigarh). Lack of skill in writing a research article. and propose a research agenda for mental health. the barren land for research in mental health may hopefully become fertile in the near future. RML hospital (New Delhi). The allocation for mental health research might be negligible or almost nil. If properly planned and executed.20] can reveal why major teaching institutions have been able to churn out research data. and CIP (Ranchi). Central budget allocation for training and research — 20082009 Central budget allocation for research — 2008-2009 A bird's eye view on the Central Budget allocation under the Health Ministry[19.[19] IPS should focus on this issue and try to facilitate research in psychiatry. Lack of proper training in research methodology. 3. 2. It would be worthwhile to look at the budget allocation for research. partly due to the myopic vision of the mental health planners in the ministry or due to ―masterly inactivity‖ of the state psychiatric associations.

[21. 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. 5. 2006).[8. and article 42 (maternity relief). discrimination and oppression are rampant. article 51 (A) (e) (dignity of women). NRHM having 10786. article 16 (equality of opportunity). Women' issues Forty-eight per cent of the Indian population is constituted by women. Poverty. Advocacy to reallocate and channelize research grants. Despite all this. article 15 (1) (no discrimination by the State). Physical illness in mentally ill . The networking of the international association may render assistance to mental health research in India.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. Poverty and malnutrition may have a direct link in causing depression during pregnancy and the post partum period. illiteracy. especially in rural areas. such as. the medieval period denied equal rights. The Dowry Prohibition Act of 1961.22] 5. The Indian constitution has many provisions for the welfare of women as can be learnt from article 14 (equality). are geared toward the welfare of women.8 per 1000. Less than 10% of the households are matriarchal. 4. Although Indian history depicts equal rights for women in ancient India. National Policy for the Empowerment of Women in 2001. encompasses the National Drug De-addiction Control Program (11 crores) and Information Education and Communication (171. whereas. NMHP has 58 crores as its share. The hormonal milieu of the female gender may render vulnerability to emotional disorders and may influence the pharmacokinetics of drugs. article 39 (equal pay).25 crores as budget allocation. infections. It has been predicted that the growth rate of crimes against women might surpass the population growth rate by 2010.1. Women's mental health issues have been discussed elsewhere. 4. Young researchers group under IPS may have a positive impact.7 crores).[8] Women are twice prone to develop depression compared to men. Research methodology training to selected psychiatrists. The core group may try to include mental health related programs under NRHM.21. 2. and The Protection of Women from Domestic Violence Act of 2005 (which came into force in October. malnutrition. 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). 3. Orientation in skills in drafting a research article.

The rates are as high as 64% in certain cities. mainly accounted for in Maharashtra and Nagaland. anemia. Depression is associated with hyperglycemia and other metabolic abnormalities.[23] Let me now focus on two specific issues relevant to the Indian context — Diabetes and HIV. India has earned recognition as the diabetic capital of the world. 4. defective perception of the psychological impact on physical disorders. The revised prevalence estimate in July 2007. Lack of proper training. Depression may also add to disability and decreased Quality of Life (QOL). improper rationalization about the somatic symptoms of depression. About half of the Indian population consists of adults in the sexually active age group. The characteristics of higher glycemic response to all food items. Concurrent hepatitis C/B. and higher high-sensitivity Creactive protein levels) demonstrate a higher vulnerability to develop type II diabetes. secreting more insulin in response to glucose. Depression increases the risk of coronary heart disease (CHD) in established DM. Co-morbid depression may affect glycemic control and diabetes self-care behavior. Manipur ranks first. Diabetics are twice as likely to have depression. The drug—drug interaction may pose a therapeutic dilemma. Depression is associated with other physical precipitants of heart disease.28] 1. Depression is a risk factor in the development of Type II diabetes mellitus (DM). The National Family Health Survey conducted between 2005 and 2006. The relationship between depression and diabetes may be summarized as follows:[27. With a 40 million diabetic population. 2. with six times the prevalence of Maharashtra and 20 times that of Tamilnadu. and a tunnel vision of medical pathology may culminate in the physician's non-recognition of the psychopathology.[24–28] A meta-analysis of 42 studies has shown clinically relevant depression in 31% of diabetics. lower adiponectin. leading to increased morbidity. Co-morbid depression in the medically ill is often undiagnosed and untreated. has measured HIV prevalence among the general adult population of India. suggests that around 2. 5. The HIV prevalence in female sex workers in India is around 5%.Several large studies show that psychiatric patients suffer a high rate of co-morbid medical illnesses. tuberculosis.5 million people in India are living with HIV. 3. HIV prevalence is high in intravenous drug users (IDU). and cellulitis complicate the management of HIV in IDU. Treatment of depression may reduce the risks of DM and its complications. Co-morbid psychopathology may contribute to the therapeutic nonadherence to medical regimen.[29–31] . greater abdominal adiposity. and the Asian Indian Phenotype (increased insulin resistance. with a projected 70 million by 2025. Medication nonadherence can lead to increased morbidity and mortality.

the NIMHANS model of child psychiatry specialization is a welcome step. focused. Child psychiatry training in India is available only in very few centers. higher than the rate reported elsewhere. Geriatric psychiatry . environment. 6. However. the rates of AIDS dementia are pretty low (1 – 2%). Nonpharmacological treatment Training in the nonpharmacological management of psychiatric disorders is abysmally poor in India. Most of the postgraduate training centers do not address psychological/psychiatric issues in a desired format. depression. There is an urgent need to pool the available child psychiatrists of India and to initiate timebound. 7. or a combination of the two.The psychiatric disorders in HIV may range from adjustment disorders. thanks to the lack of proper training in that specialty. 8. working together. A broad range of services is often required to meet the needs of these young people and their families. can help children and adolescents with mental disorders.‘ relegating the very essence of a good doctor – patient relationship and nonpharmacological management principles.[29] Research in psychiatric disorders in HIV will be an area where young researchers in Psychiatry have to focus. However. Child psychiatry It is estimated that as many as one in five children and adolescents may have identifiable mental health disorders requiring treatment. A hostile. a majority of the practitioners employ ‗common sense‘ psychotherapy. training workshops. Mental health disorders in children and adolescents are caused by biology. threatening or uncomfortable environment provides the breeding ground for many negative perceptions with resultant emotional and behavioral disturbances. It has to be remembered that a ‗psychological mattress‘ is essential for a ‗pharmacological pillow‘. and anxiety states to acquired immune deficiency syndrome (AIDS) dementia. Rates of depression in Indian HIV cases range from 10 – 40%. The upswing of psychopharmacological research has provided a generation of ‗pill pushers. The cry for a super specialty in child psychiatry did not impress the authorities. Families and communities. The time is ripe to initiate skill development in cognitive behavior therapy (CBT) and other nonpharmacological management strategies. Although very few teaching institutions impart the knowhow of cognitive behavior techniques and basic psychotherapeutic skills.

37] Kerala leads in per capita consumption of liquor at a whopping 8.28 crore from the KSBC (Kerala State Beverages Corporation) alone as its share. The only reliable morbidity data is on dementia and its estimated prevalence is 33. abuse of cannabis / cannabis products. Addiction psychiatry The World Health Organization (WHO) estimates suggest that there are 60 to 70 million alcoholics in India.5 years in 2006. caregiver burden.38. and other ‗over-the-counter‘ (OTC) drugs delineate unbridled regulation at sale outlets.9 liters)] as against four liters in the rest of the country. NIMHANS at Bangalore. The age of initiation to alcohol has come down from 19 years in 1986 to 13. . Kerala has been emerging as one of the largest consumers of alcohol in the world.3 liters [pushing Punjab to second place (7. to help psychiatrists in the identification. (24%) and others (6%). In a report for WHO.6 million in 2001 to 137 million by 2021. falls.49 crore during 2007 – 2008. The sale of Indian Made Foreign Liquor (IMFL) in Kerala has jumped to Rs 3. a multicenter collaborative study — ‗Injury and Alcohol‘ — at NIMHANS Bangalore. and service delivery of dementia subjects. psychotropics. Services catered to the comprehensive array of psychological. above 60 years.9 per 1000 in the rural and 33. with inefficient legal measures. violence (24%). The Departments of Geriatric Mental Health at Lucknow. and care of the elderly. accidents. found that the proportion of injuries 'linked' to alcohol use was 58.9% of all injuries.39] Addiction to heroin (1 million). besides crores of rupees from bar licenses. assessment. Kerala. and physical problems of the elderly have to be provided.[36.669. 10/66 dementia research groups have contributed to our understanding of the prevalence. often quoted as ‗Gods own country‘ ranks high in suicide rates. and alcoholism. from a mere Rs 81.914.[32–35] The geriatric specialty wing of IPS should organize a focused workshop. The feelings of loneliness along with the natural age-related decline in physical and physiological functioning are catalysts to psychological disturbances. Alcohol-related injuries include road accidents (46%0. The state had received revenue of Rs 2.6 per 1000 in the urban population. of which 50% are ―hazardous drinkers‖ and require treatment. cognitive.[36. 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). and a private psychiatric center at Varanasi have to be congratulated in their efforts on geriatric care. One really wonders whether ‗God's own country‘ will be swallowed by the devil's advocate — alcoholism. Of late.The elderly population in our country will increase from 7. 9. BYL Nair Hospital at Mumbai.42 crore in 1987 – 1988. the most literate of Indian states.

Delhi. The IPS task force. The medical council of India (MCI) has to intervene urgently to include psychiatric training (doctor – patient relationship. Undergraduate psychiatry It is a paradox that the undergraduate (graduate) medical curriculum has lesser provision (hours of training) for psychiatry than the nursing curriculum. and Guwahati have inflicted considerable psychological trauma. There was a suggestion for introducing emergency health management in the MBBS curriculum and inservice training of Hospital Managers and professionals. over 40 million hectares is prone to floods. Bangalore. as a part of terrorism. Hyderabad. 10. should take immediate steps to ‗psychoeducate‘ the agencies concerned. the efforts of empowering primary care providers will be a disaster. Despite repeated efforts to provide more thrust on Psychiatry in graduate medical education. However. Undergraduate psychiatric training will also minimize irrational psychotropic use and ‗doctor-shopping‘ of hapless subjects. I hope. have driven the Indian society to a state of panic. many man-made disasters. Major natural disasters include the super cyclone in Orissa. . and 68% of the area is susceptible to drought. with unexplained physical symptoms. and advice the policy planners. about 8% of the total area is prone to cyclones. somatic symptoms and their relevance. 11. in 1989. on advocacy.The addiction specialty section. United Nations General Assembly. and basic nonpharmacological and pharmacological principles). medical graduates trained in ―body medicine‖ will be miserable in identifying common mental disorders. and the tsunami in Tamil Nadu. About 60% of the landmass is prone to earthquakes of various intensities. the status quo remains. will pay more attention in training psychiatrists on substance use disorders. Jaipur. Disaster management India has been traditionally vulnerable to natural disasters on account of its unique geoclimatic conditions. comorbidity of psychiatric disorders in physical illness. identification of common psychiatric problems. the involvement of psychiatric professionals either in crisis management or in managing psychological sequelae is not highlighted. 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. With the current training. The bomb blasts in Mumbai.[40] In recent times. If not. declared the decade 1990 – 2000 as the International Decade for Natural Disaster Reduction. educate the society on the evils of drug abuse. the earthquake in Lathur and Gujarat. so as to contradict the WHO definition of health.

is another organization involved in training and service delivery. you have a reciprocal responsibility to live your life so that others may stand on your shoulders.Vernon Jordan CONCLUSION I have tried to outline certain areas that need special attention by the psychiatric fraternity. IPS has links with the Indo-American Psychiatric Association. and Indo-Canadian Psychiatric Association. national and international.IPS has already got a taskforce on disaster management. Indo-Australian Psychiatric Association. The Royal College of Psychiatrists can assist in teaching and training. the “what” is far more predictable than the “when. The collaboration and the goodwill of these bodies should be encouraged for the benefit of Indian Psychiatry. The society has to be involved in disaster management programs of the country. British Indian Psychiatric association.  Other Sections▼ 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. for better psychiatric care. I shall try to initiate the process with your cooperation. ―You are where you are today because you stand on somebody's shoulders. “When looking at the future. The SAARC psychiatric federation comes under the Asian Federation of Psychiatric Association (AFPA).” . in collaboration with IPS. It's the quid pro quo of life. This will also facilitate faculty exchanges and research collaborations. And wherever you are heading.” And the “how” will always feel different than predicted. I hope the networking will open new avenues of teaching and research in India. representing 18 countries. We exist temporarily through what we take. The South Asian Forum International (SAFI). 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. If you stand on the shoulders of others. but we live forever through what we give‖ .[41] IPS is a member of the WPA (World Psychiatric Association) and the South Asian Association for Regional Cooperation (SAARC) psychiatric federation. you cannot get there by yourself.

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