PsychiatrPsychiatryy inin India:India: TTrainingraining && trainingtraining centrcentreses Second Edition

Editors: T.S. Sathyanarayana Rao & Abhinav Tandon

Psychiatry in India: Training & training centres Second Edition

Editors: T.S. Sathyanarayana Rao Abhinav Tandon

Publisher:

Indian Journal of www.indianjpsychiatry.org Psychiatry in India : Training & training centres Second edition, the supplement of Indian Journal of Psychiatry

Editors: T.S. Sathyanarayana Rao Abhinav Tandon © Indian Journal of Psychiatry, 2015 Original ISBN No: Print ISSN 0019-5545 E-ISSN 1998 - 3794 Archived at www.indianjpsychiatry.org First print: 2011 Revised & Updated edition : 2013 Second Edition: 2015 Composed and Printed at: Ramya Creations 2nd Floor, Madvesha Complex Nazarbad Main Road, Mysuru 570 010, India. Phone: 0821 2445187 Email: [email protected] Cover design by : Darshan M.S. Consultant Neuropsychiatrist Formerly Resident, Dept. of Psychiatry, JSSMC Mysuru, Karnataka, India. & Late Anjana M.S.

Copyright © 2015 The entire contents are protected under Indian and International copyrights. Disclaimer: The information and opinions presented in the Journal and in this book Indian Research in Psychiatry: A Journey of six decades reflect the views of the authors and not of the Journal or its Editorial Board or the Publishers. Publication does not constitute endorsement. Neither the Indian Journal of Psychiatry / Indian Research in Psychiatry: A Journey of six decades nor its publishers nor anyone else involved in creating, producing or delivering the materials contained therein, assumes any liability or responsibility for the accuracy, completeness, or usefulness of any information provided nor shall they be liable for any direct, indirect, incidental, special, consequential or punitive damages arising out of their use. The Indian Journal of Psychiatry/ Indian Research in Psychiatry: A Journey of six decades, nor its publishers, nor any other party involved in the preparation of material contained herein represents or warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from the use of such material. Readers are encouraged to confirm the information contained herein with other sources.

Editorial Office T. S. Sathyanarayana Rao Professor and Formerly Head, Department of Psychiatry, JSS Medical College Hospital, JSS University M.G. Road, Mysuru - 570004, India Tel : 0821-2335187 Mob: +91 9845282399 Fax: No. 0821- 2335501 Email: [email protected] [email protected] Website: www.indianjpsychiatry.org Editorial Team

Honorary Editor T. S. Sathyanarayana Rao, Mysuru

Honorary Associate Editors K.S. Shaji, Trissur Sandeep Grover, Chandigarh

Honorary Deputy Editor Prasad G Rao, Hyderabad O.P. Singh, Kolkata

Honorary Assistant Editor Abhinav Tandon, Allahabad

Honorary Field Editors Swaminath G, Bangalore Ajay Singh, Mumbai Bhatia M.S., Delhi Chittaranjan Andrade, Bangalore Debasish Basu, Chandigarh Devasish Ray, Kolkata Kamala Deka, Dibrugarh Kangan Pathak, Guwahati Margoob Mustaq Ahmed, Srinagar Om Prakash, New Delhi Nilesh Shah, Mumbai Prathap Tharyan, Vellore Rajshekhar Bipeta, Hyderabad Sonia Parial, Raipur Sujata Sethi, Rohtak Sujit Sarkhel, Ranchi Suresh Kumar, Chennai Tandon S.K., Bhopal Thara, Chennai Vikram Kumar Yeragani, Bangalore Vinod Sinha, Ranchi Vivek C. Kirpekar, Nagpur

IPS Executive Council Members

President Vidhyadhar Watve, Pune

Vice President / President elect: Prasad G. Rao, Hyderabad

General Secretary N N Raju, Vishakapatnam

Hon. Treasurer Vinay Kumar, Patna

Hon. Editor T.S. Sathyanarayana Rao, Mysuru

Immediate Past President T.V. Asokan, Chennai

Immediate Past Secretary Asim Kumar Mallik, Kolkata

IPS Executive Council Kishore Gujar, Pune Mrugesh Vaishnav, Ahmedabad O.P. Singh, Kolkata Arabind Brahma, Kolkata K.K. Mishra, Sevagram Om Prakash, New Delhi Sunil Goyal, New Delhi

Foreword Indian Psychiatric Society (From the first edition) One of the key aim and objectives of the Indian Psychiatric Society, a professional body of in India, is to promote and advance the subject of psychiatry and its allied sciences. It also aims to formulate and advise on the standards of education and training for medical and auxiliary personnel in Psychiatry and to recommend adequate teaching facilities for the purpose. Indian Psychiatric Society (IPS) was founded in January 1947 and it goes to the credit of the founding visionaries that in the same year the Society appointed a committee on Postgraduate Psychiatry Education. However, it took the Society a little more than six decades to produce and recommend a formal statement on the essentials of Postgraduate Training in Psychiatry that needs to be followed uniformly in India. In the year 2010, IPS has made recommendations to Govt. of India and the Medical Council of India for “Minimum Standards of Competency Based Training in Psychiatry”. It details the subjects specific and other learning objectives, practical competencies, teaching – learning and evaluation methods. While undertaking this task, it was felt by the Society that the profession should have a complete appraisal of Psychiatry Training facilities available in India and the standards followed for the same in various training centres. The Society has great satisfaction that this acute need for a comprehensive appraisal is being partially fulfilled by this Special Supplement of the Indian Journal of Psychiatry, “Psychiatry in India: Training and Training Centres”. In this Supplement, a wide range of articles are being covered scanning the philosophy of training in psychiatry, past and future trends, models of training as practiced abroad and their relevance to India, issues of specialty training etc. A very interesting and highly useful and relevant segment covers training needs of trainees, especially day-to-day practical needs in their clinical work. This useful Supplement could not have been possible but for the untiring efforts of Dr. T.S.S. Rao, Hon. Editor of Indian Journal of Psychiatry and his editorial team, as well as, the excellent contributions to this Supplement by various eminent authors. Indian Psychiatric Society hopes that this Supplement will help to complete a long standing void in our information and knowledge and be the torch bearer in terms of guiding the trainees in Psychiatry. Ajit Avasthi M. Thirunavukarasu U. C. Garg President Vice-President General Secretary

From the President, Indian Psychiatric Society (From Revised and Updated edition) Foreword This book “Psychiatry in India: Training and Training centres” traces the early history about training in Mental Health and critically evaluate the present system of training and also recommends measures for further improvisation. What one appreciates in this book is not a birds eye view of relevant sections but an in-depth analysis because of the contributions of legends in the respective field. It is commendable to see chapters on education and training in other countries for comparison of our state which will pave way for further emulation. I congratulate Prof. T.S.S.Rao for conceiving the concept and compiling this academic registry on Psychiatry training. I am sure that this book “Psychiatry in India: Training and Training centers”would be perceived as a significant contribution in the annals of academic psychiatry. Fiat Lux, Prof. T.V. Asokan Zone 16 Representative, WPA President, Indian Psychiatric Society 2014

Foreward Indian Psychiatric Society

It gives great pleasure to see the "Psychiatry in India; Training and Training Centres" by the Honorary Editor Prof. T.S.S. Rao and his editorial team. The long felt need is to look into the issues of undergraduate and post graduate education in India, which is a key aim of Indian Psychiatry Society, the professional body of psychiatrists of India. The First edition was brought out in 2011. It helped in the formulation of the policies for mental health deliverance. Indian Psychiatric Society, since it was founded in 1947, through innumerable visionaries has been in the fore front of formulation of psychiatric education in medical curriculum. The Psychiatric education both in undergraduate and post graduate level need to be streamlined for uniformity, consistency and assessment of the imparted education. IPS has recommended after a due work out, a formal statement to the Government of India and the Medical Council of India. The main body related to academic education was apprised of the update from time to time. Lot of changes further evolved and so also there are many more centres of training in medical education both at undergraduate and post graduate level. So the need to upgrade the details of the centres of education and Indian Psychiatric Society has again taken on itself to work up all the aspects comprehensively. The society is very pleased and has great satisfaction that a comprehensive appraisal has gone in once again to update all the aspects of psychiatric education and training. We are aware of the interactions between our society and Government of India, through Minister of health on the one hand and the Medical Council of India on the other hand is a very dynamic, continuous process. In the current supplement, we are happy that lot more details are covered on academics, including the forthcoming "New Mental Health Care Bill", especially the Rights of Mentally Ill. This issue also covers on the most important topics Viz.: How to read and write research papers, covers metabolic syndrome, cultural formulation etc. We are sure that this edition will help young students and teachers in psychiatry immensely and also the psychiatrists and the medical professionals as a ready to use information. To the consultants and the medical education planners we are sure this volume is going to be of great help, as a ready reckoner and reference book. We congratulate Prof. T.S.S. Rao and his team for the conceptualization and incorporation of the topics most needed, and for their hard work. Indian Psychiatric Society hopes this supplement will complement and fills the gaps since the last publication. The information contained are pearls of wisdom and will benefit one and all. Long live Indian Psychiatric Society. DR VIDYADHAR WATVE DR G. PRASAD RAO PRESIDENT VICE –PRESIDENT / PRESIDENT ELECT Welcome Address

It is a matter of pleasure to note that a book on “Psychiatry in India: Training and Training centres” is brought at a time when such information is hard to find. I appreciate the efforts of Dr. T.S.S.Rao, Editor, Indian Journal of psychiatry for his efforts to collect the required information and present in a form needed to many of us. This helps in understanding the strides which were taken to shape the psychiatric education in the country. As is well known, the training across the country is not the same and it is time a standardized modules are developed so that all the qualified psychiatrists would receive the same standards of skills. I am sure Indian Psychiatric Society, the largest organization of mental health professionals with other related bodies will play a significant role to create level playing field.

I once again congratulate the entire team for their successful effort of compilation!

Dr. N N Raju General Secretary, IPS Acknowledgements (From the first edition) 1. I am grateful to all the office bearers – President Thirunavukarasu M, Immediate Past President Ajit Avasthi, President Elect Roy Abraham Kallilvayalil, Honorary General Secretary – Uttam C. Garg, Treasurer – Asim Kumar Mallick, and Immediate Past General Secretary Govind M Bang and all the executive council members for their whole hearted support and encouragement.

2. I sincerely thank the co- chairperson P N Shukla, Associate editors, Roy Abraham and Sandeep Grover, Deputy Editors, G. Prasad Rao and Ajit V. Bhide, Assistant Editor G. Swaminath, all the Field editors and Section Editors, Statistical Consultants, Editorial Board Members, Members of Journal Committee, National & International Advisory Board Members, authors and reviewers for their help and involvement.

3. Poojya Sri Shivarathri Deshikendra Mahaswamiji, the President, JSS Mahavidyapeetha, Mysore and Chancellor, JSS University, Mysore.

4. Sri. B.N. Betkerur, Executive Secretary, JSS Mahavidyapeetha, Mysore and Pro- Chancellor, JSS University, Mysore.

5. B. Suresh, Vice-Chancellor, JSS University, Mysore.

6. Mruthyunjaya P Kulenur, Registrar, P.A. Kushalappa, Deputy Registrar (Academics), Vijay Simha, Deputy Registrar (Evaluation) and other staff members at JSS University, Mysore.

7. H. Basavanna Gowdappa, Principal, JSS Medical College, K. Veerabhadrappa, Medical Superintendent and C.N. Mruthyunjayappa, Addl. Medical Superintendent JSS Hospital, Mysore.

8. My sincere thanks to K.S. Jagannatha Rao, Director, Institute for Scientific Research and Technology Services, Clayton, City of Knowledge, Republic of Panama and to Rajashekhar J. Brahmabhatt, Director, KAMA Institute of Sexual Studies , Mumbai.

9. My special thanks to K.H. Basavaraj, Prof. of Dermatology and N.M. Shama Sundar, Prof. & Head, Dept. of Anatomy, JSS Medical College.

10. My Colleagues: Rajesh Raman, Dushad Ram, Bindu A., L.S.S. Manickam, P. Kalaiah, V.S.T. Krishna, Nawab Akhtar Khan.

11. My Post Graduate Students: Nimisha Mishra, H.R Abhijith, N. Saraswathi, A. Rashmi, M.S. Darshan, Payel Roy,Vatsala JK, Karthik KN, Harsha GT, Keya Das and a special thanks to Abhinav Tandon for his sincere efforts. 12. Departmental Staff and others: Bramharamba, B.S. Renuka, M.R. Vidya, N. Ravi, Jyoshna, Poornima, M.S. Anjana, P. Lingambika, Sharath Kumar C, Rekha S. Rao, Vinaya.

13. I thank Sahu and Medknow team for excellent work in preparing the Special Supplement of Indian Journal of Psychiatry.

14. My heartfelt thanks to R. Vasudev Bhat of Ramya Creations, Mysore for printing and publishing this reference text book. T.S. Sathyanarayana Rao Editors Speak

“Mental health… is not a destination but a process. It's about how you drive, not where you're going” – Noam Shpancer The Good Psychologist

The current edition of the book : “Psychiatry in India: training and training centres” was initially conceived as a supplement on 'Iconic institutions in India' in 2011 but subsequently modified into 'Training centres in India'. The book was conceptualized keeping in view, the major lacunas existing in our country in the area of training and lack of a standard detailed module highlighting different aspects of, training graduates and postgraduates in psychiatry. The book went through a number of phoenix rebirths to reach its current form, very true to the saying:

“The phoenix must burn to emerge”- Janet Fitch.

There are many centres and many universities offering degrees with varied syllabi and different modes of training. The statutory bodies governing the training too have taken up proper integration of syllabi and training and this being the right time to respond to them positively with the considered opinion in a single voice from our society. This is an attempt to get different ideas, intellectual inputs and practical experiences in Indian psychiatric society at one place. Being in the globalized world the ideas and the practical experiences from experts world-over is worth looking into. This volume represents an attempt in this direction. It looks into some of major areas of debate like :Writing/reading a research paper, psychiatric interview, training in psychiatry in other countries, etc Only a strong foundation is going to give us well trained mental health professionals for the future

This book has been thoroughly updated, revised and edited incorporating the proposed new 'Mental Health Care Bill, 2013' and 'The Rights of Persons with Disabilities Bill,2014'. Around 10 articles have been added to this edition covering metabolic syndrome, cultural formulation, CME and other topics. This volume has been prepared keeping in mind the trainees. This also provides the basis of approach to the new teachers and consultants. I am confident it meets the needs of both the groups and our esteemed members. Our Sincere thanks and regards to the Past Presidents Ajit Avasthi, Thirunavukarasu M., Roy Abraham Kallivayalil, Indira Sharma and T.V. Asokan, President Vidyadhar Watve, President Elect – G Prasad Rao, Immediate Past General Secretary Asim Kumar Mallick, General Secretary N N Raju, Treasurer Vinay Kumar, all the other office bearers, executive council members, advisory board members, editorial team and each and everyone involved with this project directly and indirectly.

We are grateful to Poojya Sri Sri Shivarathri Deshikendra Mahaswamiji, Chancellor, JSS University for the blessings. Our sincere thanks to Dr. B Suresh, Vice Chancellor, Dr. B. Manjunatha, Registrar, Dr. Kushalappa, Director Academics, Dr. Vijaya Simha, Controller of Examination, Dr. Sudeendra Bhat, Deputy Controller of Examination, Dr. H. Basavana Gowdappa, Dean, Faculty of Medicine and Principal, Dr. M.D. Ravi, Director, JSS Hospital and Vice Principal, Dr. Balaraj, Vice Principal, Dr. Guruswamy, Medical Superintendent, JSS Hospital, Mr. Satish Chandra, Administrator, Mr. Jayashankar, PRO, JSS Medical College and all the administrators and Staff and students from JSS Medical College and JSS University involved with the project.

Special thanks to my departmental colleagues: Rajesh Raman, Dushad Ram, Kishor M, Bindu A, Shivananda Manohar, L S S Manickam, Nawab A Khan, VST Krishna, and PGs in my department – Vinay Kumar, Swetha, Mehak Nagpal, Arun Kumar V, Neha Leister, Shwetha M.S, Sudha P. Naik, Tharun Krishnan, Ramya Shruthi D, Najla Eiman, Sindhur N, Suhas Chandran, Shreemit Maheshwari, Navya Spurthi, and Saswinder Kaur. The Secretarial help was provided by Ravi N, Renuka BS, Anitha C. and Vikram G. We are also grateful to the publisher of the book Sri Vasudev Bhat, Ramya Creations, Mysore and as the supplement of IJP by Wolters Kluwer Health and Medknow Publications and Media Pvt. Ltd. Mumbai.

“Mental illness is the only disease that can make you deny its own existence. Certainly the idea that the brain can deny its own illness is a frightening thought” - Natasha Tracy

Long Live IPS & IJP

T.S. Sathyanarayana Rao, Abhinav Tandon Mysuru, Karnataka. [email protected], [email protected] Contributors List

K.R. Aarya Junior Resident, Department of Psychiatry PGIMER, Chandigarh

Abhinav Tandon Asst Editor, Indian Journal of Psychiatry Director, Dr AK Tandon Neuropsychiatric Centre Allahabad

Adarsh Tripathi Lecturer Department of Psychiatry CSM Medical University (Erstwhile K.G. Medical University) Lucknow

M. Afzal Javed Pakistan Psychiatric Research Centre Fountain House, 37- Lower Mall Lahore, Pakistan

A.K. Agarwal Past President, Indian Psychiatric Society B104/2 Nirala Nagar, Lucknow

Ajit Avasthi Professor Department of Psychiatry Postgraduate Institute of Medical Education & Research Chandigarh

Alakananda Dutt Department of Psychiatry, PGIMER, Chandigarh Alka A. Subramanyam Asst. Professor Department of Psychiatry TNMC & BYL Nair Ch. Hospital Mumbai

Amit Kulkarni Consultant BCJ Hospital and Asha Parekh Research Centre Mumbai

Anand K. Pandurangi Professor of Psychiatry Virginia Commonwealth University P.O. Box 980710 Richmond, Virginia, 23298 USA

Anil Kumar Tandon Ex-President IPS-CZ Professor (Retd.) in Psychiatry MLN Medical College Allahabad.

Anil Nischal Associate Professor Department of Psychiatry CSM Medical University (Erstwhile K.G. Medical University) Lucknow

Anindya Das Senior Resident, Department of Geriatric Mental Health Chhatrapati Shahuji Maharaj Medical University UP, India.

Anita Gautam Gautam Hospital & Research Center and Institute of Behavioural Sciences and Alternative Medicine, Anju Kuruvilla Professor of Psychiatry, Christian Medical College, Vellore Anna Tharyan Dept. of Psychiatry Christian Medical College and Hospital, Bagayam, Vellore

Anoop Raveendran Resident Department of Psychiatry Christian Medical College Vellore.

Anuradha Nadkarni Research Officer CCRAS, Dept. of Psychiatry, PGIMER-Dr RML Hospital New Delhi.

Anurag Srivastava Professor & Head. Dept of Psychiatry, Mediciti Institute of Medical Sciences Hyderabad.

Arabinda Brahma 14, Parsi Bagan Lane Kolkata

Archana Malik Department of Ophthalmology Government Medical College and Hospital Chandigarh

Arun N.R. Kishore Consultant Psychiatrist Sussex Partnership NHS Foundation Trust, U.K. Educational supervisor and SAS Tutor, Sussex Partnership NHS Foundation Trust , Sussex, U.K. Greenacres, Homefield Road, Worthing West Sussex BN11 2HS U.K. Aude Caria Psychologist Project Manager WHO Collaborating Centre for research and training in Mental Health (Lille, France)

Paula Bastow Paula Bastow, DH CSIP Eastern, UK

P. B. Behere Professor and Head Department of Psychiatry, M.G.I.M.S. Recipient of Dr. B.C. Roy National Award Sevagram;Dist Wardha, Maharashtra, India Bangalore

M. Bharti Principal Employees State Insurance Corporation College of Nursing Indiranagar, Bangalore

R .J. Bishnoi DNB – Secondary Candidate Deva Institute of Healthcare & Research Pvt. Ltd.,

Chandrashekar H. Bangalore Medical College and Research Institute, Bangalore

B.S. Chavan Professor and head Department of psychiatry, GMCH- Chandigarh

Charles Pinto Prof. Emeritus Department of Psychiatry TNMC & BYL Nair Ch. Hospital Mumbai P.K. Dalal Professor & Head of the department Department of Psychiatry CSM Medical University (Erstwhile K.G. Medical University)

M.S. Darshan Formerly Resident in Psychiatry Dept. of Psychiatry JSS University, JSS Hospital (JSS Medical College) M.G. Road, Mysore Debjani Bandopadhyah Consultant Psychiatrist MANSIJ, Burdwan West Bengal

Deepak Giri PG Resident Institute of Medicine Tribhuvan University –Teaching Hospital Kathmandu, Nepal

Deepak Jayarajan Senior Resident Centre for Addiction Medicine, Department of Psychiatry National Institute of Mental Health and Neuro Sciences (NIMHANS) Bangalore

Dhanya Raveendranathan Senior Resident of Psychiatry Department of Psychiatry National Institute of Mental Health and Neuro Sciences, (Deemed University), Bangalore

Dinesh Bhugra Professor of Mental Health and Cultural Diversity, Department of Health Service and Population Research, Institute of Psychiatry, King's College London, De Crespigny Park, London SE5 8AF, UK K.J. Divina Kumar Associate Professor, Department of Psychiatry, Armed Forces Medical College, Pune

Dushad Ram Asst. Prof. of Psychiatry JSS Medical College and Hospital Mysore.

Gautam Bandhopadhyay 14, Parsi Bagan Lane Kolkata.

Gautam Saha Consultant Psychiatrist Clinic Brain Barasat, West Bengal

Geetha Desai Associate Professor, Coordinator, Seminars Department of Psychiatry National Institute of Mental Health & Neurosciences Bangalore, India

Girish Menon Consultant Psychiatrist Vijayawada

I.D. Gupta Psychiatric Center SMS Medical College, Jaipur

Gurvinder Kalra Assistant Professor, Dept. of Psychiatry, L.T.M.M.C. & L.T.M.G.H., Mumbai

Harischandra Gambheera National Institute of Mental Health Colombo, Sri Lanka Harish Shetty Psychiatrist, Dr L. H. Hiranandani Hospital Powai, Mumbai.

Ipsit V. Vahia Stein Institute for Research on Aging Department of Psychiatry University of California, San Diego 9500 Gilman Drive #0664 La Jolla, CA 92093

K.S. Jacob Professor of Psychiatry, Christian Medical College, Vellore 632 002

James T. Anthony Past President, IPS TC – 38 – 1375, Poothole Road, Thissur – 680004, Kerala.

Janardhanan Narayanaswamy Senior Resident of Psychiatry Department of Psychiatry National Institute of Mental Health and Neuro Sciences, (Deemed University), Bangalore

Jean Luc Roelandt Psychiatrist, Director of the WHO Collaborating Centre for research and training in Mental Health (Lille, France), Head of East Lille Services EPSM Lille Métropole

R.C. Jiloha Director, Professor & Head Department of Psychiatry Maulana Azad Medical College, GB Pant Hospital & University of Delhi & Chairman, Psychiatry Education Committee Indian Psychiatric Society Jugal Kishore Professor Community Medicine, Maulana Azad Medical College, New Delhi

Jyoti Prakash Reader, Department of Psychiatry, Armed Forces Medical College, Pune

S. Kalyanasundaram Principal RF PG College, Hon. CEO Richmond Fellowship Consultant Psychiatrist, Bangalore.

K.V. Kishore Kumar Senior Psychiatrist NIMHANS, Bangalore

V.S.T. Krishna Asso. Professor (PSW) Department of Psychiatry JSS Medical College & Hospital M G Road, Mysore

Laurent Defromont Psychiatrist, Consultant WHO Collaborating Centre for research and training in Mental Health (Lille, France), Head Medical Information and Research Department, EPSM Lille Métropole

Manaswi Gautam Gautam Hospital & Research Center and Institute of Behavioural Sciences and Alternative Medicine, Jaipur. L.S.S. Manickam Professor in Clinical Psychology Department of Psychiatry JSS University Mysore and Hon. General Secretary of the Indian Association of Clinical Psychologists.

Mathew Samuel A/Clinical Director, Mental Health Fremantle Hospital and Health Services Fremantle, Australia.

P.S. Meena Psychiatric Center SMS Medical College, Jaipur Jaipur.

Mohan Isaac Professor of Psychiatry The University of Western Australia Perth, Australia. L6, W Block, Fremantle Hospital 1 Alma Street, Fremantle WA 6160 Australia.

Muhammad Nasar Sayeed Khan Associate Professor and Head Department of Psychiatry and Behavioural Sciences, Services Institute of Medical sciences Lahore-Pakistan

N.V. Muninarayanappa Former Prof. cum Principal School of Nursing Sciences and Research Sharada University Greater Noida (UP)

T. Murali President, World Association for Psychosocial Rehabilitation. Professor & head of Psychiatry, M.S. Ramaiah Medical College, Tumkur K. Nagaraja Rao Prof & Head Department of Psychiatry JJM Medical college Davangere

S. Nambi Prof and HOD, Dept of psychiatry, Chettinad Hospital & Research Institute, Kelambakkam, Chennai, Formerly Prof of Psychiatry, Madras Medical College, Chennai,

Narayana Manjunatha Assistant Professor of Psychiatry Department of Psychiatry MS Ramaiah Medical College Bangalore

Naren P. Rao Senior Resident in Psychiatry Department of Psychiatry NIMHANS Bangalore

Naresh Nebhinani Dept. of Psychiatry 3rd Floor, Cobalt Block Nehru Hospital, PGIMER Sector - 12 Chandigarh

S. Nath Classified Specialist in Psychiatry Command Hospital(SC), Pune

C. Naveen Kumar Assistant Professor, Coordinator, Assessments Department of Psychiatry National Institute of Mental Health & Neurosciences Bangalore, India Nawab Akhtar Khan Lecturer, (Clinical Psychology) Department of Psychiatry JSS Medical College & Hospital M G Road, Mysore

Nicholas A. Deakin MA Medical Student University of Bristol Senate House Bristol BS8 1TH UK

Nicolas Daumerie Clinical Psychologist, Project Manager WHO Collaborating Centre for research and training in Mental Health (Lille, France)

Nilesh Shah Professor & Head, Dept. of Psychiatry, L.T.M.M.C. & L.T.M.G.H., Mumbai

Nirmala Srinivasan Director, ACMI, Bangalore

Nishanth Jayarajan Senior Resident Department of Psychiatry National Institute of Mental Health & Neurosciences Bangalore

Om Prakash Singh Prof and HOD, Psychiatry Kolkata Medical College Kolkata

K.S. Pavitra Associate Professor, Department of Psychiatry, SDM Medical College, Dharwar, Karnataka, India Payel Roy Formerly Resident in Psychiatry Dept. of Psychiatry JSS University, JSS Medical College M.G. Road ,Mysore

Prabha S. Chandra Professor & Chairperson, Academic Programmes Department of Psychiatry National Institute of Mental Health & Neurosciences Bangalore, India

Prabhat Chand Associate Professor, Coordinator Research Forum Department of Psychiatry National Institute of Mental Health & Neurosciences Bangalore, India

G. Prasad Rao Consultant Psychiatrist Director, & Division, Asha Hospital, Hyderabad

N.R. Prashanth Bangalore Medical College and Research Institute,

Prathap Tharyan Professor of Psychiatry Christian Medical College, Vellore Tamil Nadu, India

R. Raghuram Professor & Head Department of Psychiatry, KIMS Bangalore

Rajan Nishanth Jayarajan Senior Resident in Psychiatry NIMHANS Bangalore Rajeev Krishnadas Clinical Lecturer in Psychological Medicine Southern General Hospital, University of Glasgow, UK.

Rajesh Nagpal Director, Behavioral and Neuroscience Academy of India (BANAI), New Delhi

Rajesh Sagar Associate Professor Department of Psychiatry All India Institute of Medical Sciences Ansari Nagar, New Delhi, India-110029 & Secretary, Central Mental Health Authority

Raman Deep Pattanayak Senior Research Associate (CSIR) Department of Psychiatry All India Institute of Medical Sciences Ansari Nagar, New Delhi

G.S. Ramkumar Final year Junior Resident Department of Psychiatry National Institute of Mental Health & Neurosciences Bangalore

I.R.S. Reddy Director VIMHANS Hospital Vijayawada

S.M. Reddy Resident Department of Psychiatry, M.G.I.M.S. Sevagram;Dist Wardha, Maharashtra, India

A.R. Rozatkar Senior Resident Department of psychiatry GMCH- Chandigarh Russell D'Souza Director of Clinical Trials and Bipolar Program Northern Psychiatry Research Centre Melbourne University 185 Coopers Street, Epping Victoria 3076 Australia

Late J.W. Sabhaney Wing Commander AMC IAF (Retd) Senior Consultant Neuro-Psychiatrist Advisor, Psycho-analyst, Psycho Therapist & Sexologist, Bangalore.

Sandeep Grover Assistant Professor Department of Psychiatry PGIMER, Chandigarh

Sanjay Kumar Munda Assistant Professor of Psychiatry Central Institute of Psychiatry Kanke, Ranchi.

Santosh K. Chaturvedi Professor & Head Department of Psychiatry National Institute of Mental Health & Neurosciences Bangalore, India

M.T. Sathyanarayana ”Swarnashri” 2nd Cross, Ashoka Nagar, Tumkur, Karnataka

T.S. Sathyanarayana Rao Prof. & Formerly Head, Department of Psychiatry, JSS University, JSS Medical College Hospital M.G. Road, Mysuru

Satish Kumar Budania Junior Resident Department of Psychiatry National Institute of Mental Health & Neurosciences Varanasi. Savita Malhotra Professor of Psychiatry Post Graduate Institute of Medical Education and Research, Chandigarh

Shaji K.S. Professor of Psychiatry Medical College Thrissur-680596 Kerala, India

P.S.V.N. Sharma Prof. and Head, Dept. of Psychiatry, KMC, Manipal

R. Shashikumar Associate Professor, Department of Psychiatry, Armed Forces Medical College, Pune

P.C. Shastri Professor of Psychiatry T.N. Medical College Hon. Psychiatrist B.Y.L. Nair Hospital

Shehan Williams Department of Psychiatry Faculty of Medicine University of Kelaniya Sri Lanka

Shekhar P. Seshadri Professor & Coordinator, Programme Department of Psychiatry National Institute of Mental Health & Neurosciences Bangalore, India

Shiv Gautam Gautam Hospital & Research Center and Institute of Behavioural Sciences and Alternative Medicine, Jaipur. P.T. Shivakumar Assistant Professor, Coordinator, Modular training Department of Psychiatry National Institute of Mental Health & Neurosciences Bangalore, India

Shivaram Bhat P. Associate Professor, Department of Psychiatry, Armed Forces Medical College, Pune

Shridhar Sharma Emeritus Professor, National Academy of Medical Sciences and Institute of Human Behaviour & Allied Sciences D-127, Preet Vihar, Delhi 110092.

Smita Manjunath Junior Resident Department of Psychiatry National Institute of Mental Health & Neurosciences Bangalore

Smita N. Deshpande Consultant, Professor & Head Dept. of Psychiatry & De-addiction Services, PGIMER- Dr. RML Hospital, New Delhi

O. Somasundaram, (Old#:30) New#:17 23rd cross Street, Besant Nagar, Tamilnadu.

Srikala Bharath Professor of Psychiatry NIMHANS , Bangalore

R. Srinivasa Murthy Professor of Psychiatry(retd) C-301; CASA ANSAL Apartments, 18, Bannerghatta Road, J.P.Nagar 3rd Phase, Bangalore Srivastava K. Scientist 'F' & Clinical Psychologist, Department of Psychiatry, Armed Forces Medical College, Pune

S.V.S. Subbarao Ryali Professor & Head, Department of Psychiatry, Armed Forces Medical College, Pune

Sudipto Chatterjee Consultant Psychiatrist Sangath, Goa.

Sujata Sethi 122/8, Shivaji Colony, Rohtak-124001, Haryana, India.

Sujit Kar Senior resident, Department of Psychiatry, C. S. M. Medical University UP (Upgraded K. G. Medical University) Lucknow

Suresh Bada Math Associate Professor of Psychiatry Department of Psychiatry National Institute of Mental Health and Neuro Sciences, (Deemed University), Bangalore

G. Swaminath Department of Psychiatry, Dr B R Ambedkar Medical College Kadugondanahalli Bangalore.

Tapas Kumar Aich Professor of Psychiatry Universal College of Medical Sciences, Bhairahawa, Nepal R. Thara Director, Schizophrenia Research Foundation Chennai.

S.C. Tiwari Professor and Head Department of Geriatric Mental Health Chhatrapati Shahuji Maharaj Medical University UP, India. Chairperson, Specialty Section of Indian Psychiatric Society.

J.K. Trivedi Professor & Ex-Head, Department of Psychiatry, C. S. M. Medical University UP (Upgraded K. G. Medical University) Lucknow

G. Venkatasubramaniam Associate Professor, Coordinator, Basic Science training Department of Psychiatry National Institute of Mental Health & Neurosciences Bangalore, India

S. Venkatesan Professor in Clinical Psychology All India Institute of Speech and Hearing, Mysore

Vihang N. Vahia Professor Emeritus of Psychiatry Cooper Hospital 261, D.N.Road, Fort, Mumbai Lucknow

Vikram Patel Professor of International Mental Health & Wellcome Trust Senior Research Fellow in Tropical Medicine, London School of Hygiene & Tropical Medicine and Sangath, Goa, India Vineet Kumar Senior Resident Department of Psychiatry PGIMER, Chandigarh

Vishal Indla Chief Psychiatrist, VIMHANS Hospital Vijayawada

Vivek Benegal Additional Professor of Psychiatry Centre for Addiction Medicine, Department of Psychiatry National Institute of Mental Health and Neuro Sciences (NIMHANS) Bangalore

Contents

1 Psychiatric Training T.S. Sathyanarayana Rao, G. Swaminath & G. Prasad Rao 1

2 Psychiatric Education in India: Past, Present and Future Shridhar Sharma 7

3 Undergraduate Psychiatry B.S. Chavan, A.R. Rozatkar 17

4 Psychiatry training during internship: Can we make it better? Rajan Nishanth Jayarajan & K.S. Shaji 25

5 Postgraduate Training in India: Agenda for Indian Psychiatric Society Ajit Avasthi, Naresh Nebhinani, Sandeep Grover 31

6 Recommendations for Post-graduate (MD) Curriculum in Psychiatry R.C. Jiloha 39

7 Innovations in Postgraduate Psychiatric Teaching and Training: Experiments at NIMHANS Santosh K. Chaturvedi, Prabha S. Chandra, Shekhar P. Seshadri, G. Venkatasubramaniam, Geetha Desai, Prabhat Chand, P.T. Shivakumar, C. Naveen Kumar 57

8 Provisions for Training Centres: Recent Developments R. Sagar, R.D. Pattanayak 69

9 Role of Academic Centers in meeting the Mental Health needs of Indian Population R. Srinivasa Murthy 77

10 Psychiatric Nursing: Past, Present and Future N.V. Muninarayanappa, M. Bharti 87

11 Post Graduate Training: An Asian Scenario Sujit Kar, J.K. Trivedi 93 12 Psychiatric Training in Sri Lanka and its relevance to India Harischandra Gambheera, Shehan Williams 101

13 Teaching & Training in Psychiatry: Pakistani Perspectives Muhammad Nasar Sayeed Khan, M. Afzal Javed 107

14 Psychiatry in Nepal: Training and Training Centres and it's Relevance to India Tapas Kumar Aich, Deepak Giri 115

15 Psychiatric training in the UK and its relevance to India Dinesh Bhugra, Gurvinder Kalra, Nilesh Shah 125

16 Psychiatric Training in USA and relevance to India Anand K. Pandurangi 131

17 Psychiatry Training in Australia and its relevance to India Russell D'Souza 143

18 Psychiatric training in Australia and India: Similarities and differences Mohan Isaac, Mathew Samuel 151

19 Community Mental Health Service: An experience from the East Lille, France Jean Luc Roelandt, Nicolas Daumerie, Laurent Defromont, Aude Caria, Paula Bastow, Jugal Kishore 157 Specialty Section

20 Psychiatric Training in the Indian Armed Forces V.S. Subbarao Ryali, P. Shivram Bhat, K. Srivastava & K. Divinakumar 177

21 Psychiatry In Armed Forces: Special Issues In Management P. Shivaram Bhat, V.S. Subbarao Ryali, R. Shashikumar, Jyoti Prakash, S. Nath 187

22 Training in Child Psychiatry in India - A Review of Current Status and Recommendations Savita Malhotra 197 23 School Mental Health Program - Role of the Mental Health Professional Srikala Bharath, K.V. Kishore Kumar 203

24 Practicing Sexual Medicine - A primer for trainees T.S. Sathyanarayana Rao 213

25 Sexuality training in the West and its relevance to India Gurvinder Kalra 221

26 : Overview and Relevance in Post Graduate Training S. Nambi 233

27 Relevance of Forensic Psychiatry in Postgraduate Training Abhinav Tandon, Anil Kumar Tandon, T.S. Sathyanarayana Rao, Dushad Ram 237

28 Training in Geriatric Mental Health: Needs, Ways and Contents S.C. Tiwari, Anindya Das 271

29 Psychiatric Rehabilitation: Training for psychiatrists T. Murali and M.T. Sathyanarayana 285

Specialised Training

30 Psychiatric Interview Vihang N. Vahia, Ipsit V. Vahia, Amit Kulkarni 289

31 How to make a case presentation P.K. Dalal, Adarsh Tripathi, Anil Nischal 297

32 Teaching Post-graduate Psychiatry Through Clinical Rounds P.S.V.N. Sharma 305

33 About Professional Biomedical Journals K. Nagaraja Rao 313

34 How to read a research paper Sandeep Grover, Vineet Kumar 323

35 How to write a research paper Sandeep Grover, Archana Malik, Alakananda Dutt 333 36 How to carry out internet literature search: Basic tips Sandeep Grover, Archana Malik 347

37 Reshaping Journal clubs in Medical education: Enhancing learning Arun N.R. Kishore 353

38 in Psychiatry – An Overview Ganesan Venkatasubramanian, Naren P. Rao 365

39 Clinical Neurology for Psychiatrists – An Overview Naren P. Rao, Ganesan Venkatasubramanian 369

40 Redefining Psychological Assessment for Contemporary PG Clinical Training Programs in Psychiatry across India S. Venkatesan 375

41 Clinical Psychology Training in India L.S.S. Manickam 395

42 : What do post-graduate psychiatric residents need to Know? Suresh Bada Math, Janardhanan Narayanaswamy, Dhanya Raveendranathan 401

43 Relevance of Genetics to the Psychiatric Post Graduate Curriculum Smita N. Deshpande 419

44 Metabolic Syndrome with Special Reference to Schizophrenia Shiv Gautam, P.S. Meena, Anita Gautam, Manaswi Gautam, I.D. Gupta 423

45 Post graduate psychotherapy training can rise from the ashes Anna Tharyan 439

46 Psychodynamic – Where are they today? Anurag Srivastava 443

47 Clinical Viva: What is it after all? Sujata Sethi 457

48 Culture and its impact on diagnosis and management of mental disorders: The cultural formulation K.S. Jacob, Anju Kuruvilla 463 49 Role of Continuing Medical Education (CME) Programs in Psychiatric Training Rajesh Nagpal 477

50 The role of mentoring for trainees T.S. Sathyanarayana Rao 481

51 Psychiatry Unbound Raghuram 487

52 Management of Uncooperative Patient H. Chandrashekar, N.R. Prashanth 491

53 Alternative and Complementary Health Practices in postgraduate psychiatry training K.S.Pavitra 501

54 Ayurvedic concepts of mental disorders and their management Anuradha Nadkarni, Smita N Deshpande 509

55 Understanding of Human Emotions Dushad Ram, Abhinav Tandon, M.S. Darshan, Payel Roy 527

56 Importance of networking during psychiatric training S. Kalyanasundaram 547

57 Organicity in Psychiatry: Pitfalls and Strategies Charles Pinto, Alka A. Subramanyam 553

58 Assessment and management of acute alcohol intoxication Narayana Manjunatha, Deepak Jayarajan, Vivek Benegal 563

59 Acute Management of Alcohol and Opioid Dependence Vishal Indla 571

60 Clinical Evaluation of Suicide and Related Issues P.B. Behere, S.M. Reddy 587

61 Psychiatric Emergencies: Recognition and General Management in Psychiatric and Medical setup Sanjay Kumar Munda , Dushad Ram 597

62 Risk & its Assessment in Psychiatry Rajeev Krishnadas 613 63 Critical Care In Psychiatry Debjani Bandopadhyay, Gautam Saha, Om Prakash Singh 631

64 Measuring Disability and Functioning R. Thara 637

65 Expanding horizons of psychiatric social work V.S.T. Krishna, Nawab Akhtar Khan, T.S. Sathyanarayana Rao 643

66 ABC of Training for Psychiatrists: Carer's Perspectives Nirmala Srinivasan 655

67 Media and Mental Health Harish Shetty 657

68 Good Psychiatric Practice: A primer for psychiatric trainees and professionals Prathap Tharyan 663

69 Good Clinical Practice - Key ethical issues in clinical trials in psychiatry in India Sudipto Chatterjee & 679

70 'Four Principles' approach to medical ethics Nicholas A. Deakin MA, Dinesh Bhugra 689 Trainee Perspectives

71 Expectations from a training program in psychiatry: A trainee's viewpoint K.R. Aarya 699

72 Trainee Perspectives of Psychiatry: Training at NIMHANS Santosh K. Chaturvedi, Prabha S. Chandra, Nishanth Jayarajan, G.S. Ramkumar, Smita Manjunath, Satish Kumar Budania 703

73 Expectations of a psychiatry resident Anoop Raveendran 713

74 Trainee Perspectives of Psychiatry R.J. Bishnoi 717

75 Of all the dreams- 'I chose this' M.S. Darshan 719 Reminiscences

76 The All India Institute of Mental Health, Bangalore in the 1950s O. Somasundaram 723

77 Post graduate training in Psychiatry in sixties - Reminiscences A.K. Agarwal 729

78 Changing Perspectives in Psychiatric Practice James T. Antony 735

79 Reminiscences on Psychiatric Training: Then and Now J.W. Sabhaney 741

80 Psychiatric Training - Then and now P.C. Shastri 745

Influential Teachers

81 Girindrasekhar Bose and Psychiatric Education Arabinda Brahma & Gautam Bandhopadhyay 749

82 Prof. Narendra Nath Wig - A man ahead of his time R. Srinivasa Murthy 753

Appendix - Psychiatric Courses 777

Index 781

Editorial 1 Psychiatric Training

T.S. Sathyanarayana Rao, G. Swaminath & G. Prasad Rao

Psychiatry and Psychiatrists

There are probably as many public misconceptions of what psychiatrists actually do as there are about the training needed to become one. The cliched picture of the bearded man, nodding sagely by a patient flat out on the couch, is rather difficult to shift. Sometimes psychiatrists are confused with psychologists or counsellors or, worse still, regarded as eccentric therapists without proper medical qualifications who practise their spurious brand of “treatment” on a gullible public. However, in fact, psychiatry usually attracts committed individuals with a desire to make a positive mark in a specialty which can be one of the most stimulating, interesting, and rewarding in medicine. 1

Like all medical specialists, psychiatrists are doctors first and specialists second. Thus, psychiatry is emphatically a medical career, and shares with other medical disciplines the authority to prescribe drugs and recommend treatments. 1 Through work in the area of evidence based medicine, together with the reliability of its outcome measures, psychiatry has proved that it is as clinically effective as any other medical specialty. 1

Psychiatrists develop skills which help people to cope with their mental health problems, enabling them to make progress towards a solution after other help has failed. People with mental illness are often extremely unhappy and difficult to reach; may feel cut off from the rest of the world and find it almost impossible to have trust or confidence in anyone. Their psychiatrist can be the one person who can make a difference and can give hope at the most despairing times. While cures are often difficult to effect, psychiatrists can make an enormous contribution to improving the quality of life of their patients, reducing their symptoms and distress and making an impact on their social conditions. 1

Because of the nature of their work, psychiatrists draw heavily on the social sciences, in particular sociology and psychology. This makes the specialty 2 Psychiatry in India : Training & training centres attractive to those of an inquisitive and thoughtful disposition. An innovative and creative mind is required, together with patience and well developed problem solving skills. A leaning towards detective work can be helpful, since piecing together the clues to a (hopefully) satisfying end is a regular task. 1

Psychiatry offers the opportunity for doctors to try to understand very complicated phenomena. Trying to make sense of the seemingly incomprehensible is intellectually challenging; patience is also a crucial requirement. Some complex questions have no straight forward answers, so coping with uncertainty is an important skill, which can be developed over time. Psychiatry is particularly an appropriate choice for doctors who enjoy listening and learning about the infinite variety of human behaviours, close working relationships with patients, and for whom uncertainty is a challenge rather than an irritant. 1

The speciality of Psychiatry is becoming more responsive to changes with significant development over recent years with expansion of knowledge in molecular biology, neurobiology, genetics, cognitive neurosciences, neuro- imaging, psychopharmacology and other related fields contributing to the growth of psychiatry; a number of new methods of teaching and training are being tried in many countries. 2

Mental health and training

The burden of mental illness in India is enormous. As per the Government of India's National Commission on Macroeconomics and Health Report of 2005, the prevalence of 'serious' mental illness in the Indian population is at least 6.5%, roughly translating to 71 million people. 3 There are only around 4000 psychiatrists to serve this huge burden.4 The estimated deficit of psychiatrists in India, based on the available number of psychiatrists and the ideal number required (1 psychiatrist per 100,000 population) revealed the average national deficit of psychiatrists to be 77% with 17 states / union territories below this average. 3 This is based on 2001 census and could be worse now given the continuing expansion in population coupled with minimal increase in psychiatrists over the last decade. 3

The importance of postgraduate teaching and training in forming the knowledge base for future medical specialists is widely acknowledged. 2 A good psychiatrist, however, must not only be well-informed but also find a workable balance between the toughness necessary to face up to difficult and even threatening behaviour on a regular basis, while at the same time retaining sensitivity, compassion, and first rate interpersonal skills. Such a career is by no means easy, but the rewards can be great. 1 Psychiatric training imparts the trainee with the relevant theoretical knowledge and assists him Rao et al : Editorial: Psychiatric Training 3 to develop practical and clinical skills and attitudes, including communication skills, training in research methodology, and thesis writing skills.5 It empowers him to be able to deal with complex cases.

With an increase in the incidence and prevalence of mental disorders, the need for having more psychiatrists and trained professionals therefore becomes inevitable as these doctors will not only play a pivotal role in reducing the burden of mental disorders but also being imparters of knowledge and skill to trainees, students and other multi-disciplinary staff; they will increase the repertoire of knowledge amongst a rapidly evolving speciality. 2

The first M.D. Psychiatry course was started by Medical College at Patna in 1941 and the first M.D. Candidate was late Prof. L.P. Verma, Past President of I.P.S. and Past Editor of Indian Journal of Psychiatry and Neurology. 5 Since then Psychiatric training centres have played an important role in churning out qualified graduates most of whom have migrated to different corners of India, providing service. However the deficit is still huge and the present centres are unable to bridge the gap.

Training posts are spread across various state medical colleges. There are a few central institutions that offer postgraduate training, namely: the National Institute of Mental Health and Neurosciences (NIMHANS) in Bangalore; Post Graduate Institute of Medical Education and Research (PGIMER) in Chandigarh; All India Institute of Medical Sciences in Delhi; and Central Institute of Psychiatry in Ranchi. Training in these institutions, including some centres in Mumbai and Chennai, are highly sought after. Standards of training vary across institutions but training standards in some institutions are high. 6

As on 14th Dec 2014, there are 160 Medical Colleges and Postgraduate Institutes, which admit 371 M.D. degree students in Psychiatry each year, besides which, 59 Medical Colleges have training facilities for 125 D.P.M. students. In addition 50 to 60 Postgraduates appear for D.N.B. of the National Board of Examination. This is a remarkable achievement when compared to the past. From 1947 to 1967 there were only six institutes in India offering postgraduate degrees (MD), and from these centers about 14 psychiatrists qualified as MDs. 5 There are 83 centres offering MD (psychiatry), 46 centres offering Diploma in Psychological Medicine (DPM) and 22 centres offering Diplomate of National Board. Strikingly, 25% of the medical colleges in India do not have a Psychiatry Department. 4

Training to be a psychiatrist

Postgraduate training in psychiatry, like most other specialities, is on a 3-year residency system with an exit exam leading to the degree of Doctor of 4 Psychiatry in India : Training & training centres Medicine (MD); 2-year diploma courses are run by a small number of institutions. Competition to undergo postgraduate training is intense, with limited training posts available. Entry to postgraduate training in all specialities is via entrance examinations conducted by each state and also by a countrywide common entrance examination. Some central institutions, highly regarded for their training, conduct their own entrance examinations. 6

Trainees rotate through out-patient and in-patient and on-call placements with training hours not regulated and can be lengthy and antisocial. 6 There are positive aspects of the training scheme in that it is structured with a clear time frame of 3 years, with emphasis on compulsory research in the form of a MD thesis which the trainee has to complete in order to achieve the degree. This involves a research project, which the trainee plans, executes and writes up under the guidance of a supervisor from within the same department. 6

However, one of the glaring deficits is the lack of uniformity in the training offered by various institutions, with training in some institutions comparable to the best in the world and training in others being poor7. Also, there is a paucity of supervisors/consultants with formal training and expertise in various forms of psychotherapy8 and few centres provide sub-speciality services for training.

The aim of this supplement was to bring the focus of the psychiatric community on psychiatric training as well as training centres. Psychiatrists trained in India make their mark wherever they go. Psychiatric Institutions providing training to mental health professionals have been 'iconic'. It is time to acknowledge the superb effort of our institutions which have integrated clinical care, training and research as well as mentored outstanding trainees sought after all over the world.

Psychiatry is still an evolving speciality in India. There is an organised and well-proven postgraduate training programme; however, the number of training places and psychiatrists is low. Training in sub-specialities of psychiatry is in its infancy. Services are both hospital and private sector based. In terms of providing psychiatric care, there is a need for a more coherent and involved policy from the government and national bodies (i.e. The Indian Psychiatric Society) alike. There is need to evolve a consistent national programme of training. The Indian Psychiatric Society — needs to be more involved in the process of training and services planning.

REFERENCES:

1. Dean A. Career focus Psychiatry. BMJ 1996; 313 : S2-7071 2. Javed MA, Ramji MA, Jackson R. The changing face of psychiatric training in the UK. Indian J Psychiatry 2010;52:60-5 Rao et al: Editorial: Psychiatric Training 5 3. Thirunavukarasu M, Thirunavukarasu P. Training and National deficit of psychiatrists in India - A critical analysis. Indian J Psychiatry 2010;52:83-8 4. Mohandas E. Roadmap to Indian Psychiatry. Indian J Psychiatry 2009;51:173-9 5. Sharma S. Postgraduate training in psychiatry in India. Indian J Psychiatry 2010;52:89-94 6. Das M, Gupta N, Kavitha N. Psychiatric training in India. Psychiatric Bulletin 2002;26: 70-72 7. K Kuruvilla, Editorial: Towards Greater Integration With Other Medical Specialities. Indian Journal of Psychiatry 1996; 38(4):194-195. 8. Pratap Sharan, Book Review: A Textbook of Psychoanalitically Oriented Psychotherapy : Theory and Technique, Au. Shakuntala Dube; Indian Journal of Psychiatry, 1998; 40, 3; 306.

T.S. Sathyanarayana Rao Prof. & Formerly Head, Department of Psychiatry, JSS University, JSS Medical College Hospital M.G. Road, Mysuru - 570004. www.indianjpsychiatry.org E-Mail: [email protected], [email protected]

G. Swaminath Department of Psychiatry, Dr B R Ambedkar Medical College Kadugondanahalli, Bangalore.- 560045, Karnataka, India [email protected]

G. Prasad Rao Consultant Psychiatrist Director, Schizophrenia & Psychopharmacology Division, Asha Hospital, Hyderabad [email protected]

2 Psychiatric Education in India: Past, Present and Future

Shridhar Sharma

ABSTRACT

The review provides historical information and evolution of psychiatric education with regards to undergraduate and postgraduate training in Psychiatry in India. It also gives latest information about psychiatric education and suggests useful parameters as guidelines for future developments in the field.

Information about undergraduate and postgraduate Psychiatry education in India preceding 1947 is largely unavailable. However, modern medical education in India began in 1822 in a medical school at Calcutta. The medium of instruction was the language of the region, into which English medical books were translated. In the year 1833, Lord William Bentick, the then Governor General of India, appointed a Committee to examine the question of medical education in India. The committee recommended the abolition of the medical school and the establishment of a medical college in its place. Consequently, in the year 1835, two medical colleges were started in India - one in Calcutta and the other in Madras. The duration of the medical course was four years, which was later extended to 5 years in 1845.1 Till 1946, there were only 16 medical colleges and by 1949, the number increased to 29 and in 1958 there were 50 medical colleges. As on 14th Dec 2014, the number has increased to 398 with an annual admission of 51955 undergraduate students.2

The Indian Medical Council Act No. XXVII of 1933 was brought into force on the 1st of November, 1933 and the Medical Council of India (MCI) was constituted there under on the 15th of February, 1934. From time to time, amendments have been made in this Act. The council, initially, was primarily concerned with undergraduate medical education. Before the establishment of Medical Council of India, the General Medical Council of Britain was inspecting the standards and facilities of Medical Colleges and Schools in India.1 8 Psychiatry in India : Training & training centres Interestingly, even before the MCI was established, the first survey to ascertain what facilities existed to acquire some knowledge in Mental disorders was done by Col. Berkeley Hill (1932)3 from European Hospital (now Central Institute of Psychiatry), at Ranchi in 1931 (in undivided India). Information was obtained from 14 Medical Colleges and 25 Medical Schools and only 2 colleges did not respond to the questionnaire. The number of lectures devoted to the field varied from no teaching to 20 lectures and clinical work in Mental Hospitals ranged from 7 days to 30 days. All the colleges were devoid of competent Psychiatrists and the training was restricted to Mental Hospitals.4,5

There was also some effort to form an association of mental health workers in this country during the same period. Much earlier, due to the pioneering efforts of Col. Berkley-Hill, Medical Superintendent, European Hospital, Ranchi, an association known as the Indian Association for Mental Hygiene was formed in 1929, which was affiliated to the National Council for Mental Hygiene in Great Britain, was formed. The aims and objects of this association were to encourage the study of the mental health of the community with a view of “(a) removing those factors which militate against good mental health; (b) combating the prevailing ignorance regarding mental disorders and (c) improving the psychological environment of both children and adults”. This association did valuable work and published a quarterly bulletin for a number of years, after which it ceased to exist. Membership of this association was open to all persons interested in the above aims and objectives.6

Later efforts to form an exclusive association of psychiatrists in this country was made by Dr. Banarsi Das, the Superintendent of Mental Hospital, Agra, in 1935. He wrote personal letters to the Medical Superintendents of Mental Hospitals of the country on the 24th of June, 1935, suggesting that a Conference of the Indian Psychiatrists be held to serve as a forum for the exchange of ideas as well as act as a clearing house of administrative experience.6

The first mention of a proposed Indian Division of the Royal Medico- Psychological Association (RMPA) occurs in the records of the RMPA in 1936, when the Association's Council gave sanction of the Division to be formed. However, there was some delay in getting the Indian Division of the Royal Medico Psychological Association (RMPA) started and the first meeting was not held until January in 1939. This meeting was attended by 20 Psychiatrists under the Chairmanship of Lt. Col. Lodge Patch, from Punjab Medical Hospital in Lahore and Dr. Banarasi Das from Agra.

According to information supplied by Dr. Alexander Walk, Honorary Librarian Sharma: Psychiatric Education in India 9 of the RMPA, the first Chairman of the Division was Dr. C. J. Lodge-Patch, and the first Secretary was Dr. Banarsi Das. In accordance with the Bye - Laws the Division was entitled to four representatives on the Council of RMPA (including the Chairman) and these were - Drs. C. W. Will, J.E. Dhunjibhoy and Moore Taylor.

The Indian Division had another meeting which was held at Agra in November, 1941. This was the "Second Triennial Meeting". At this meeting Dr. Banarsi Das was elected Chairman Major Moore Taylor from Ranchi Secretary. In 1944, after Dr. Banarasi Das's death, Major Moore Taylor became the Chairman and colonel B.P. Bhattacharya, the Secretary.

After the formation of Indian Psychiatric Society in 1947, the Indian Division of the RMPA, accordingly, was declared dissolved.

The emergence of Psychiatry as a specialty in India was heralded in 1947 with the birth of the Indian Psychiatric Society. In the same year the Society ap- pointed a committee on postgraduate psychiatric education but a committee on undergraduate teaching of psychiatry by Indian Psychiatric Society was for the first time appointed only in 1962. This sub-committee was required to go into the problems connected with the teaching standards in Psychiatry at the undergraduate level and make necessary recommendations. The report of this committee gave a survey of the undergraduate teaching of Psychiatry in 1963, based on the questionnaires circulated to the 56 medical colleges. Out of these, only 35 medical colleges responded and of these 11 medical colleges had no teaching facilities in Psychiatry. The completed questionnaires were received from 22 institutions out of 56 medical colleges. The survey further revealed that at that time the number of lecture hours in mental health varied from 10 to 40 hours during the entire undergraduate medical course with an average of 20.5 hours and the clinical work in Psychiatry ranged from 5 to 35 hours with an average of 7 hours. Interestingly, in this report too, there was no mention of teaching of Psychiatry in general hospitals and whether this teaching should be established in general hospitals or mental hospitals was left unanswered. A careful review of the survey further revealed some very interesting features - firstly it showed that the number of hours devoted to theoretical lectures was much higher than the clinical work. Secondly, it did not mention teaching of Psychiatry in a general hospital setting. Even the recommendations of this committee, which were published in the Indian Journal of Psychiatry in 1965, failed to mention how these recommendations were going to be implemented, except stating that there should be increase in both clinical work and theoretical lectures at the undergraduate level.7,8

Later, in November, 1965, a meeting on undergraduate teaching in Psychiatry was organised under the joint auspices of W.H.O. and the Directorate General 10 Psychiatry in India : Training & training centres of Health Services, Government of India, at Central Institute of Psychiatry at Ranchi.9 In this meeting not a single paper focused on the implementation of various curriculum, except one paper by Dr. C.C. Saha on Methodology of Psychiatric Teaching, which stressed that the teaching should be started in the first year and should continue till the end. Till very recently, there was never any serious attempt to implement the various recommendations made by the professional societies, like Indian Psychiatric Society and other academic bodies.

However, during the last few decades, forces within and outside the field of medicine are impelling new trends in psychiatric services.10-13 One of the major trends during the last few decades is a change from "closed" to "open" system of psychiatric care with the resultant change from traditional custodial, secluded mental hospital system to an open system with a wide range of flexibility. One of the consequences of the change was the opening of general hospital psychiatry which was a positive addition to traditional mental hospital system.

In 1976, in a review of Psychiatric facilities in India , it was observed that there was significant increase in such facilities and the number of psychiatric units in general hospitals increased to 76, in contrast to 25 mental hospitals, which had undergraduate teaching programme.14 From the latest figures of Dec 2011, out of 335 medical colleges in the country over 133 medical colleges have MD post-graduate psychiatric training facilities and almost 90 per cent have some Psychiatric facility or the other.15 The other significant change which has taken place since our independence in 1947 is the increase in the number of medical colleges. In 1947 we had 19 medical colleges only. However, after independence, the Government was determined to tackle the health problem and medical education at a nation-wide level and in the first five year plan in India, it increased its medical colleges from 30 to 43. The beginning and end of the five year plans are vital dates in our nation's history. Each five year plan is an assessment of the past and a call for the future. It seeks to translate into practical action the aspirations and ideals of the over 1.1 billion population of the country. The rapid expansion of medical education is un-paralleled anywhere in the history of the world medical education. A review of this progress is relevant as the increase in the psychiatric beds and the teaching programme in mental health is not consistent with the progress in other fields. It was only after mid-sixties that we have seen an increase in both quantity and quality of teaching at undergraduate level.16,17 The need for this increased quantum of mental health education became more apparent at every national conference on medical education, which clearly recognized the need for a change in the existing system of medical education and also that the education should be need- oriented. In one of the national conferences on medical education held in Sharma: Psychiatric Education in India 11 New Delhi in 1971, it was emphasized that psychiatry was gaining due importance and a strong foundation of the subject had to be built at the undergraduate level.

Today, the medical educationists of our country and our health planners are sensitive about the need for a change and also the importance of mental health to meet the health needs of the people.We are aware that the important objective of medical education anywhere is to produce good and competent doctors according to the need of the community they serve, at that particular time and place. We also know that the needs of the community are not static but flexible and correspondingly the problems are also different in different parts of the world. In India, like some other developing countries, medical education has reached a stage in its history when deviation from the traditional structure of the past has become imperative. It is a truism that the curriculum of 40-50 years ago was best suited for the needs of those days. The scientific revolution that has occurred in the interim period, with phenomenal growth both in knowledge and technology coupled with the greater availability of funds for research, has had an improved effect not only in the curriculum and teaching methods but also in the delivery of the health care system. This builds the need for setting up of innovative models in medical education and a consequent mental health delivery system for the future. As society changes its needs, the medical schools are also called upon to function differently to meet these needs. To prepare physicians for the needs of tomorrow, it is imperative to develop a new curriculum and include mental health within its folds. Many of the desired changes are not easy to implement due to varied reasons. The obstacles are broadly grouped as- (a) Dynamic Conservatism, the homo-static tendency of individuals and institutions to try to keep things as they are (b) Institutional bureaucracy -is a social invention perfected during the industrial revolution and it is today the prevailing and supreme type of organization, which acts as a powerful barrier, (c) Sheer Complexity - any change in educational programme is a complex undertaking and it requires both time and expertise to bring about the necessary changes (d) Lack of institutional drive - this is closely related to the complexity of the problem, and the lack of models. Perhaps no factor plays as important a role in promoting change as examples of successful changes for others to see.

Many centuries ago one of the well known saints of India, Vaghbhat had said "we must move with time and if we do not move we perish". This change of moving is a dynamic and continuous process and as mental health experts we are, perhaps, in a better position to understand this than other medical teachers.

To implement the various recommendations and to fulfill the various lacunae 12 Psychiatry in India : Training & training centres in the existing mental health curriculum at the undergraduate level, it is necessary for psychiatrists and all concerned in the field of medical education to understand the role of factors necessary to bring about the change – including rapid progress of medical science, the needs of the society and the consequent environmental changes in the society. There are many obstacles to the execution of such change, such as lack of educators, lack of enthusiasm from those concerned, or lack of pressure from various governmental agencies and even lack of reaction of students for such a change which influences all, jointly or separately. In this context it is necessary for us to stimulate the students who can be powerful agents of change because they with their keen reactions can be stimulated to cooperate closely with teachers in any discipline in medical education. Before this change can be implemented, three questions need to be raised - (l) what is the minimum amount of knowledge the student must acquire and what is the justification to arrive at such conclusion, (2) how is evaluation to be done in the fast changing scientific environment, (3) how clinical education should be evaluated in relation to the needs of the patients or the community. These questions are not new and have been asked in the past, but we all know that medical education is basically a mission-oriented endeavor which is influenced by social, scientific and technological advances.

The extent to which undergraduate medical students should be trained to impart mental health care would naturally vary with the availability of resources and the acuteness of the need. Nevertheless, whatever the extent, the content of the training would contain the basic principles necessary for the practice of mental health in the community and should focus on develop- ing:

a) diagnostic skills to detect common mental health problems of the population;

b) therapeutic abilities to deal with them independently;

c) ability to selectively refer patients to the specialist;

d) psychosocial orientation towards all health problems in the community; and

e) ability to further train community health workers and other paramedical personnel.

There are no well-thought-out answers to questions of duration and site for training but the answers will depend on the selective priorities and defining their tasks. Once we have identified their tasks, a suitable training programme can be developed and efforts are already underway to answer Sharma: Psychiatric Education in India 13 some of these questions.

Postgraduate Training in Psychiatry

Specialist training in any subject builds upon basic undergraduate training and general clinical training and leads to continuing education. Though undergraduate medical training in modern medicine started in 1835, the first postgraduate training in Medicine started only in 1913 and later it was followed in surgery and obstetrics and gynecology. The first M.D. Psychiatry Course started in 1941 in Patna University but Postgraduate training programme got major impetus with the establishment of All India Institute of Mental Health (now NIMHANS) at Bangalore in 1955 and Central Institute of Psychiatry in Ranchi in 1962, and other Universities and institutes like AIIMS, New Delhi and PGIMER at Chandigarh.18

Training of Clinical Psychology, Psychiatric Social Work and Psychiatric Nursing

It may be of relevance to add that in NIMHANS, Bangalore and Central Institute of Psychiatry, Ranchi, both under the Government of India, a good beginning was made to train postgraduate diplomas in the field of clinical psychology (DMCP), psychiatric social work and psychiatric nursing. This provided a sound base for mental health service and training programmes in India. Today, the training programmes are upgraded to the level of M. Phil. and Ph.D. in each discipline. There are at least 11 institutes which are offering M. Phil. which is recognized by Rehabilitation Council of India.

Today, there are 160 and 59 medical institutions providing postgraduate MD and DPM training in psychiatry. This is a remarkable achievement. Till 1967 there were only six institutes in India offering postgraduates degrees (M.D.) and DPM. However, there is no reliable data available on the number of doctors from India trained in the UK and USA, though figures from the Institute of Psychiatry, London, do give an indication of their number. From India alone 101 received training at Institute of Psychiatry at London in psychiatry between 1949 and 1966; they formed about 10 per cent of the total number of trainees during those years.19, 20,21 During the same period, some were trained in Canada and USA.

This trend is gradually changing and during the last four decades dramatic developments have taken place regarding the growth of Psychiatry. Today, it is obvious that like most other specialties, psychiatry is becoming increasingly specialized and diversified.

Psychiatrists have played a prominent role in shaping mental health programme and providing mental health care to the patients in each country. 14 Psychiatry in India : Training & training centres It is true for India. However, their influence is in part a byproduct of their own professional preparation. The information about the quality and quantity of training of psychiatrists trained from different centres is largely unavailable. Similarly, there is a wide variation in the training programme in spite of MCI regulations and guidelines. A constant need for introspection has arisen. How satisfactory the training in the changing social, economic and technological environment is an area which needs constant evaluation and improvement. Similarly, the mechanism to regularly incorporate the latest knowledge and skills in the curriculum and the data on such matters is not easily available in our country. There is a need to make serious efforts in this direction.20

Recently, WHO in collaboration with WPA (World Psychiatric Association) has brought out an interesting publication called "Atlas: Psychiatric Education and Training across the World 2005".21 It is a joint publication of WHO and the WPA. At the global level, the Atlas provides an overview of the situation and brings out the existing regional variation and reveals a general deficiency and a marked variability in training across the world. The report provides some useful data regarding the availability of mental health resources. The major limitation of the study was the low response rates from countries. The responses were received from 73 countries out of the 192 countries of the World. Even in the ones received, many of the key contacts were those who were not directly involved with the policies and implementation of Medical Education policy in their countries. This has given rise to some gross inaccuracies and faulty conclusions. To fulfill such a complex and difficult study, it is essential to include persons who are directly responsible for medical education and training in their country, and who are knowledgeable about laws and policies in the field of medical education and health services. The following parameters are suggested as useful guidelines for future studies:

(1) The structure and requirements of the health care delivery system in each country,

(2) The number of Medical Colleges and Public Private Institutions and how their standards are regulated,

(3) The role of legal and other accreditation bodies like MCI established under the law of the land, who define and set standards of post-graduate medical education in the universities and the medical institutions, who maintain and implement standards and impart training.

It needs to be emphasized that the goal of post-graduate training in all specialties, including the field of Psychiatry, is to produce competent and knowledgeable specialists and teachers, who can meet the needs of the Sharma: Psychiatric Education in India 15 community, carryout professional obligations ethically and are aware of contemporary advances in the discipline with some foundation in the principles of research methodology.

There are some established systems of the education system which are applicable to the field of postgraduate training in medicine, including psychiatry, and which can be usefully incorporated to help in this direction viz. (a) Uniform admission policies, (b) some uniformity in the content of the training programme, (c) the organization of the curriculum, which can be evaluated regularly (d) the outline of the training programme including the standard methods of instructions, (e) objective assessment methods, and uniformity in examinations (f) to develop acceptable guideline regarding the relationship between the institution/College/University and the external, national or International licensing bodies.

Today, specialists licensed in one country rarely have extended practice and privileges in another country. In some countries, the license is even restricted to practice only in some provinces of the Country. The implications are obvious - that the assessment method should be harmonized within the country and some international standards need to be developed. WHO is an established body under the U.N.O. (United Nations Organization). Accordingly, WHO is a body which can take necessary steps to meet this goal. It is not an easy path but needs patience and sustained efforts to meet the challenge.

The WHO, whose primary mission is that of directing and coordinating International Health Work, should take vigorous steps to develop standards of medical education at undergraduate and post-graduate level and strengthen accreditation process. This will certainly improve the quality of health care.

REFERENCES

1. Patel CS. History of the Medical Council of India. M.C.I. Silver Jubilee Souvenir 1959, MCI, New Delhi, 1959. 2. MCI Website: http://www.mciindia.org/InformationDesk/MedicalCollegeHospitals/ ListofCollegesTeachingMBBS.aspx 11th Dec 2014 3. Berkeley Hill O.A.R. The place of Psychiatry in the Medical Colleges and Schools in India. The Indian Medical Gazette Vol. LXVII No. 10, Oct. 1932. 4. Berkeley Hill O.A.R. The Position of Psychology in the Teaching of Medicine. The Indian Medical Gazette, Vol. LXV No. 5, May 1930. 5. Berkeley Hill O.A.R. Psychiatry and General Medicine Part III Patna Journal of Medicine. Vol. VIII Jan 1933. 6. Sharma S, Nizamie SH, Goyal N. History of Indian Journal of Psychiatry. Indian J Psychiatry 2009; Commemorate Volume, 48-59. 7. Saha CC. Presidential Address. Indian J Psychiatry 1962; 4(1):32. 16 Psychiatry in India : Training & training centres 8. Indian Psychiatric Society First Report of the Subcommittee on undergraduate Teaching in psychiatry. Indian J Psychiatry 1965; 7(1): 63-72. 9. D.G.H.S. Proceedings of the Curriculum Committee on Undergraduate Teaching in Psychiatry, Directorate General of Health Services (DGHS), Ministry of health & Family Planning, New Delhi pp. 65-66, 1965. 10. Sharma Shridhar. General Hospital Psychiatry and Undergraduate Medical Education. Indian J Psychiatry1984; 26(3): 259-263 11. Bhaskaran K. Editorial, Undergraduate Training in Psychiatry and Behavioural Sciences – The need to train the trainers. Indian J Psychiatry 1990; 32(1): 1-3. 12. Reddy IR. Undergraduate psychiatry education: Present scenario in India. Indian J Psychiatry 2007; 49(3): 157-158. 13. Dale JT, Bhavsar V, Bhugra D. Undergraduate medical education of Psychiatry in the West. Indian J Psychiatry 2007; 49(3): 166-168. 14. Sharma SD. Psychiatric facilities in India. Rural Mental Health Published by Indian Psychiatric Societies at Sevagra, Wardha on 13 Feb. 1976. 15. Sharma S. Postgraduate training in Psychiatry in India. Indian J Psychiatry Supplement January 2010. 16. Murthy RS, Khandelwal S. Undergraduate training in Psychiatry: World perspective. Indian J Psychiatry 2007; 49(3): 169-1174. 17. Manickam LSS, Rao TSS. Undergraduate medical education: Psychological perspectives from India. Indian J Psychiatry 2007; 49(3): 175-178. 18. Kulhara P. Postgraduate Psychiatric Teaching Centres: Finding of a survey. Indian J Psychiatry 1985; 27(3): 221-226. 19. Sharma Shridhar. Postgraduate Training in Psychiatry in India. The Bulletin of the Royal College of Psychiatrists, London Oct. 1979; pp. 154-156. 20. Thirunavukarasu M, Thirunavukarasu P. Retrospective introspection. Indian J Psychiatry 2009; 51(2): 85-87. 21. WHO Atlas Psychiatric Education and Training across the World 2005, WHO Geneva 37, Switzerland, 2005.

Shridhar Sharma Emeritus Professor, National Academy of Medical Sciences and Institute of Human Behaviour & Allied Sciences D-127, Preet Vihar, Delhi 110092. [email protected] 3 Undergraduate Psychiatry

B.S. Chavan, A.R. Rozatkar

Many academic psychiatrists perceive the need to strengthen undergraduate training of psychiatry.1-6 This justification is based on (a) high prevalence of mental health problems in India,7 (b) high percentage of patients reporting to primary care have psychological problems,8 (c) patients with mental illness frequently report to physicians,9 (d) high prevalence of co-morbid mental health problems and substance abuse in those with physical illness, (e) after achieving better control of infectious disorders , there is increased concern about lifestyle related disorders (diabetes mellitus and hypertension) wherein stress and psychological problems play crucial role (f) better under- graduate training will decrease stigmatization of the mental health profession and mental health services,6,10 (g) doctors would have better communication skills when well trained in psychiatry.4,11

World Health Organization (WHO) Alma-Ata declaration12 states that “attainment of highest possible level of health (including mental health) is most important world-wide social goal'. In spirit of the Alma Ata declaration, WHO has observed that many common mental disorders can be managed at primary health care level.8,13 In accordance, WHO has also published ICD- 10 Primary Care for primary care practice (ICD-10 PC Chapter V).14 In India, the National Mental Health Programme (NMHP) and the District Mental Health Programme (DMHP) intend to incorporate mental health care in primary care. It is, however, apparent that unless the physician is well trained to diagnose and treat common mental disorders, such programmes are unlikely to achieve expected results.

Training in psychiatry and behavioural science during under-graduation medical studies has significantly changed in most western nations.4,15 This change was eminent with the recognition that behavioural problems can lead to significant problems related not only to employment and acquiring new learning skills but also initiation and course of other medical and surgical disorders. Thus, in addition to de-institutionalization, incorporating knowledge and skills to manage behavioural problems during medical education is essential. The Medical Council of India syllabus for psychiatry 18 Psychiatry in India : Training & training centres recommends 20 lectures and 2 weeks posting in psychiatry.16

The current scenario of psychiatry in India can only be deplored. Possibly, it is the only branch to be viewed as loosely scientific and ineffective by medical students.17 Although this doubt is expressed only by a few; no one doubts in a similar manner about other clinical branches. This professional stigmatization adds to the already existing societal stigma which is detrimental for mental health services.18

Professionals,1-3,5,6 various committees/ reports (Bhore committee 1946, Shrivastav committee mid-1970's, Bajaj committee 1986, Kacker committee 1992, Majumdar 2004)5,19 and professional bodies (Indian Psychiatric Society19, World Psychiatry Association11) have advocated the need to improve undergraduate training in psychiatry. Seminars and national workshops have been conducted at CIP- Ranchi (1965), JIPMER- Pondicherry (1983) and AIIMS- Delhi (1994).19 Collectively the recommendations include (a) revising the curriculum and enhancing the quality of training: 60 hrs of lectures spread over all 4 years, independent theory and practical exam conducted by psychiatrist, clinical posting of atleast one month and 2 to 4 weeks internship in psychiatry (b) strengthening teachers in psychiatry: each medical college to have atleast one professor, one associate professor and two assistant professor/ Sr Lecturer (c) improved research in mental health care.

Very well said on paper, the ground realities remain unchanged. Recently, we have made sustained efforts with various authorities to take up the issue. Informal interactions have revealed some constant concerns of the authorities. This includes: Is our zeal to enrich undergraduate education justified? If so, how is it going to benefit the student? Is this going to benefit the discipline of psychiatry? With the current infrastructure, are we in a position to bring about this revolution? What are potential loop holes that we are over-looking? In this paper we attempt to make an argument for all these concerns. Undoubtedly additional remarks, in the form of comments, will further enrich understanding of this issue. Is our zeal to enrich undergraduate education justified? Neuropsychiatric conditions contribute to 21% of all disease burden of the world. The burden on families ranges from economic difficulties to emotional reactions to the illness, the stress of coping with disturbed behaviour, the disruption of household routine and the restriction of social activities.20 Physical illness may be consequence of maladaptive behaviours or may lead to psychological distress. Thus, disorders of the mind cannot be ignored in holistic medicine. Chavan & Rozatkar: Undergraduate Psychiatry 19 Experience suggests that understanding of psychiatric phenomenology among medical students is below average. It is not uncommon to find students rattling out classification of anti-psychotic drugs (possibly learnt in pharmacology) and then stumbling on elementary knowledge of schizophrenia. Interventions (pharmacological and psychotherapeutic) are viewed by students with scepticism. Electro-convulsive is assumed to be a last resort and drugs are expected to be effective immediately after ingestion! In the absence of practical exams for the subject, students trust concise notes on the subject for their theory exam and give complete disregard for clinical postings. The result, of the 40,385 undergraduate generated by the country every year,21 most are inept at diagnosis and management of even the commonest psychiatric disorders.

Studies have shown that very high number of patients with mental disorders report to primary care physician; usually with somatic complains.9,19 With improved training, these physicians would be better equipped in handling such cases. Referral to higher centres would be discrete thus reducing hassles of the patients and reducing load at the secondary centre. There would be savings in terms of unnecessary investigations and inappropriate drugs being prescribed but also lessening the morbidity of these disorders. Common psychiatric problems will be dealt by lesser stigmatizing professionals therefore maintaining continued care.

Similarly, if these students pursue other clinical streams their knowledge would help to send appropriate referral to psychiatric services. We can expect clinicians to promote behaviour modifications more effectively and take our help whenever required (eg quitting alcohol in those with alcoholic liver disease). This can have immense impact on management of life-style related disorders (hypertension, diabetes mellitus, smoking etc) that are becoming increasingly common in our population. Clinicians can move on to 'bio- psycho-social model' of illness rather than the currently practiced medical model. Additionally, communication skills of students will improve and there would be lesser likelihood of patients going doctor-shopping and hence improved client retention.

Improved training of medical students will also help handle stress at various points in life. Recently there have been instances where resident doctors have attempted and sadly some successfully completed suicide. If well trained in psychiatry, these residents suffering from any psychological stress for what- so-ever reasons would be more likely to approach psychological services. Of now, India produces 416 psychiatry degree holders and 129 diploma in psychological medicine holders per year.22 With the opening of 11 centres of excellence, this number is likely to increase to around 500 per year. The initial 6 months of MD course allows for orientation in psychiatry. In this period 20 Psychiatry in India : Training & training centres junior residents become familiar with phenomenology, assessment and reporting techniques, basics of psychological interventions and principals of biological and pharmacological management. Additionally, in initial 6 months they are supposed to submit a dissertation protocol. Unfortunately, without any understanding of basic concepts and insight into research methods used in psychiatry, the residents are unable to decide their research priority and end up taking simple topics of limited relevance.

A student trained in psychiatry during graduation will be forearmed with knowledge of symptoms, assessment (mental status examination), diagnosis and basic treatment principles. Thus orientation period will be drastically cut- down and junior residents can begin with academic or research activities. This will stimulate an environment of learning in the department in addition to early inclusion of junior resident into clinical service provision. Department may also consider opening additional services like community teams or special clinics. Over a period of time, and thankfully to recent allotment of funds to improve mental health services by Government of India, there would be enhanced quality in our research and clinical work. There will also be pressure on teachers to be familiar with and updated on recent concepts in psychiatry.

With the current infrastructure, are we in a position to bring about this revolution?

This is among the most serious concerns. Many medical colleges in India do not have a fully functional department of psychiatry4 & thus post the undergraduate students to mental hospitals. Posting to such institutions during early part of their career might lead to many misconceptions, thus stigmatizing the field of psychiatry. Those medical colleges that have psychiatry department have many shortcomings like inadequate inpatient facilities, inadequate full-time teachers or inadequate support staff (clinical psychologists and psychiatric social workers). Currently in the developed world, around 90 hrs to 240 hrs of teaching time is devoted to psychiatry and behaviour sciences.4 In addition clinical posting vary from 8 weeks to 3 months. In US (United States), clinical postings in psychiatry are equivalent to obstetrics and gynaecology and lesser than general medicine and surgery (both 12 weeks). In some countries where one intends to be primary practitioner additional training in psychiatry is required.

Indian Psychiatric Society has around 4000 members some of whom are not currently based in the country. Subtracting those who are in private practice and those at various levels of residency, let's assume that around 750 psychiatrists are qualified to teach psychiatry at undergraduate level. There are 398 MCI recognised Medical Colleges with MBBS courses being Chavan & Rozatkar: Undergraduate Psychiatry 21 conducted, all over the country, enrolling about 51,955 students per year.21 Even if there are two psychiatrists per college, each would have to invest anywhere between 30 to 40 hrs for undergraduate theory teaching! In addition there would be significant time invested in clinical posting teaching that could lead to reduced time for clinical services.

Another aspect would be conducting exams. With a maximum of 25 students to be examined on exam days and exams involving two internal and two external examiners, all Senior faculty members in psychiatry shall be on “exam duty” for 15-25 days per year. This would be an additional loss of time for clinical services.

What are potential loop holes that we are over-looking?

An evident problem of incorporating intensive psychiatry training in under graduation is that with current infrastructure, it would be taxing job for faculty. In places where the department provides for postgraduate degree/ diploma, the increased responsibility may shift the focus of psychiatry training towards undergraduates with possible neglect of post-graduate trainees. The other option of neglecting undergraduate training will only make matters worse than what already is. To avert such a scenario the number of psychiatry faculty must be increased much more than the recommended 'one professor, one associate professor and two assistant professor'. Consequently, medical colleges would require having structural changes (additional beds) and also increasing man-power (psychiatric nurse, social worker etc). Experience suggests that for almost all colleges this task will be daunting.

It has been quite a while since undergraduate psychiatry in its current form is in place. Before we bring about a change in the current system, it would be worthwhile to introspect. Have we done our best in whatever time is allotted to psychiatry? What efforts are we putting to make psychiatry familiar to undergraduate? Are we using methods that help them understand the subject (like audio/ video recordings)? It is easy to declare that our services are stigmatized- but are we continuously engaged in de-stigmatization of psychiatry within the hospital? These questions are important and require serious and urgent introspection.

In summary, to improve undergraduate training in psychiatry two things must happen simultaneously. Firstly, psychiatry must be made an independent subject and should have an independent exam conducted by psychiatry department. This shall help change the attitude of the student towards the discipline and enrich their clinical competence. Secondly, department of psychiatry in all medical colleges must be strengthened. For both of these to happen, we must continuously sensitize various authorities in all possible 22 Psychiatry in India : Training & training centres forums and communications. The benefit of these measures would finally be the person in distress and the society at large.

REFERENCES

1. Thiruavukarasu M. Psychiatry in UG curriculum of medicine: Need of the hour. Indian J Psychiatry. 2007 Jul-Sep;49(3):159-60. 2. Ghosh AB, Mallick A. Why should psychiatry be included as examination subject in undergraduate curriculum? India J Psychiatry. 2007 Jul-Sep;49(3):163-65. 3. Trivedi JK, Dhyani M. Undergraduate psychiatry training in South Asian countries. India J Psychiatry 2007. 2007 Jul-Sep;49(3):163-65. 4. Murthy RS, Khandelwal S. Undergraduate psychiatry: World perspective. Indian J Psychiatry. 2007 Jul-Sep;49(3):169-74. 5. Manickam LSS, Rao TSS. Undergraduate medical education: Psychological perspective from India. Indian J Psychiatry. 2007 Jul-Sep;49(3):175-78. 6. Shivanand K. Undergraduate clinical posting in psychiatry: Are we paying enough attention? India J Psychiatry. 2010 Apr-Jun;52(2):194 7. Math SB, Chandrashekhar CR, Bhugra D. Psychiatric epidemiology in India. India J Medical Research. 2007 Sep;126:183-92 8. Reddy I. Making psychiatry a household word. India J Psychiatry. 2007 Jan-Mar;49(1):10-18 9. World Health Organization. Mental Health Gap Action Programme (mhGAP): Scaling up care for mental, neurological and substance use disorders. Geneva: WHO Press; 2008. 10. Reddy JP, Tan SM, Azmi MT, Shaharom MH, Rosdinom R, Maniam T et al., The effect of clinical posting in psychiatry on attitudes of medical students towards psychiatry and mental illness in a Malaysian medical school. Ann Acad Med Singapore. 2005;34:505-10 11. World Psychiatry Association. World Federation of Medical Education [Internet]. 2010 [cited 2010 Dec 23]. Available from: http://www.wpanet.org/detail.php?section_id =7&category_id=81&content_id=109 12. World Health Organization. Declaration of Alma-Ata [Internet]. 2010 [cited 2010 Dec 23]. Available from: http://www.who.int/hpr/NPH/docs/declaration_almaata.pdf 13. World Health Organization. Organization of Mental Health Services in Developing Countries: Sixteenth Report of the WHO Expert Committee on Mental Health. Technical Report Series 564. Geneva: WHO Press; 1975. 14. World Health Organization. Diagnostic and Management Guidelines for Mental Disorders in Primary Care: ICD-10 Chapter V Primary Care Version. Geneva: WHO Press; 1996. 15. Dale JT, Bhavsar V, Bhugra D. Undergraduate medical education of psychiatry in west. Indian J Psychiatry. 2007 Jul-Sep;49(3):166-68. 16. Medical Council of India. Salient features of graduate medical examination, 1997 [Internet]. 2014 [cited 14th December 2014]. Available from: http://www.mciindia.org/ RulesandRegulations/GraduateMedicalEducation Regulations1997.aspx 17. Jugal K, Mukherjee R, Parashar M, Jiloha RC, Ingle GK. Beliefs and attitudes towards mental health among medical professionals in Delhi. Indian J Community Med [serial online] 2007 [cited 2007 Nov 30];32:198-200. Available from: http://www.ijcm.org.in/text. asp?2007/32/3/198/36827 18. Sartorius N, Schulze H. Reducing the stigma of mental illness. A report from a global programme of the World Psychiatry Association. New York: Cambridge University Press; 2005. 19. Reddy I. Undergraduate psychiatry education: Present scenario in India. Indian J Psychaitry. 2007 Jul-Sep;49(3):157-58. Chavan & Rozatkar: Undergraduate Psychiatry 23 20. World Health Organization. World Health Report 2001. Mental Health: New understandings new hope. Geneva: WHO Press; 2001. 21. Medical Council of India. List of colleges teaching MBBS [Internet]. Last Accessed: 14th Dec 2014. Available from: http://www.mciindia.org/InformationDesk/Medical CollegeHospitals/ListofCollegesTeachingMBBS.aspx 22. Medical Council of India. List of colleges teaching PG courses [Internet]. Last Accessed: 14th Dec 2014. Available from: http://www.mciindia.org/InformationDesk/ForStudents/ ListofCollegesTeachingPGCourses.aspx

B.S. Chavan Professor and head Department of psychiatry, GMCH- Chandigarh [email protected]

A.R. Rozatkar Senior Resident Department of psychiatry GMCH- Chandigarh

4 Psychiatry training during internship: Can we make it better?

Rajan Nishanth Jayarajan & K.S. Shaji

ABSTRACT

Undergraduate training in psychiatry needs to be improved. We must make best use of the two weeks training in psychiatry, which is now mandatory during internship. This calls for a review of the undergraduate program and efforts to strengthen it. Aim: Development of a training module to impart knowledge and skills needed for management of mental health problems in non-specialist settings. Methods: Focus group discussions were held to chart out the objectives and framework of training. We collected feedback from successive batches of interns and inputs from doctors in primary care settings. Results: We developed a module with 10 sessions. We gave priority to conditions commonly encountered in primary care. Video clippings, role plays and seminars were used to make training module interesting. The module encourages the application of mental health knowledge and skills to improve health outcomes . Discussion: This flexible module allows us to make best use of the two week training during internship. Use of such modules will strengthen undergraduate psychiatry training.

BACKGROUND Mental health, though recognised as an important component of health care, has not yet been integrated into general health care. The small number of specialists in psychiatry cannot provide services for a population which exceeds a billion. If we were to achieve a reasonable level of coverage in providing services, we have to equip the non-specialist health care providers to deliver mental healthcare. 26 Psychiatry in India : Training & training centres Clinicians who lead services in primary care and general hospital settings, can assume a key role in delivering health care in these primary and secondary level settings. More importantly, they can also take up the responsibility of guiding and supporting the care delivered through the outreach services. To assume these two important roles, the clinician should have the knowledge and clinical skills to diagnose and manage mental health problems seen in these settings. Undergraduate training in psychiatry should aim to meet this requirement. This is important for scaling up of services.[1] Issues related to undergraduate training in psychiatry has been a focus of discussion in India .The short period of training has always been a matter of concern. The present system allows two weeks of clinical posting in psychiatry during the fourth or fifth semester. There are separate sessions for theory classes. The recent change in the Medical Council of India (MCI) regulations, has made two weeks of training in psychiatry mandatory during the rotatory internship after MBBS. This is a short period for imparting adequate training. However, we need to make best use of this opportunity. A training module can help to provide relevant and specific training in the available time. We can have a broad outline with predetermined content and multiple training methods to choose from. This would ensure proper coverage while allowing flexibility. We made a beginning in this regard at the department of Psychiatry, Government Medical College, Thrissur in Kerala. We would like to share our experience. [1] METHODS We decided to develop a module for training in psychiatry during internship. The matter was discussed with the faculty. Our first task was to fix the broad principles and objectives of the training .The specifics of the programme were then discussed and agreed upon. We used informal interactions as well as focus group discussions to arrive at a consensus. The interns and residents took active interest in developing this module along with the faculty. Inputs from doctors working in PHC setting were also incorporated. While conceiving this programme, the following objectives were kept in mind: The training shall aim to: 1) make trainees realise the importance of mental health in the broader context of general health care. 2) improve their clinical skills in identifying and managing common psychiatric problems. 3) make trainees realise the importance of interpersonal and communication skills in the practice of medicine. 4) sensitize the trainees about issues like burden due to illness, psychosocial and economic impact of illness etc. Jayarajan & Shaji: Psychiatry training during internship 27 5) enlist trainees as partners in efforts to reduce stigma about mental illness We also realized that we need to make a list of topics/tasks which has to be covered during the limited time. While priorities could be fixed, certain degree of flexibility has to be allowed. The availability of clinical material and learning opportunities could vary from time to time. We tried to make this as simple as possible in order to make it feasible even in resource limited settings. RESULTS There were about four interns posted in psychiatry department at a time. They work in the outpatient, inpatient, casualty and consultation liaison services. The interns were informed about the development of the module. They participated in formal training sessions which usually lasted thirty to forty-five minutes. These were lead by a consultant. The emphasis during sessions was on skill building. Group discussions were also held. Sessions were interactive and allowed opportunities for clarifying doubts. After every session a feedback was taken and recorded. The goal was to make modifications in the module to cater to the requirements of trainees. After the completion of training for a few batches of interns, an outline of a ten session module evolved. The sessions in the module dealt with the following topics. Table 1: Overview of training module for interns

SESSION FOCUS TOOLS AND PROCESSES USED NO 1 Introduction and overview of psychiatry Group discussion 2 Psychiatric emergencies Problem based learning using case vignettes 3 Common symptoms Clippings, discussion 4 Common drugs Drug kit, discussion 5 Stigma Clippings, discussion 6 Communication skills Role play, discussion 7 Management in a PHC setting: Substance use Topic presentation 8 Management in PHC setting: Somatoform, anxiety and depressive disorders. District Mental Health Programme, Disability act, Problem based learning using case vignettes 9 Multiple Choice Questions, Feedback MCQs 28 Jayarajan & Shaji: Psychiatry training during internship as well as social consequences were discussed. Basics of pharmacological management and behavioural techniques for alcohol and tobacco use were covered.

Session 9: Management of somatoform, depressive and anxiety disorders in PHC setting were discussed. Salient aspects of the District Mental Health Programme (DMHP) and disability act were discussed. The interns were given a list of PHCs involved in the DMHP programme.

Session 10: Multiple Choice Questions (MCQ) which are important for postgraduate entrance examinations were discussed. Feedback about the training was sought at the end.

Residents undergoing post graduate training also played a part in the development of this training program. Their role was mainly in supervising the interns and monitoring their work.After undergoing the training, most interns reported a distinct change in their attitude towards psychiatry and psychiatrists! Use of videos and movie clippings to illustrate psychopathology went down well with the interns. They also appreciated the session on post graduate entrance examination questions in the end.

DISCUSSION

The stipulated training in psychiatry during MBBS falls short of the actual requirement. Medical Council of India has now made two weeks training in psychiatry mandatory during the compulsory rotatory internship after MBBS course. This is a step in the right direction. There is provision for additional two weeks of elective training in psychiatry. This is a good opportunity to train future doctors in mental health care. [1.2]

While developing this programme, we tried to factor in the needs of trainees and the resources available for training. Interns are expected to take part in providing clinical services. This includes inpatient, outpatient and emergency services. They learn about management of schizophrenia, bipolar disorder and other psychotic disorders as part of their routine work during this posting. Hence we did not give any additional focus on psychotic disorders.[3,4]

Conditions like depression, delirium, suicidal attempts, anxiety disorders, sexual dysfunction, adjustment disorders, disorders etc are common in general hospital settings. We tried to focus on these conditions. They will encounter many of these conditions when they start practising medicine. The importance of focussing on such disorders had been pointed out earlier [5, 6]. This relative emphasis should encourage the trainees to use their newly acquired knowledge. They will soon recognise the feasibility and effectiveness of these interventions. This will mitigate the therapeutic Psychiatry in India : Training & training centres 29 Session 1: A brief introduction and overview of psychiatry. The concepts of the interns regarding psychiatry and their expectations from the training programme were ascertained. Most of the interns thought that schizophrenia was the most common disorder treated by psychiatrists. The prevalence and burden of different disorders were discussed during this session. Co- existence of medical and psychiatric morbidity was pointed out.

Session 2: Next two sessions were dedicated to psychiatric emergencies as the interns have to attend calls from the casualty and the wards during the posting. Case vignettes were used and we encouraged active discussion. We discussed topics like management of aggressive patients, alcohol withdrawal state, lithium toxicity, acute dystonia, neuroleptic malignant syndrome.

Session 3: This session was again on psychiatric emergencies and the topics covered included suicidal behaviour, delirium, somatoform and dissociative disorders. There was special emphasis on differentiating pseudo neurological symptoms from neurological symptoms. Focus was on the bare essentials needed for management of cases without much emphasis on neurobiological underpinnings.

Session 4: This session focussed on clinical methods of eliciting common psychiatric symptoms. In this session, emphasis was laid on eliciting depressive and anxiety symptoms rather than psychotic symptoms. This was done in view of the larger prevalence of neurotic symptoms as well as the subtler presentations. Video clippings were used.

Session 5: This was a session on common drugs used in psychiatric practice. Various drugs used in psychiatric practise were shown. A kit of samples of each drug was arranged for display and demonstration. Interactions with commonly prescribed medicines was explained e.g.; NSAIDS precipitating lithium toxicity.

Session 6: Stigma and related issues were discussed in this session. Concepts of stigma were discussed. Examples from previously stigmatized illnesses like tuberculosis and leprosy were used and the reasons for decrease in stigma towards theses illnesses were explored. Myths and realities were discussed. This session included a demonstration on ECTs and indications and side effects were discussed. Video clippings were used.

Session 7: Communication skills session involved a role play with the interns engaging in a mock interview. Ways to establish rapport and break bad news were demonstrated.

Session 8: Management in a primary health care setting focussed on substance use. Various aspects of alcohol use and their medical complications 30 Psychiatry in India : Training & training centres nihilism which often prevents delivery of care for mental health disorders. The module also serves to sensitize trainees to issues like the burden of psychiatric illness in the community and attempts to endow them with a public health perspective. The programme would require periodic review to make it more effective and user friendly.

Locally developed flexible training modules would provide some structure which is essential for making best use of the limited time for training. It would be worthwhile to agree upon a certain minimum requirement for under graduate training in psychiatry in India. Investing in psychiatric training during undergraduate education can pay rich dividends in the long-term. We are sharing our views and plans regarding the compulsory two week rotation during the internship after MBBS. We look forward to the views of others. We welcome your suggestions and criticisms. We hope to review the programme at the end of the year when about 150 trainees complete the training.

REFERENCES

1 Murthy RS, Khandelwal S. Undergraduate training in Psychiatry: World perspective. Indian J Psychiatry 2007 July;49(3):169-74. 2 Dale JT, Bhavsar V, Bhugra D. Undergraduate medical education of Psychiatry in the West. Indian J Psychiatry 2007 July;49(3):166-8. 3 Trivedi JK, Dhyani M. Undergraduate psychiatric education in South Asian countries. Indian J Psychiatry 2007 July;49(3):163-5. 4 Reddy IR. Undergraduate psychiatry education: Present scenario in India. Indian J Psychiatry 2007 July;49(3):157-8. 5 Oakley C, Oyebode F. Medical students' views about an undergraduate curriculum in psychiatry before and after clinical placements. BMC Med Educ 2008;8:26. 6 Jacob KS. Psychiatric education for medical students. Natl Med J India 1998 November;11(6):287-9.

Rajan Nishanth Jayarajan Senior Resident in Psychiatry NIMHANS Bangalore - 560 029

K.S. Shaji Professor of Psychiatry Medical College Thrissur - 680596 Kerala ,India [email protected] 5 Postgraduate Training in India: Agenda for Indian Psychiatric Society

Ajit Avasthi, Naresh Nebhinani, Sandeep Grover

ABSTRACT

The burden of mental illness is huge, and the problem is expected to increase in the coming years. To deal with this huge burden, there is need to have more trained mental health professionals who can cater to the needs of the community. Over the years number of centres providing postgraduate psychiatric training have increased, but so has the heterogeneity in the training. This paper outlines the current level of postgraduate training in India and what needs to be done to improve the psychiatric training at the postgraduate level.

Psychiatry, like other branches of medicine, has to establish, maintain and monitor the standards of excellence and competence in its practice. The need to do so keeps increasing with the advances made in basic sciences, the advent of new technologies and the burgeoning of subspecialties in psychiatry.[1]

The burden of mental illness in India is enormous. According to the Government of India's Health Report of 2005, the prevalence of 'serious' mental illnesses in Indian population is 6.5%, which comes to a total of around 71 million people.[2] Mental health disorders alone account for about 25% of total DALYs lost due to non-communicable diseases. India had 77.66% deficit in psychiatrists as compared to the ideal number of 1 per 100,000 populations.[3]

With an increase in magnitude of mental disorders, the need for having more psychiatrists and trained professionals therefore becomes inevitable as these doctors will not only play a pivotal role in reducing the burden of mental disorders but also being imparters of knowledge and skills to trainees, students and other multi-disciplinary staff; they will increase the repertoire of knowledge amongst a rapidly evolving specialty. 32 Psychiatry in India : Training & training centres There is no emphasis on psychiatry at the undergraduate level. Students have to undergo a fifteen days clinical posting along with just one short note on psychiatry in final year examination & that too is optional most of the time. Due to this, the undergraduate medical students spend very little time in psychiatry and do not acquire any competence in dealing with common mental disorders.[4]

Postgraduate training in psychiatry is of three types in India, MD and DPM under Medical Council of India (MCI) and DNB under National Board of Examination (NBE), with the duration of three years for MD and DNB, while two years for DPM. There has been tremendous growth in medical education in India during the last three decades. As of today, there are 335 recognized medical colleges that admit 40,385 students in various branches of medicine every year. There are 133 medical colleges and postgraduate institutes, which admit 327 M.D. degree students in psychiatry each year, besides which, 56 medical colleges, have training facilities for 125 D.P.M. students. In addition 50 to 60 postgraduates appear for examinations leading to the award of DNB in psychiatry by the NBE per year.[5]

The implementation of psychiatric education, including its objectives and standards is guided by the MCI, a body of statutory standing. Since 1956 it has a permanent Committee on Postgraduate Medical Education, whose function is to formulate rules and curricula of studies and minimum requirements for postgraduate teaching centres. The MCI has provided detailed guidelines for both the undergraduate and the postgraduate teaching standards in psychiatry. For any medical college providing undergraduate medical training or postgraduate training to be recognized by the MCI, the college must have a department of psychiatry, including inpatient/ outpatient facilities and scope for academic exposure.[5]

The Indian Psychiatric Society (IPS) was founded in January 1947 and in the same year the Society appointed a committee on Post-graduate Psychiatry Education. IPS is a professional body of Psychiatrists in India that aims to promote and advance the subject of Psychiatry and allied sciences in all their different branches, to promote the improvement of the mental health of the people and mental health education, and to formulate and advise on the standards of education and training for medical and auxiliary personnel in psychiatry and to recommend adequate teaching facilities for the purpose.

IPS has played a leading role in the growth and expansion of psychiatric teaching in India through different subcommittees. Further as a body, it organizes various Continuing Medical Education (CME) programs at the national, zonal and state levels. It provides opportunities to the budding psychiatrist to learn the skills of scientific paper presentation and interact Avasthi et al: PG Training: Agenda for IPS 33 with faculty from various parts of the country and abroad.

Significance of improving undergraduate and postgraduate training in psychiatry was highlighted in an editorial of the Indian Journal of Psychiatry.[6,7] Though much has been talked about psychiatric training in undergraduate medical curriculum,[6,8-16] the same enthusiasm has not been shown regarding post-graduate training.[7,17-20] In 2010, IPS has made recommendations to the Government of India and MCI for 'Minimum Standards of Competency Based Training in Psychiatry'. It has mentioned the detailed account of subject specific and other learning objectives, practical competencies, and teaching and learning methods.

It needs to be emphasized that the goal of postgraduate training in all specialties, including the field of psychiatry, is to produce competent and knowledgeable specialists and teachers, who can meet the needs of the community, carry out professional obligations ethically, be aware of contemporary advances in the discipline, and have some foundation in the principles of research methodology. Major components of the postgraduate curriculum are theoretical knowledge, practical and clinical skills, thesis writing, attitudes including communication skills, and training in research methodology.

In a survey of postgraduate training centers in India, it was found that trainees had no opportunity of exposure to mental hospitals in about half the centres, lack of association with a rural clinic which hampered training in community psychiatry in 65% centres, along with inadequate staffing in majority of the centres. The authors felt that the situation in most centres was not conducive to comprehensive teaching at the postgraduate level, as the trainees were ill-equipped to take up the challenging roles of leaders, as envisaged by the NMHP.[21] The variability in duration of courses, in the content of curricula, in clinical postings and in research requirements has been pointed out.[22] Neglect of important areas of psychotherapy, subspecialty training or research methodology has been mentioned. [23-25]

Organization of the teaching program is a complex task for anyone given this kind of responsibility. It is easy to preach ideals but difficult to practice, and at present our leaders face two formidable tasks: to train and provide service to the mental healthcare of 1.2 billion population of India, and to maintain high standards in the scientific field in order to ensure a high quality of teaching and research activity.

Agenda for IPS

Although the postgraduate psychiatry has moved forward in terms of number 34 Psychiatry in India : Training & training centres of seats available for training, there are no uniform guidelines and consistency in standards are sorely lacking. The standards of teaching vary from place to place and even the content of training is variable and so is the examination system. Some teaching centres are mental hospitals while majority are general hospital psychiatric units, with this setting training gets stilted in one or other way. The quality of education imparted is near world class level at some centres across the country, while in the vast majority of postgraduate centres, owing to a multitude of causes, the standard is alarmingly low.[26] PGIMER, Chandigarh and AIIMS, Delhi being autonomous institutes have developed their own training module, while the other prestigious institutes like NIMHANS, CIP, JIPMER, CSMU (King George Medical College, Lucknow) have also made the same but they are under the ambit of MCI, so they have to follow certain guidelines. However, many teaching centres are inadequately staffed. These issues need serious attention to improve the quality of postgraduate psychiatric education.

Hence, there is need for formation of well-defined curricula and syllabi for a three-year MD degree in psychiatry. There is a need to implement a quality assurance program in our post-graduate training, both with respect to its form and its content. Irrespective of the institute in which they are trained, all the residents pursuing psychiatry postgraduate course should undergo postings in the outpatient department, inpatient department, drug de- addiction, consultation-, community psychiatry and other subspecialties like child psychiatry, geriatric psychiatry and psychosexual clinics. In addition to this, they should be exposed to training mental hospital psychiatry, with emphasis on forensic psychiatry and should also receive basic understanding of the psychological testing. The centres which don't have facilities for all the above, should liaise with the centres which have competent faculty to train in various subspecialties. The World Federation of Mental Health and the World Psychiatric Association have developed a core curriculum in psychiatry that can be used as a guideline for making changes in the curriculum so as to meet the local needs.[4]

Under the aegis of MCI and IPS there is need to form a centralized examination and accreditation body so that uniform standards are maintained by all the institutions. There is a great need to formulate the basic modules of postgraduate teaching, which should be field-tested, periodically revised and universally employed in training.

The training should be based on utilization of modern, inexpensive and efficient tools and techniques of medical and psychiatric education, such as case and psychopathology videotapes, teleconferencing and telepsychiatry. There is a need at the level of MCI and IPS to device certain formula for Continuing Professional Development (CPD) for Psychiatrists. The teachers/ Avasthi et al: PG Training: Agenda for IPS 35 trainers should also be evaluated by a feedback system so that they can also improve themselves in various aspects of psychiatry.

Although writing a research protocol and thesis is more or less compulsory in most of the training centres, but there is lot of variation in the quality of the research. Further, at most of the centres the trainees are not provided any knowledge about the research methodology and statistics due to which many a times the trainee psychiatrist are not only unable to understand and formulate their own results, but also are not able to evaluate the research papers. Hence, there is a need for a short term research methodology and statistical training for all the candidates undergoing postgraduate degree course.[4]

These many issues have to be dealt with streamlining our training program, but we lack a central body which can draw up a meaningful program and implement it effectively. In countries like the USA, UK and Australia, the national organizations of psychiatrists like American Psychiatric Association, Royal College of Psychiatrists, and Australian and New Zealand College of Psychiatrist are endowed with the power to formulate and implement training programs. Unfortunately, the IPS has not been recognized for such a role. The curriculum is not prepared with prioritizing the concern for the trainee and the patients, so it is required to develop a teaching program which is neither teacher centered nor dependent purely on the opinion of the trainee, but something which is based on the experience of the former and the aspiration of the latter.[7]

Other important needs are to introduce the concept of visiting guest faculty and short inter-institutional trainee exchanges, to impart specific education aspects that are presently lacking at parent institutions. Infrastructure monitoring along with some regulations for floating teachers can be improved with active partnership of IPS. Similar to the Royal College of Psychiatrists, IPS should be enabled to start fellowship programs and accredited CMEs.

In our country, treating doctors enjoy deep trust of the patients and their relatives, therefore, huge ethical responsibility has to be shouldered by the treating team and every effort should be made to ensure the safety of the patient vis-à-vis research. Quality assurance of training as well establishing uniformity in curriculum and examination system would help in producing ethically upright and clinically sound psychiatrists having the right attributes to render service.

It is incumbent upon those in teaching and training of psychiatrists that they adequately train the blossoming psychiatrists well in the art and craft of 36 Psychiatry in India : Training & training centres ethical practice of psychiatry in the domains of patient-doctor relationship, doctor-pharma relationship, private practice and managed care, psychiatric research and research publication. It is also of importance to appreciate that unless senior psychiatrists act as good and desirable role models, the young ones will not follow ethical standards.

The IPS draft for 'Minimum Standards of Competency Based Training in Psychiatry' has mentioned the importance of history of medicine with special reference to ancient Indian texts, medical ethics, consumer protection, medical audit and bio-medical statistics. Postgraduate should be competent to manage psychiatric disorders of all age groups including infants, should be able to recognize the health needs of the community, should be competent to handle effectively general medical problems and should be aware of the recent advances pertaining to his specialty. Contents of the course can't be fixed and limited as postgraduate is expected to know the subject in depth with emphasis on the more prevalent diseases / health problems in that area. The need to conduct the common teaching programme on regional basis in collaboration with professional bodies / MCI has been highlighted.

Though psychiatry has come a long way in India a lot still remains to be done. The burden of mental illness is large, and the problem is expected to increase in the coming years. With a national deficit of psychiatrists in most states, we are clearly not prepared to deal with the situation in foreseeable future. The only way forward is to strengthen psychiatric teaching at all levels to produce more doctors in the country well versed with psychiatric knowledge and skills to deal with this issue. In the last, how satisfactory is the training in the changing social, economic, and technological environment, is an area that needs constant evaluation and suggestions for improvement by the sole representative body of all the psychiatrists in India- Indian Psychiatric Society.

REFERENCES

1. Kulhara P, Chakrabarti S. Current status and future directions. Postgraduate Psychiatric Training in India-I. In: Agarwal SP, editor. Mental Health: An Indian Perspective 1946- 2003. New Delhi: Elsevier; 2005.p215-17. 2. NCMH Background Papers - Burden of Disease in India. National Commission of Macroeconomics and Health, 2005. 3. Thirunavukarasu M, Thirunavukarasu P. Training and National deficit of psychiatrists in India – A critical analysis. Indian J Psychiatry 2010; 52:S83-88. 4. Kulhara P, Grover S. Postgraduate psychiatry. In: Souvenir of National Mid term CME of Indian Psychiatric Society (Raipur), 2007. 5. MCI Website: http://mciindia.org/apps/search/show_colleges.asp Last Accessed : 8-12- 2014. 6. Bhaskaran K. Undergraduate training in psychiatry and behavioural sciences - The need to Avasthi et al: PG Training: Agenda for IPS 37 train the trainers. Indian J Psychiatry 1990; 32:1-3. 7. Kuruvilla K. A Common Minimum Programme Needed in Post-Graduate Training in Psychiatry. Indian J of Psychaity 1996; 38:118-19. 8. Sharma S. General hospital psychiatry and undergraduate medical education. Indian J Psychiatry 1984; 26:259-63. 9. Tharyan A, Datta S, Kuruvilla K. Undergraduate training in psychiatry an evaluation. Indian J Psychiatry 1992; 34:370-2. 10. Reddy IR. Undergraduate psychiatry education: Present scenario in India. Indian J Psychiatry 2007; 49:157-8. 11. Ghosh AB, Mallick AK. Why should psychiatry be included as examination subject in undergraduate curriculum? Indian J Psychiatry 2007; 49:161-2. 12. Trivedi JK, Dhyani M. Undergraduate psychiatric education in South Asian countries. Indian J Psychiatry 2007; 49:163-5. 13. Dale JT, Bhavsar V, Bhugra D. Undergraduate medical education of psychiatry in the West. Indian J Psychiatry 2007; 49:166-8. 14. Murthy RS, Khandelwal S. Undergraduate training in psychiatry: World perspective. Indian J Psychiatry 2007; 49:169-74. 15. Manickam LSS, Rao TSS. Undergraduate medical education: Psychological perspectives from India. Indian J Psychiatry 2007; 49:175-8. 16. Pickren W. Psychology and medical education: A historical perspective from the United States. Indian J Psychiatry 2007; 49:179-80. 17. Gopinath PS, Kaliaperumal VG. Comparative study of different assessment methods for postgraduate training in Psychiatry: A preliminary study. Indian J Psychiatry 1979;21: 153-4. 18. Kulhara P. Postgraduate psychiatric teaching centres: Finding of a survey. Indian J Psychiatry 1985; 27:221-6. 19. Kulhara P. General hospitals in postgraduate psychiatric training and research. Indian J Psychiatry 1984; 26:281-5. 20. Sharma S. Postgraduate training in psychiatry in India. Indian J Psychiatry 2010;52:89-94. 21. Kulhara P. Postgraduate psychiatric teaching centres: findings of a survey. Indian J Psychiatry 1985; 27:221–6. 22. Channabasavanna SM. Editorial, Psychiatric education. Indian J Psychiatry 1986; 28:261. 23. Shamasundar, C. The need for a national forum for psychotherapy. Indian J Psychiatry 1997; 39:215. 24. Master RS. Psychiatric education in India. In: Desousa, 2A ed. Psychiatry in India. Bombay: Bhavani Book Depot 1984:491–518. 25. Patel V. Research in India: not good enough? Indian J Psychiatry 2001; 43:375. 26. Agarwal AK, Katiyar M. Status of Psychiatric Education at Postgraduate Level. Postgraduate Psychiatric Training in India-I. In: Agarwal SP, editor. Mental Health: An Indian Perspective 1946-2003. New Delhi: Elsevier 2005:218-220. 38 Psychiatry in India : Training & training centres Ajit Avasthi Professor Department of Psychiatry Postgraduate Institute of Medical Education & Research Chandigarh 160012, India [email protected]

Sandeep Grover Assistant Professor Department of Psychiatry PGIMER, Chandigarh -160012, INDIA

Naresh Nebhinani Dept. of Psychiatry 3rd Floor, Cobalt Block Nehru Hospital, PGIMER Sector - 12 Chandigarh - 160012 6 Recommendations for Post-graduate (MD) Curriculum in Psychiatry

R.C. Jiloha

Modern medical education in India is the legacy of British rule dating back to the third decade of nineteenth century [1]. It was only after the Medical Council of India (MCI) was constituted under the Indian Medical Council Act of 1933 that the regulation of medical education began in the country. Initially the MCI catered to the needs of the under-graduate medical education. Till 1946, there were only 16 medical colleges in the country and the primary aim of the council was to look after the undergraduate (UG) medical education in these colleges, but during the last six decades, particularly after the new Medical Council Act of 1956, regulation of postgraduate (PG) medical education has become an important and integral part of MCI’s functions [2]. With the rapid expansion of medical education, the number of medical colleges in the country increased to 50 by 1958 and a majority of them provided PG training in important disciplines. The Council has been empowered to prescribe standards of postgraduate medical education and the Postgraduate Medical Education Committee of MCI has made valuable recommendations regarding the nomenclature of postgraduate degrees, the courses and the period of studies, examination patterns, recognition of training institutes, and postgraduate teachers [3].

Beginning of general hospital psychiatry brought the discipline of mental health in the mainstream curriculum of medical education. However, lack of trained teachers and desired infrastructure limited both UG and PG training in Psychiatry leading to gross under-representation of the specialty in the delivery of health services. Soon after the Indian Psychiatric Society (IPS) was founded in January 1947. The Society appointed a committee on Post- graduate Psychiatry Education to examine the status of PG training in the country[4].The need for Psychiatric training in under-graduate medical education and post-graduate courses has been expressed through the editorials [5] [6] and several articles that have appeared in Indian Journal of Psychiatry [7],[8],[9],[10],[11],[12],[13],[14],[15],[16] from time to time and some of them have 40 Psychiatry in India : Training & training centres assessed methods, [17] survey of postgraduate training centers [18], and the role of general hospitals in postgraduate teaching. [19] They all made a significant contribution to the advancement of both undergraduate and postgraduate training.

From 1947 to 1967 there were only six institutes in the country offering postgraduate degree (MD) in psychiatry, and from these centers about 14 psychiatrists qualified as MDs every year. This trend has gradually changed and during the last four decades, dramatic developments have taken place in the growth of PG training in psychiatry. Today, it is obvious that like most other specialties, psychiatry is becoming increasingly specialized and fragmented [1]. In 2014, there were 398 medical colleges in the country with the capacity of enrolling 47,588 (22,633 in government colleges and 24,955 in private ones) students for [20] under-graduate training every year. 25% of these medical colleges do not [21] have a psychiatry department and 160 and 59 institutions are providing PG (MD & DPM respectively)[3] training in Psychiatry. The permanent Committee on Postgraduate Medical Education in the MCI, which formulates rules and curricula of studies and the minimum requirements for teaching centers, also maintains the quality of teachers and examinations conducted by the universities, so as to bring about uniformity of standards [2].To produce competent and knowledgeable specialists, teachers and researchers in the field of mental health it is necessary to recognize the health needs of the community to carry out professional obligations ethically. To master most of the competencies, it is necessary to grasp the specialty required for the needs at the secondary and tertiary levels, and be aware of the contemporary advances in the discipline [1]. To acquire a spirit of scientific inquiry, research methodology and epidemiology are essential. It is also required that the trainees acquire the basic skills in teaching the medical and the paramedical professionals.

CONDITIONS TO BE OBSERVED BY THE POST-GRADUATE TEACHING INSTITUTIONS3

1. Three years course is there in case of post-graduate degree and two years in case of diploma course after obtaining MBBS degree. 2. Post-graduate curriculum should be competency based. 3. Learning in post-graduate programme should be essentially autonomous and self directed. 4. A combination of both formative and summative assessment is vital for successful completion of the PG programme. 5. A modular approach to the course curriculum is essential for achieving systematic exposure to the various sub-specialties concerned with Psychiatry. Jiloha: Recommendations for Post-graduate Curriculum 41 6. The training of PG students should involve learning experiences derived from or targeted to the needs of the community. It is necessary to expose the students to the community based activities.

As a result of unequal distribution of teachers and the facilities, there has been a wide difference in the quality of training at different centres. Training and expertise in non-pharmacological modes of therapy is not provided at all centres; the quality and intensity of such training varies across centres.[22] To bring uniformity in training across centres, the Indian Psychiatric Society recommends the following curriculum for the MD (Psychiatry) training:

Preamble:

A postgraduate specialist (MD) having undergone the required training for three years should be able to recognize the health needs of the community; should be competent to handle effectively medical problems and should be aware of the recent advances pertaining to his specialty. The PG student should acquire the basic skills in teaching of medical / para-medical students. He /she is also expected to know the principles of research methodology and modes of consulting library.

SUBJECT SPECIFIC LEARNING OBJECTIVES

At the end of postgraduate training, the learner should be able to:

1. Diagnose and appropriately manage common Psychiatric ailments in a given situation. 2. Identify Psychiatric situations calling for urgent or early intervention and refer at the optimum time to the appropriate centres. 3. Provide adequate follow-up care of persons suffering from chronic relapsing psychiatric ailments. 4. Counsel and guide patients and relatives regarding need, implications and problems of psychiatric ailments in the individual patients. Students must acquire communication skills in this regard (should be part of assessment during final examination) 5. Provide emergency measures in acute crisis arising out of various psychiatric illnesses including drug detoxification and withdrawal. 6. Recognise the mental condition in infants and children characterized by self absorption and reduced ability to respond to the outside world (e.g. Autism), abnormal functioning in social interaction with or without repetitive behaviour and/or poor communications, etc. 7. Organize and conduct relief measures in situations of mass disaster 42 Psychiatry in India : Training & training centres leading to psychological disorders (eg. acute stress reaction and post traumatic stress disorders). 8. Effectively participate in the various components of National Mental Health Programmes. 9. Discharge effectively medico-legal and ethical responsibilities and practice his specialty ethically. 10. Perform psychiatric procedures (e.g.: modified ECT). 11. Perform clinical audit. 12. Regularly participate in departmental academic activities by presenting Seminars, Case discussions, Journal Clubs and Topic discussions on weekly basis and maintain its logbook. 13. Demonstrate sufficient understanding of basic sciences related to the specialty. 14. Plan and advise measures for the prevention and rehabilitation of patients belonging to the specialty. 15. Demonstrate competence in basic concepts of research methodology. 16. Develop good teaching skills. 17. Have the ability to apply humanistic values in health care delivery and respect the patient’s dignity, privacy and confidentiality; demonstrate effective communication skills during interaction with patients, family members, peers and other health care workers from diverse cultural background. 18. Recognize the need for lifelong learning and knowledge about latest scientific developments. The basic learning methods should include grand rounds, bedside teaching, interactive group discussions and demonstrations from a clinical and public health perspective. Seminars, research forums / journal clubs, case conferences, reviews, symposia and guest lecturers should have precedence over didactic lectures. The learner should have adequate training in performing various medical, surgical and psychosocial procedures and ability to interpret relevant findings. Exposure to newer and specialized procedures concerning the specialty for assessment and intervention should be provided. 19. Know different methods of treatment (pharmacological and non- pharmacological) and prevention.

SPECIFIC LEARNING OBJECTIVES

Research: Trainee should know the basic concepts of research methodology Jiloha: Recommendations for Post-graduate Curriculum 43 and plan a research project in accordance with the ethical principles. He/she should also be able to interpret research finding and apply it to his/her practice. He/She should know how to access and utilize information resources and should know how to consult the library. Basic knowledge of statistics is also required.

Teaching: The trainee should learn the basic methodology of teaching and develop competence in teaching medical / paramedical students, health professionals, members of allied disciplines (e.g. behavioural sciences), law enforcement agencies, families and consumers and members of the public.

CURRICULUM

Course Contents (Components of curriculum):

No limit can be fixed and no fixed number of topics can be prescribed as course contents. A trainee is expected to know the subject in depth; however emphasis should be on the diseases/health problems most prevalent in that area. Knowledge of recent advances and basic sciences as applicable to his/her specialty should get high priority. Competence in managing behavioural problem commensurate with the specialty must be ensured.

SUBJECT SPECIFIC THEORETICAL COMPETENCIES

1. General topics:

A student should have fair knowledge of basic sciences (Anatomy, Physiology, Biochemistry, Microbiology, Pathology and Pharmacology) as applied to the specialty. He/she should acquire in-depth knowledge of his subject including recent advances. He/She should be fully conversant with the bedside diagnostic and therapeutic procedures and have knowledge of the latest diagnostics and therapeutics procedures available.

The activities may be organized as a common teaching programme for postgraduate students of all the departments at institution/university level. A possibility of conducting the programme on regional basis in collaboration with professional bodies/associations, Medical Council of India, University Grants Commission and others may also be explored.

1. History of medicine with special reference to ancient Indian texts. 2. Health economics : basic terms, health insurance. 3. Medical sociology, doctor-patient relationship, family adjustments in disease, organizational behaviour, conflict resolution. 4. Computers–record keeping, computer aided learning, virtual reality, robotics. 44 Psychiatry in India : Training & training centres 5. Hazards in hospital and protection in terms of psychological hazard. 6. Medical audit, evidence based medicine, quality assurance of investigation and therapeutic procedures. 7. Concept of essential drugs and rational use of drugs. 8. Procurement of stores and material management. 9. Research methodology - library consultation, formulating research, selection of topic, writing protocol thesis, and ethics related to research. 10. Bio-medical statistics, clinical trials including drug trials. 11. Medical ethics. 12. Consumer protection. 13. Newer psychotropic substances. 14. Problem of treatment resistance. 15. Advances in imaging technologies. 16. Disaster management, Psychosocial effects of mass casualties. 17. Design of Psychiatric unit and drug dependence treatment unit with essential equipments. 18. Critical care in psychiatric care with co morbid medical conditions. 19. Physical and chemical restraint for emergency psychiatric situations (e.g. violence, delirium etc.) 20. Legal issues in the practice of psychiatry. 21. Child and adolescent Psychiatry. 22. Geriatric Psychiatry. 23. Clinical Psychology as related to psychiatry. 24. Rehabilitation of psychiatric patients.

2. Components of curriculum:

A list of topics or sub-topics in Psychiatry does not appear to be required. A standard text book may be followed, which will also identify the level of learning expected, of the trainees. Following are the must know topics for learning for the trainees: 1. Theoretical concepts 2. Psycho-neuro-endocrinology 3. Genetics of psychiatric disorders 4. Concept of Normality/abnormality 5. Emotional/social intelligence 6. Learning - Theories 7. Memory Jiloha: Recommendations for Post-graduate Curriculum 45

8. Mind – the evolving concept 9. Neuro-psychology (including psychological features of cerebral disorders), clinical assessment etc. 10. Theories of Personality and Personality disorders 11. History of Psychiatry 12. Classification in Psychiatry 13. History Taking, Neurological Examination, Mental Status Examination etc 14. Psychosis (Including Schizophrenia, Schizophreniform Disorder, Schizoaffective Disorder, Delusional Disorder, Brief Psychotic Disorder, Shared Psychotic Disorder, etc). 15. Mood Disorders (Including Depressive Disorders, Bipolar Disorders, Cyclothymic Disorder, etc.) 16. Anxiety Disorders (Including Panic Disorder, Agoraphobia, Phobias, Obsessive-Compulsive Disorder, Post traumatic Stress Disorder, Acute Stress Disorder, Generalized Anxiety Disorder, etc). 17. Dissociative Disorders (including Dissociative Amnesia, Dissociative Fugue, Dissociative Identity Disorder, Depersonalization Disorder, etc). 18. Somatoform Disorders (Including Somatization Disorder, Undifferentiated Somatoform Disorder, Conversion Disorder, Pain Disorder, Hypochondriasis, Body Dysmorphic Disorder, etc.) 19. Impulse-Control Disorders (Including Intermittent Explosive Disorder, Kleptomania, Pyromania, Pathological Gambling, Trichotillomania, etc.) 20. Eating Disorders (Including Anorexia Nervosa, Bulimia Nervosa, etc.) 21. Sleep Disorders (Including Insomnia, Narcolepsy, Breathing-Related Sleep Disorders, Circadian Rhythm Sleep Disorders, Parasomnias, Nightmare Disorder, Sleep Terror Disorder, Sleepwalking Disorder, etc.) 22. Substance Related Disorders (Including Alcohol-Related Disorders, Amphetamine-Related Disorders, Caffeine-Related Disorders, Cannabis-Related Disorders, Cocaine-Related Disorders, Hallucinogen-Related Disorders, Inhalant-Related Disorders, Nicotine-Related Disorders, Opioid-Related Disorders, Phencyclidine-Related Disorders, Sedative-, Hypnotic-, Or Anxiolytic- Related Disorders, etc.) 23. Sexual and Gender Identity Disorders (Including Sexual Desire Disorders, Sexual Arousal Disorders, Orgasmic Disorders, Sexual Pain Disorders, Vaginismus, Paraphilias, etc) 46 Psychiatry in India : Training & training centres 24. Mental Health Issues In Women 25. Pre-Menstrual Dysphoric Disorder 26. Post-Partum Psychiatric Disorders 27. Organic Psychiatry (Including Amnestic Disorders, Catatonic Disorders, Cerebro-vascular Disorders, Delirium, Dementia, Endocrine Epilepsy, Head Injury, Headache, HIV – AIDS, Infections, etc.) 28. Mental Retardation 29. Emergencies In Psychiatry 30. Suicide, management and medico-legal aspect. 31. Miscellaneous: Non-compliance, Malingering, Antisocial Behaviour, Borderline Intellectual Functioning, Age-Related Cognitive Decline, Bereavement [Including Death], Academic Problems, Occupational Problems, Identity Problems, Religious or Spiritual Problems, Acculturation Problems, Phase of Life Problems, Chronic Fatigue Syndrome, etc.) 32. Factitious Disorders 33. Culture Bound Syndromes 34. Child Psychiatry (Including Learning Disorders, Motor Skills Disorder, Communication Disorders, Pervasive Developmental Disorders (Autistic Disorder, Rett’s Disorder, Childhood Disintegrative Disorder, Asperger’s Disorder), Attention-Deficit Hyperactivity Disorder, Conduct Disorder, Oppositional Defiant Disorder, Pica, Tic Disorders, Elimination Disorders, Separation Anxiety Disorder, Selective Mutism, Reactive Attachment Disorder of Infancy or Early Childhood, Stereotypic Movement Disorder, etc.) 35. Forensic and Legal Psychiatry (Including Indian Lunacy Act, Mental Health Act, Persons with Disability Act, Narcotic Drugs and Psychotropic Substance Act) 36. Geriatric Psychiatry 37. Community psychiatry 38. Psychosomatic Disorders 39. Consultation-Liaison Psychiatry 40. Movement Disorders (Including Medication-Induced Movement Disorders, etc) 41. Stress and related disorders 42. Adjustment disorders. 43. Trans-cultural Psychiatry 44. Abuse (physical/emotional/sexual) or neglect of child/adult/elderly Jiloha: Recommendations for Post-graduate Curriculum 47 45. Placebo Effect 46. Psychology (Clinical) as applied (Psychometry/ Psychodiagnostics) 47. Psychodynamics 48. Psychopharmacology 49. Electro-Convulsive Therapy 50. 51. Statistics/Research Methodology/Epidemiology 52. Rehabilitation of psychiatric patients 53. Ethics In Psychiatry

3. Symptoms based approach to the patient with psychopathology:

Symptoms Auditory hallucinations Visual hallucinations Pseudo hallucination True seizures and pseudoseizures Panic attack Manic symptoms Behavioral symptoms of schizophrenia Catatonia Delirium Malingering Delusions Depressive ideations Bedside testing of cognitive functions

SUBJECT SPECIFIC PRACTICE BASED OR PRACTICAL COMPETENCIES

A student should be expert in good history taking, physical examination, mental state examinations, and able to establish rapport and counsel family members and patients on scientific basis. He/she should be able to choose the required investigations for both short and long term management. At the end of the course the learner should:

1. Be able to obtain a proper relevant history, and perform a humane and thorough clinical examination including a detailed mental status examination. 2. And to achieve the first objective, students must be taught communication skills. Evaluation and assessment must be done at 48 Psychiatry in India : Training & training centres the time of final examination and be essential component to pass the examination separately in communication skills. 3. Arrive at a logical working diagnosis and differential diagnosis after clinical examination. 4. Order appropriate investigations keeping in mind their relevance and cost effectiveness and additional relevant information from family members to help in diagnosis and management. 5. Be able to perform quick intervention for suicide attempt and high risk suicidal patients. 6. Write a complete case record with all necessary details. 7. Write a proper discharge summary with all relevant information. 8. Obtain informed consent for any examination/procedure. 9. Be able to perform modified ECT 10. Be able to use rationale pharmacotherapy. 11. Be skilled in using psychobehavioural interventions.

At the end of the course learners should be able to perform:

Skills Conduct detailed MSE Behaviour therapy Cognitive behaviour therapy Supportive psychotherapy Modified ECT Clinical IQ assessment Management of alcohol withdrawal Alcohol intoxication management Opioid withdrawal management Opioid intoxication management Management of Delirious patients Issues related to treatment, side-effects, clinical uncertainities, consent Interpersonal therapy Family therapy/ Marital therapy Management of suicide attempt/Violence Crisis intervention

Skills are to be learnt initially on the models and later on performed under supervision before performing independently. Provision of psychiatric skills in the Medical Colleges will facilitate this process. Jiloha: Recommendations for Post-graduate Curriculum 49 TEACHING AND LEARNING METHODS

The trainee should learn the basic methodology of teaching and develop methods in teaching medical/paramedical students. Student should have hands-on training in performing various procedures and ability to interpret various tests/ investigations. Exposure to newer specialized diagnostic/ therapeutic procedures concerning the specialty should be given. Self learning tools like assignments and case based learning may be promoted. The learner should have fair knowledge on: Psycho-pharmacology & broadening the treatment options using medicines.

l Neuro-imaging techniques to understand behaviour and psychiatric illness.

l Community-Psychiatry.

Community psychiatry must go beyond familiarization with National Mental health programme. It is desirable that the candidate has experience with :

l General Physician Training Programme

l Organizing Mental Health Camps

l Functioning of .

l Carrying out Health Education Activities

l Forensic / Legal Psychiatry

l Integration of Mental health Care with general Health Care

Thesis writing and research:

Thesis writing is compulsory. Presentation / publication of papers in conferences/Journals is desirable. He/she should know the basic concepts of research methodology, be able to plan a research project, be able to retrieve information from the library. He/she should have a basic knowledge of statistics.

Teaching:

Each PG student will bae required to teach undergraduate students, (clinical demonstration) - at least 20 sessions. Student should learn the basic methodology of teaching and develop competence in teaching medical/paramedical students. 50 Psychiatry in India : Training & training centres Academic Activities including Thesis (for MD)

a. Seminars: There should be a weekly seminar in which the junior residents present material on assigned topics in rotation. It should be followed by discussion in which all trainees are supposed to participate. Generally the topics covered should be those that supplement the formal teaching programme. b. Case Conference: A case conference should be held every week where a junior resident prepares and presents a case of academic interest by rotation and it is attended by all the members of the Department. c. Psychosomatic Rounds: This is a presentation of a case of psychosomatic illness, or a medical illness with pronounced psychiatric problems. It should be held weekly in collaboration with various departments and attended by the faculty and the residents of psychiatry and the concerned department. d. Research Forum: There should be a meeting at least once in 6 months of one hour each in which the residents present their plan of research as well as the report of the completed work of their projects. The other research scholars/workers in the department also participate in it. The faculty, residents and the non-medical professionals make critical comments and suggestions. e. Journal Club: It should be a monthly meeting in which a senior resident presents a critical evaluation of a research paper from a journal. Residents are expected to attend. f. Case presentations: All new in-patients and outpatient cases should be routinely reviewed with one of the consultants. In addition, the resident is required to present case material at routine rounds and other case conferences. Senior residents will conduct classes on clinical topics. g. Extra-mural activities: Residents are encouraged to attend certain academic/semi-academic activities in the allied subjects outside, e.g. seminars/lectures held at Departments of Sociology, Psychology, Neurology etc. h. Psychotherapy tutorials: These should be held in small groups supervised by a consultant, in which a case is presented by a resident and psychotherapeutic management discussed. i. Attendance at special clinics/units as applicable. e.g. Child and Adolescent Psychiatry Clinic, Marital and Psychosexual Clinic, Community Outreach Clinics, Drug de-addiction unit etc. j. Training in ECT administration. k. Thesis: Every M.D. candidate shall be required to submit a thesis as an essential requirement for the award of the degree. Guidelines have Jiloha: Recommendations for Post-graduate Curriculum 51 to be followed. The work for the thesis is to be done by the candidate under the supervision of a faculty member of the department. l. As a part of extra-mural activity, students are also encouraged to attend community health/mental health activities, mental health camps, GP training programme etc. ie, District Medical Health Programme.

Clinical Postings

1. A major tenure of posting should be in General Psychiatry. It should include care of in-patients, out-patients, special clinics and maintenance of case records for both in and out patients.

2. Exposure to the following areas should be given as a schedule of clinical postings for M.D Psychiatry *(36 months):

Area/ Specialty

1. Ward & OPD (Concurrent) including: 33 months

(i) Emergency

(ii) Consultation Liaison Psychiatry

(iii) Clinical Psychology

(iv)

(v) Child and Adolescent Psychiatry

2. Psychiatric hospital and Forensic Psychiatry 1 month

3. Neurology - 2 months

* The stated duration can be subject to minor modifications depending on the available resources. This is applicable only for trainees in General Hospital Psychiatric units. Trainees in Psychiatric hospitals would have extended period of exposure to consultation -liaison psychiatry and other medical specialties

The learner is to be given full responsibility for the patient care and the record keeping under the supervision of the senior residents and consultants. The learner shall also take patients for psychological interventions in an individual as well as group setting. He/she must complete a minimum of 100 hours of supervised psychological interventions with documentation. 52 Psychiatry in India : Training & training centres Rotation of posting

Inter-unit rotation in the department should be done for a period of up to one year (divided during the first year and third year while candidate stays in the parent unit through out the duration of his thesis work).

Clinical meetings:

There should be intra - and inter-departmental meetings for discussing the uncommon / interesting medical problems. Each student must be asked to present a specified number of cases for clinical discussion, perform procedures / present seminars / review articles from various journals in inter- unit / interdepartmental teaching sessions. They should be entered in a Log Book and signed by the authorized teacher and Head of the Department.

ASSESSMENT

FORMATIVE ASSESSMENT

Internal assessment

Assessment during the P.G. degree training programme should be based on: Case presentation, case work up, case handling/management (once a week), Seminar/journal club presentation (Once a week) Psycho-diagnostic/Scale administration ( weekly) Knowledge of principle of procedures, eg. ECT, abreaction etc Attendance at Scientific meetings, CME programmes, and Assessment of log book at the end of the posting Assessment – multi-source feedback.

END-ASSESSMENT

Internal assessment : as per the guidelines of the university

Postgraduate Examination (50% marks for theory and 50% marks for practical)

Thesis to be submitted by each candidate at least 6 months before the commencement of theory examination and should be approved.

Theory - 4 papers of three hours each

Paper I: Basic Sciences as related to Psychiatry

Paper II: Clinical Psychiatry Jiloha: Recommendations for Post-graduate Curriculum 53 Paper III: Psychiatric theory and Psychiatric specialties

Paper IV: Neurology and General Medicine as related to Psychiatry

Current format is restrictive and needs to be modified. However, the structure of paper setting will be in accordance of faculty of medical sciences.

Practical:

Presentation of long case of Psychiatry

Neurology short case

A short case of Psychiatry

Viva –voce: Due importance should be given to Log Book Records and day-to-day observation during the training, Spot viva on psychological test material, skiagrams, CT Scan, MRI, EEG etc is included.

At present there is a wide variation in the training programs in spite of MCI regulations and guidelines. There is a constant need for retrospective introspection.[23] Indian Psychiatric Society strives to bring uniformity in the content of training programme across the country, to organize the curriculum which can be evaluated, to include standard methods of instructions, to make objective assessment and to develop acceptable guidelines with regard to the relationship between institutions/universities. Proposed recommendations serve these objectives.

Suggested text Books

1. Kaplan and Sadock’s Comprehensive Text Book of Psychiatry 2. Kaplan and Sadock ‘s Synopsis of Psychiatry 3. Fish Clinical Psychopathology 4. Lishman Organic Psychiatry, The Psychological consequences of cerebral disorder 5. Clinical practice guideline of Psychiatric disorders in India 6. Stahl Psychopharmacology 7. Oxford text book of Psychiatry 8. National Programmes and Acts

Journals

1. British Journal of Psychiatry 54 Psychiatry in India : Training & training centres 2. American Journal of Psychiatry 3. Archives of General Psychiatry 4. Acta Psychiatrica Scandinavica 5. Psychosomatic Medicine 6. Psychopharmacology 7. 8. Journal of Clinical Psychiatry 9. Journal of Child Psychology and Psychiatry 10. Indian Journal of Psychiatry 11. Journal of American Academy of Child and Adolescent Psychiatry

REFERENCES:

1. Sharma S. Post-graduate training in Psychiatry in India. Indian J Psychiatry.2010;52:89-94. 2. Patel CS. History of the Medical Council of India. M.C.I. Silver Jubilee Souvenir 1959, MCI, New Delhi. 3. MCI Website: http://mciindia.org/apps/search/show_colleges.asp Last Accessed: 14th December 2014. 4. Indian Psychiatric Society First Report of the Subcommittee on undergraduate Teaching in psychiatry. Indian J Psychiatry 1965;7:63-72. 5. Saha C.C. Presidential Address. Indian J Psychiatry.1962;4:1 6. Sethi BB. Indian psychiatric society editorial, undergraduate psychiatry. Indian J Psychiatry 1978;20:197. 7. Sharma S. General hospital psychiatry and undergraduate medical education. Indian J Psychiatry 1984;26:259-63. 8. Bhaskaran K. Editorial, undergraduate training in psychiatry and behavioural sciences - The need to train the trainers. Indian J Psychiatry 1990;32:1-3. 9. Tharyan A, Datta S, Kuruvilla K. Undergraduate training in psychiatry an evaluation. Indian J Psychiatry 1992;34:370-2 10. Reddy IR. Undergraduate psychiatry education: Present scenario in India. Indian J Psychiatry 2007;49:157-8 11. Ghosh AB, Mallick AK. Why should psychiatry be included as examination subject in undergraduate curriculum? Indian J Psychiatry 2007;49:161-2 12. Trivedi JK, Dhyani M. Undergraduate psychiatric education in South Asian countries. Indian J Psychiatry 2007;49:163-5. 13. Dale JT, Bhavsar V, Bhugra D. Undergraduate medical education of psychiatry in the West. Indian J Psychiatry 2007;49:166-8. 14. Murthy RS, Khandelwal S. Undergraduate training in psychiatry: World perspective. Indian J Psychiatry 2007;49:169-74 15. Manickam LSS, Rao TSS. Undergraduate medical education: Psychological perspectives from India. Indian J Psychiatry 2007;49:175-8. 16. Pickren W. Psychology and medical education: A historical perspective from the United States. Indian J Psychiatry 2007;49:179-80. 17. Gopinath PS, Kaliaperumal VG. Comparative study of different assessment methods for postgraduate training in Psychiatry: A preliminary study. Indian J Psychiatry 1979;21: 153-4. Jiloha: Recommendations for Post-graduate Curriculum 55 18. Kulhara P. Postgraduate psychiatric teaching centres: Finding of a survey. Indian J Psychiatry 1985;27:221-6. 19. Kulhara P. General hospitals in postgraduate psychiatric training and research. Indian J Psychiatry 1984;26:281-5. 20. The Times of India (Delhi edition) December 14, 2010. 21. Mohandas E. Roadmap to Indian Psychiatry. Indian Journal of psychiatry 2009;51:173-9. 22. Das M; Gupta N and Datta K. Psychiatric training in India. Psychiatric Bulletin.2002;26: 70-72. 23. Thirunavukarasu M, Thirunavukarasu P. Retrospective introspection. Indian J Psychiatry 2009;51: 85-7.

R.C. Jiloha Director Professor & Head Department of Psychiatry Maulana Azad Medical College, GB Pant Hospital & University of Delhi & Chairman Psychiatry Education Committee Indian Psychiatric Society [email protected]

7 Innovations in Postgraduate Psychiatric Teaching and Training: Experiments at NIMHANS

Santosh K. Chaturvedi, Prabha S. Chandra, Shekhar P. Seshadri, G. Venkatasubramaniam, Geetha Desai, Prabhat Chand, P.T. Shivakumar, C. Naveen Kumar

ABSTRACT Important aspects of adult learning need to be considered when planning an effective and meaningful teaching program for postgraduates. A well planned teaching program should take into account different types of learners, differing needs and learning methods of the whole group. Some of the innovations made in the traditional departmental programmes like seminars and journal clubs, as well as novel methods like modular teaching and small group works, role plays, have been described here. Assessment and feedback have been given due importance in not only feedback on competence and skills but also in modifying the teaching programmes. Keywords: Teaching methods, innovations, postgraduate teaching, seminars, modular teaching, assessments, feedbacks

INTRODUCTION

Postgraduate psychiatric education has developed on the British model, understandably, as most of the psychiatric practice in the pre independence era was influenced by the British Raj. However, while there have been some changes and developments in postgraduate training in different parts of the world, there have been little noteworthy changes in the training system in India.

There are several important aspects of adult learning that need to be considered when planning an effective and meaningful teaching program for postgraduates. Learning in adults is usually learner centred and relies heavily on the motivation of the learners rather than the charisma of the teacher. 58 Psychiatry in India : Training & training centres Traditional methods of teaching, such as lectures, may have an important albeit limited role specially that of whetting the student's appetite to learn more about a topic. However, methods that encourage students to be original, curious and creative allow for learning that is more sustained. Lack of research on educational needs and methods is a major caveat in postgraduate psychiatric training in India. A few studies on teaching related matters at NIMHANS help in considering innovative methods, discussed here. [1-5]

The success of a teaching program depends on several components. Figure 1 describes the elements of an effective teaching program. One of the key components is the commitment of the system (department or institution) to teaching and the facilities provided (including personnel, time and space).

Environment Motivation Culture Beliefs Systems Curiosity Peers Courage

Effective Methods Opportunities Learning Feedback Varieties Guidance Safety

Learning Styles

A well planned teaching program also takes into account various types of learners – i.e. auditory, visuo-spatial and kinesthetic types of learning and the differing needs and learning methods of the whole group. The program also needs to keep in mind differing levels of seniority, with the first years needing a slightly different program compared to third year trainees. The retention of learnt material of students depends on the methods used, as shown in the learning pyramid below. Chaturvedi et al : Innovations in PG training at NIMHANS 59 A safe space to learn without feeling harassed, bullied or being singled out is important. It is also necessary for the environment to be conducive to questioning, stating views and raising controversies without the fear of censure.

Overall, then the teaching program should have all the components described in Figure 1 and also focus on professionalism, ethics and encourage the trainees in psychiatry to achieve their full potential.

The current teaching program at the department of psychiatry has been planned keeping in mind some of these issues. Planning and managing a teaching program is a work in progress and relies heavily on trainee response and feedback. So, while the program is quite comprehensive and uses a variety of different teaching methods, it is by no means ideal or complete and needs to keep evolving.

Described below are some of the important innovations in the last few years that have been built on the traditional seminar/journal club format which have persisted for years.

The teaching program is designed, developed and monitored by the Academic Committee of the department which consists of an academic chairperson and supervisors (each program is supervised by faculty members) for seminars, research forum, modular training, psychotherapy, basic sciences and feedback / evaluation. There are trainee and senior resident representatives in each of these groups. There is a psychotherapy training programme which has been a structured and mandatory part of training since mid 1980s.

Seminars

Seminars are a regular part of the academic programme for residents and involve the trainee speaking on a topic under the guidance of a faculty member who is also the chairperson. To make the seminars more interesting and meaningful the selection of topics was handled by a seminar group which included trainees and senior residents in addition to faculty members. To add variety, debates and panel discussions have also been introduced.

To allow for feedback and evaluation, formal assessment of seminars is being done for the last two years. The assessment form consists of 10 items - completeness, presentation style, organization of slides, creativity in presentations, relevance to the topic, handling questions from the audience, critical evaluation of the topic, summarizing and concluding, handout (content, layout, referencing) and the chairpersons evaluation of the resident's preparations for the seminar. Each seminar is rated by two or three 60 Psychiatry in India : Training & training centres faculty members. The students also evaluate their own seminar on the same ten items and also rate the quality of chairperson's supervision for the seminar. Awards are given to the residents for best performances in seminars every year.

Research forum

Reading and critiquing an article is an integral part of postgraduate training programme. The research forum programme, also previously known as journal club, is held once a week. All the residents irrespective of the training years attend this programme. It was found that the first year trainees were finding it difficult to understand the methodology, statistics and other aspects of critiquing journal articles. This often led to a lack of interest and almost 'phobic avoidance' of the journal club program. Keeping this in mind, we have initiated a “preparatory research forum” programme lasting for six months for the first year trainees. This preparatory research forum which 'prepares' the trainees for the actual critical appraisal sessions, ends with a session about how to draft a protocol (Box 1)

Box 1: Domains of Preparatory research forum

A. Critical Appraisal: Principle of reviewing a paper, Reading an epidemiology paper, a RCT, meta-analysis, qualitative study B. Research Methodology: Effective PUBMED search, Asking a research question, Planning methodology, Using proper statistics C. Research Ethics using an online tutorial and case studies D. Writing a thesis protocol

In addition, there are workshops on thesis writing for the final year trainees on writing introduction and reviews of literature, depicting and discussing results and concluding and summarising. The session ends with a presentation on ways to convert the dissertation into a research paper.

There is an ongoing feedback and assessment process for the topics discussed in the research forum. The preliminary result is suggestive of satisfactory performance in presentation skills and need for improvement in the critiquing in different areas of the research paper.

The nature of articles include landmark or classic articles, controversial articles, meta analysis and Indian research. The articles are selected or nominated by trainees or faculty members and the depth and breadth of Chaturvedi et al : Innovations in PG training at NIMHANS 61 subject coverage is ensured.

Modular Training in Psychiatry

Modular training is a new teaching method reported to promote learning better than the conventional lecture method of teaching. A module is a self contained, independent unit of a planned series of learning activities. This is usually designed to help the student to achieve specific well defined objectives. Modular teaching should help the student to be more flexible and assist independent learning as far as possible. It is one of the preferred methods of teaching in many fields of education.

Components of a Module

A module has various components. It starts with a pretest assessment to evaluate the baseline knowledge of the subject. The pretest is followed by discussion on specific learning objectives. The various components of each topic in a module are covered using a variety of teaching methods that include video demonstrations, role play, small group work, discussion on case vignettes and didactic presentations. The scope for utilizing a variety of teaching methods is an important advantage of the modular teaching program. Alternative methods of teaching that promote interaction are preferred more than the didactic method. Each module ends with assessment and feedback.

Need for modular teaching

The need for modular teaching emerged from the review of examination performance of previous batch of trainees. In view of a predominant focus on clinical work, there was relatively less time for formal teaching. Significant limitations were noticed in knowledge in areas that were not routinely encountered in clinical practice. Modules that have been tried several years earlier with some success and were reintroduced. The difference this time was that instead of focusing on schizophrenia or bipolar illness that trainees anyway discuss daily in clinics, broader themes were considered. The increasing number of postgraduate trainees, need for having small group teaching to focus on individualized needs and promote interactive teaching were important reasons for focusing on modular teaching.

Topics for modular teaching

The modular program has covered several topics like Core Clinical Competencies, , Psychopharmacology, Geriatric Psychiatry, Presentation skills, Sexual dysfunction, Ethics, Psychiatric rehabilitation, Consultation Liaison Psychiatry and Forensic Psychiatry. Each 62 Psychiatry in India : Training & training centres module ranges from 4 to 8 sessions, and each session is of 2 to 3 hours. In some of the modules, like emergency module, the senior trainees play an active role in teaching along with the senior residents and faculty.

Logistic Issues in Modular training

There is logistic difficulty in organizing new teaching programs in addition to the existing schedule because of time and space constraints. Also, there is a concern about balancing between overburdening and inadequate formal teaching in postgraduate training. To cater to the current trends among students for e-learning, there is also a need for using technology in order to develop specific curriculum based on online modular teaching programs. This will provide flexibility for trainees to learn independently and also allow faculty members to 'teach' some sessions at their own pace.

The Objective Structured Clinical Assessment with Feedback (OSCAF) - This is a micro-teaching method adapted from the OSCE method and is particularly useful for skill based learning. This has been found to be useful, effective and popular with trainees. [1,3]

Psychotherapy training program

Psychotherapy and psychotherapy training has been carried out in the Department of Psychiatry since its inception. However, the training program took a mandatory, formal and structured form in 1984-85 and has a unique status in post graduate training across the country.

The structured program started as training in brief dynamic therapy but, over the years, has expanded to include Cognitive Behavioral and supportive techniques in the ambit thus becoming more eclectic in its scope and approach.

Faculty members opt to be supervisors. Currently, 18 faculty members are supervisors. Each supervisor has a trainee group consisting of 4-8 residents. The group meets once a week for the entire period of residency for group supervision.

The training program starts with a 6 session workshop series on interview and communication skills. This is followed by tutorial sessions on basic tenets of dynamic therapy. Thereafter, the trainee-therapists take up clients for therapy. Clients are drawn from the outpatient and inpatients services and across clinical units too. Therapy processes and materials are presented in group supervisory sessions. Trainees are encouraged to see a variety of clinical diagnoses and psycho-social contexts. Chaturvedi et al : Innovations in PG training at NIMHANS 63

Diploma trainees (2 year residency) are expected to complete 50 hours of supervised therapy and MD trainees (3 year residency), 75 hours over the residency and training period. The therapy processes are recorded in prescribed session reporting forms. Over the training period, trainee- therapists may see 4-10 clients for completed therapy work.

One completed therapy record is submitted for assessment at the end of the program. This submission includes a detailed process oriented proforma, all the session reporting forms and a dynamic formulation. The overall assessment is based on the quality of the submission, a presentation based on this and a viva voce. This is conducted by supervisors other than the therapy supervisor of the trainee. In addition, the individual supervisors rate their trainees on adherence to the programme and quality of engagement.

During the 2nd year of residency, a teaching module on psychotherapy comprising 8-10 classes is conducted on different schools of therapy/various aspects of therapy processes.

This is only the requirement for the "individual adult therapy program". Residents also have exposure to child, family, OCD focused or other behavior therapy and also rehabilitation . In addition, there are the psycho education sessions that residents routinely conduct in the wards with patients and their families.

The supervisors themselves meet periodically to discuss the program, supervisory experiences and conceptual issues pertaining to psycho therapy.

Feedback and evaluation of trainees

Feedback is an important aspect of training. Feedback should be holistic and focus on a trainee's knowledge, skills and professionalism. It can act as a formative assessment and encourages trainees to focus on deficit areas and hone their competence in others. Based on the several work place based assessment methods, the department has formulated this method of evaluating trainees and giving them feedback regarding their professional duties and learning as a psychiatry trainee. Many of these, are described in a chapter[5] in a book on Work Place Based Assessment. The 360 degree approach uses an overall and holistic approach rather than focusing only on knowledge. This evaluation occurs at the end of each clinical posting in the department of psychiatry. This method rates the trainee's overall performance in each domain as: requires improvement, satisfactory, very good. The following domains of training are evaluated: 64 Psychiatry in India : Training & training centres

1. Patient related a. Availability to the patients in times of crises b. Education about treatment and illness c. Ensuring confidentiality and maintaining boundaries d. Involving patients and care givers in decision making e. Psychotherapeutic skill or proficiencies in psychosocial management f. Ability to empathize with patients and families' problems g. Time spent with patients h. Meticulous physical examination and sensitivity to consider medical causes of illness

2. Knowledge a. Descriptive psychopathology b. Rational use of psychotropics c. Understanding of prescribing practices d. Diagnostic skills e. Prognostication f. Keeping abreast with latest advances

3. Skills a. Handling psychiatric emergencies b. Skills in treating difficult patients and families c. Communicating prescription to patient and families d. Writing adequate round notes and OP notes e. Ability to translate theoretical knowledge towards patient care

4. Participating in teaching programs a. Prior preparation b. Asking questions and raising issues c. Quality of presentations d. Participation in discussion/making comments

5. Communication with superiors and peers about patients a. With peers (residents/other trainees) b. With senior residents and consultants c. Discussion about ward behaviors with nurses d. Communication and clarity about treatment orders to nurses e. Communicating with senior residents/consultants from other disciplines-Clinical psychology/Social work/Neurology Chaturvedi et al : Innovations in PG training at NIMHANS 65

6. Overall attitude and professionalism

a. Punctuality and regularity; commitment towards clinical work, taking responsibility b. Planned leave and handing over cases if on leave c. Concern and care towards patients d. Recognizing limits of professional competence e. Making sure that personal beliefs do not prejudice patient care f. Ability/readiness/strategies to help all including, poor and underprivileged

7. Miscellaneous

a. Adequacy of discharge summaries b. Maintaining files/records c. Any other

Trainees are made aware of this format and details of assessment beforehand. While evaluating, consensus ratings from all the supervisors (including senior residents) in the unit are included. Any specific feedback from patients, nurses and other disciplines are also considered in the overall rating. The feedback is discussed with trainee and is also available in the departmental office. This feedback is in addition to the day to day monitoring and immediate contingent feedbacks that the trainees receive from their supervisors. This method helps in keeping track of trainees' progress longitudinally and acts as a formative assessment method.

Making learning fun and rewarding merit

As part of the teaching program, book reviews and movie clubs focusing on various aspects of psychiatry are regularly held. These are quite popular among trainees and add to the richness of the subject and break monotony.

At the end of each session, the department holds it 'Academic Oscars' during which the three best seminars, research forum/ journal clubs discussions, psychotherapy performances, are awarded. Also felicitated are trainees who have received academic awards during the year at any conference or meeting. This is a popular program and has served to motivate trainees and also adds to the bonhomie of the department.

The future

As mentioned earlier, teaching is also a learning process. We would like to focus now on enriching the basic science program keeping in mind the great 66 Psychiatry in India : Training & training centres strides in biology. This will involve more translational and applied research. Being a tertiary centre, our students often tend to see cases that are 'difficult to treat' and miss out on the 'bread and butter' psychiatry. Using methods such as OSCAF may help in overcoming some of these issues. Consultation Liaison training has also been a challenge as our trainees are posted in other hospitals with developed CLP training but monitoring and evaluation need to be streamlined. Problem based learning is another important toll that needs to be used more widely.

We need to evolve teaching and discussion spaces for training students in networking, leadership, career planning, working with NGOs and teaching skills. Using Technology effectively – e-learning, tele-psychiatric education, video conferencing will be some of the newer methods. In future, there is need to consider and adopt virtual & online teaching with Dynamic Interactive methods and develop, test and evaluate teaching methods for mental health including training of undergraduate and postgraduate teachers in psychiatry.

REFERENCES

1. Chandra PS, Chaturvedi SK, Desai G. Objective standardized clinical assessment with feedback: Adapting the objective structured clinical examination for postgraduate psychiatry training in India. Indian J Med Sci. 2009; 63:235-43. 2. Channabasavanna SM. Psychiatric education. Indian J Psychiatry 1986 ;28:261-262. 3. Chaturvedi SK and Chandra PS. Postgraduate trainees as simulated patients in psychiatric training – Role players and interviewers perceptions. Indian J Psychiatry 2010;52(4) In press. 4. Chaturvedi SK, Chandra PS, Tirthahalli J. Assessing Residents' Competencies: Challenges to Delivery in the Developing World – Need for innovation and change. In Text book of Workplace-based assessments in psychiatric training. Editors Dinesh Bhugra & Amit Malik, Cambridge University Press, London, 2011, In press. 5. Gopinath PS & Kaliaperumal VG. Comparative study of different assessment methods for postgraduate training in psychiatry—a preliminary study. Indian J Psychiatry 1979;21:153-154. 6. Murthy P, Chaturvedi SK, Rao S. Learner centred learning or teacher led teaching: a study at a psychiatric centre. Indian J Psychiatry 1996;38:133-36.

Santosh K. Chaturvedi Professor & Head

Prabha S. Chandra Professor & Chairperson, Academic Programmes

Shekhar P. Seshadri Professor & Coordinator, Psychotherapy Programme Chaturvedi et al : Innovations in PG training at NIMHANS 67

G. Venkatasubramaniam Associate Professor, Coordinator, Basic Science training

Geetha Desai Associate Professor, Coordinator, Seminars

Prabhat Chand Associate Professor, Coordinator Research Forum

P.T. Shivakumar Assistant Professor, Coordinator, Modular training

C. Naveen Kumar Assistant Professor, Coordinator, Assessments

Department of Psychiatry National Institute of Mental Health & Neurosciences Bangalore, India

For Correspondence: Santosh K. Chaturvedi Professor & Head Department of Psychiatry NIMHANS Bangalore 560029 [email protected]

8 Provisions for Training Centres: Recent Developments

R. Sagar, R.D. Pattanayak

ABSTRACT

Investment in the human capital is crucial to the growth of a nation. The huge deficit in the trained manpower limits the implementation of various mental health initiatives. The expansion of opportunities for postgraduate training can be a useful instrument for a positive change; however relatively little attention has been directed to postgraduate training centres in the previous five year plans. More recently, there have been several new initiatives to expand the postgraduate training opportunities and certain concrete steps have been taken by the government in this direction. We discuss the provisions for postgraduate training centres under five year plans with a focus on recent developments.

Key words: Training centres, Psychiatry, Provisions, India, Five year plan

Education costs money, but then, so does ignorance (Sir Claus Moser)

INTRODUCTION

Investment in building and nurturing the human capital is crucial to the growth of a nation and if done properly, can yield tremendous benefits. Inadequacy of human resources, both in terms of availability as well as expertise, has been recognized as a major impediment in meeting the mental health goals. The average national deficit of psychiatrists in India has been estimated to be 77%, considering a prevalence of 6.5% for serious mental disorders.1 Nearly one-third of the population has more than 90% deficit of psychiatrists. There is a similar, severe shortage of psychologists, nurses and other paramedical resources in the field of mental health. The expansion of opportunities for postgraduate training can be a useful instrument for positive change. So far, only little, if any, commitment was evident in the 70 Psychiatry in India : Training & training centres successive five-year plans since the beginning of National Mental Health Programme (NMHP)2 in 1982. The budgetary allocation for mental health was severely limited till the 10th five year plan (2002-07)3, when the need to upgrade psychiatric training was recognized and the budget for NMHP was increased to proposed 190 crores.2 More recently, there have been several new initiatives to further expand the postgraduate training opportunities and certain concrete steps have been taken by the government in this direction under the 11th five year plan (2007-12).4 We discuss the provisions for postgraduate training centres under National Mental Health Programme with a focus on recent developments.

Postgraduate Training Centres in India

As of 14th December, 2014, there are 160 Medical Colleges which have been recognized / permitted, which amounts to a total of 416 seats of M.D. psychiatry annually5. There are 59 MCI recognized colleges for Diploma in Psychological Medicine (DPM) with a total of 129 seats annually. The Diplomate National Board (DNB) has seats for psychiatry all over India 6. The existing training infrastructure in the country produces approximately 50 Clinical Psychologists, 25 PSWs and 185 Psychiatric Nurses per year. The non- existent psychiatry departments in as many as one in four medical colleges, limited number of postgraduate seats and difficulty in retaining teaching faculty creates a huge deficit in terms of trained manpower. In terms of human resources, as per the WHO data7, India has two psychiatrists per million (but recent estimate may be approximately four per million) and less than one per million each of Psychiatric Nurse, Clinical Psychologist and Psychiatric Social Worker . Due to acute shortage of Clinical Psychologists and Psychiatric Social Workers, persons with M.A. in Psychology and MSW in Social work had to be temporarily recruited for District mental health programme after short-term training at regional centres. Even in the postgraduate training centres, the medical staff and non-medical personnel (psychiatric nurses, psychologists, social workers, occupational therapists, etc.) are highly inadequate to provide a comprehensive training 8. These figures emphasize the urgent need to prioritize the manpower development in mental health.

Provisions under Five year Plans: The Journey so Far

India does not have a separate Mental Health Policy till date and only a limited number of provisions for mental health are incorporated in the National Health Policy. The gross inadequacies in the area of mental health care and the need to establish teaching hospitals was acknowledged in the first five year plan (1951-56) 9 itself which stated that “a beginning should be made in special and teaching hospitals and later extended to district hospitals…” . In the ensuing five year plans, some attention was directed at the establishment and support Sagar & Pattanayak : Provisions for training centres :Recent Developments 71 of Mental Health Institutes and the need for specialist training of doctors and social workers. However, most of the attention was limited to a theoretical mention while there was little, if any, separate funding for mental health which continued to remain a least priority area in the health sector. The limited infrastructure for mental health training in medical colleges coupled with dismal funding for mental health did little to advance the psychiatric training on a larger scale.

The National Mental Health Programme (NMHP)2 also envisaged improvement in manpower development in addition to its primary objectives. However it did not make much headway since its launch in 1982 either in seventh or eighth five year plan. During the ninth five year plan (1997-2002)10, the NMHP was expanded to 22 districts and the need for training of health professionals in psychiatry was highlighted. Psychiatry departments in medical colleges were expected to play a pivotal role in the operationalisation and monitoring of the programme However, there were only 50% of medical colleges with a psychiatry department by the end of twentieth century. NMHP was re- oriented and re-strategized for implementation with the introduction of District Mental Health Programme during 10th five year plan (2002-07)3 during which there was a commitment expressed for strengthening and modernization of mental Hospitals and upgradation of Psychiatric wings in the General hospitals/Medical Colleges. This reflected in a substantial increase of fiscal allocation from a mere 28 crores in the ninth plan to proposed 190 crores for the 10th plan period.

National Commission of Macroeconomics and Health (NCMH) in their 2005 report11 had recommended an additional funding for establishment of new medical, nursing, and other institutions and in-service training of health personnel. It was also noted that priority should be given to reduce the existing inequality by establishing 60 medical colleges in deficit states e.g. Uttar Pradesh, Rajasthan, Madhya Pradesh, Chhattisgarh, etc. and 225 new nursing colleges in underserved areas of India.

The 11th Five-year plan: Recent developments

The lessons have been learnt from the past difficulties encountered due to a deficit of trained manpower in mental health. As a corrective measure, the revisions have been made to NMHP under the 11th five year plan4 in consultation with various stakeholders. Part one of NMHP12 is primarily directed at Manpower Development and a strong commitment has been made for human resource development by allocating Rs 408 crores for Manpower Development Component for NMHP under 11th five year plan. An additional Rs 58 crores has been reserved for upgradation of Psychiatric wings of medical colleges, a spillover from 10th plan5. These along with other 72 Psychiatry in India : Training & training centres initiatives under 11th five year plan4, 12 have been summarized below:

Establishment of Centres of Excellence in Mental Health

The centres of excellence are being established by upgrading and strengthening identified mental health hospitals or institutes for addressing the manpower gap in the field of psychiatry, psychology, psychiatric social work and psychiatric nursing. In the most recent year (2009-10)13, seven regional institutes have already been provided funds out of at least 11 centres to be undertaken during current five year plan. The Budgetary support of upto Rs 30 crores per center has been provided for capital work, equipment and furnishings and support for faculty induction and retention during the plan period, after which the state government is expected to take over the funding. The expected outcome of this initiative is an addition of 56 postgraduate seats in mental health (4 M.D/ D.N.B. Psychiatry, 16 M. Phil. Psychology, 16 M.Phil. Psychiatric Social Work and 20 Diploma in Psychiatric Nursing) for each centre every year. This amounts to an annual increment of 616 seats of post graduation in mental health from a total of 11 centres.

Scheme for Manpower Development in Mental Health

The 11th five year plan also supports other training centers in the form of Government Medical Colleges, Government General Hospitals and State run Mental Health Institutes to provide an impetus for manpower development. These Institutes and hospitals are encouraged to start postgraduate courses or increase the intake capacity for postgraduate training in Mental Health through the improvement in basic infrastructure and engaging faculty in all specialities of mental health. Support would be also provided for setting up and strengthening 30 units of Psychiatry, 30 departments of Clinical Psychology, 30 departments of Psychiatric Social Work and 30 departments of Psychiatric Nursing with the support of up to Rs 0.5-1 Crore per postgraduate department during the plan period, after which the state government is expected to support the funding. During the year 2009-10, support has already been provided to 9 institutes with 19 PG departments for manpower development.13 The expected outcome of the manpower development schemes is 1756 Mental Health Professionals annually, which includes 104 Psychiatrists, 416 Clinical Psychologists, 416 Psychiatric Social Workers and 820 Psychiatric Nurses.

Upgradation of Psychiatric Wings of Govt. Medical Colleges/General Hospitals

Psychiatry Departments of Government Medical Colleges which have not been funded earlier during the 10th plan period will be supported as part of this spill-over scheme. Some of the deserving areas where there is no well Sagar & Pattanayak : Provisions for training centres :Recent Developments 73 established government medical college, the Government General hospitals or District hospitals could be funded for establishment of a psychiatry wing. A grant of up to Rs 50 lakhs for upgradation of facilities and equipments has been reserved per college, with a preference for colleges or hospitals planning to start/ increase seats of postgraduate courses in Psychiatry. Every medical college should ideally have a Department of Psychiatry with minimum of three faculty members and inpatient facilities of about 30 beds as per the norms laid down by the Medical Council of India. The psychiatric social workers, and psychiatric nurses are essential for an ideal psychiatric department in a medical college. Nearly one-third of the existing medical colleges in the country do not have adequate psychiatric services. Upgradation of existing psychiatry services aims at the provision of inpatient services, necessary equipments and provision for trained manpower.

Modernisation of State-run Mental Hospitals

As per the existing scheme to modernize the state-run mental hospitals, a one-time grant with a ceiling of Rs.3 crores per hospital is provided on the basis of benchmark of requirement and level of preparedness The grant is primarily aimed at development of infrastructure and equipments., with a priority for hospitals which have not been funded previously in the 10th plan .

General Initiatives for improving medical education

Ministry of Health and Family Welfare has taken several steps for development and expansion of medical education during the current five- year plan. These include relaxation of the existing norms for infrastructure and training requirements, amendments for setting up of medical colleges and increasing postgraduate seats by revision of teacher: student ratio.4 A sanction of a revised sum of Rs. 9,307 crores has been made towards envoking the establishment of six A.I.I.M.S.-like institutions within the next two years, and upgrading 19 medical college institutions of which nearly eight will be upgraded by end of this year. These general initiatives for medical education may have positive implications for the postgraduate training in psychiatry as well.

National Council for Human Resources for Health: A new step

A recent major initiative has been the proposed setting up of National Council for Human Resources for Health as an autonomous, overarching regulatory body to enhance the supply of skilled personnel in the health sector throughout the country. The Ministry of Health has already readied the National Council for Human Resource in Health Draft Bill which is now available for public comments. 14 The task force has proposed that prominent 74 Psychiatry in India : Training & training centres hospitals across the country be allowed to offer post-graduate courses. A National Health Human Resource Policy which maps the current deficits, and also projects the needs for 2020, will help define the number and location of the new institutions needed for training doctors, nurses, dentists, paramedics and other health workers especially for presently underserved districts.14 The council is expected to promote the growth and development of health personnel in a better fashion through better organization, co-ordination and accountability.

Future Outlook

Mental health has been increasingly recognized as an integral component of health, but is yet to receive its full due and credit. The growth of training centres in mental health cannot be viewed independently from the growth and development of psychiatry as a speciality. Recent developments and initiatives for training centres have been quite encouraging and likely to fuel further advances of post graduate training. The expansion of budget for mental health is a positive step with far reaching consequences for psychiatric training centres in India. However, there is a need to sustain the momentum in each successive five year plan. There is also a need to assist the training centres to provide more courses of both higher order e.g. super speciality courses to develop highly skilled resource personnel and lower order e.g. short-term courses after M.B.B.S to cater to larger population needs. There is an acute need to emphasize on the quality assurance as well as uniformity of training of psychiatrists, clinical psychologists, psychiatric nursing and psychiatric social work all across the country, which can be ensured through proper monitoring of training centres. The National Council for Human Resources in Health is expected to take over these functions in future; however the degree of emphasis on mental health remains to be seen. In recent times, the Medical Council of India (MCI) has taken a serious note on strengthening the subject of psychiatry in undergraduate medical training; therefore it may be envisaged to have an augmentation or independent status of psychiatry department in many more medical colleges. This may lead to more centres to take up post graduation in psychiatry in future. In our country, there is an acute shortage of mental health professionals coupled with high level of migration; hence the best option is to have large number of training centres producing more psychiatrists to fulfill the needs of the country.

In conclusion, the recent provisions to support the psychiatric training centres are a fresh change from the age-old neglect faced by mental health. While they may not be enough to bring a radical change, but mark a beginning for a slow and gradual change. We see them as an indicator of positive intent Sagar & Pattanayak : Provisions for training centres :Recent Developments 75 and commitment on the part of the government and perhaps, as a ray of hope to a brighter future for psychiatric training in India.

REFERENCES

1. Thirunavukarasu M, Thirunavukarasu P. Training and National deficit of psychiatrists in India - A critical analysis. Indian J Psychiatry 2010;52:83-8. 2. National Mental Health Programme1982 Minstry of Health and Family Welfare, Government of India, Available at: http://www.nihfw.org/NDC/DocumentationServices/ NationalHealthProgramme/NATIONALMENTALHEALTHPROGRAMME.html. Accessed on Dec 20, 2010. 3. Tenth five year plan 2002-07, Planning Commission, Government of India. Available at http://planningcommission.gov.in/plans/planrel/fiveyr/welcome.html. Accessed on Dec 20, 2010. 4. Eleventh five year plan 2007-2012, Planning Commission, Government of India. Available at http://planningcommission.gov.in/plans/planrel/fiveyr/welcome.html.Accessed on Dec 20, 2010. 5. Medical Council of India. Colleges and Courses. Available at: http://www.mciindia.org/ InformationDesk/CollegesCoursesSearch.aspx Accessed 14th Dec. 2014. 6. National board of examinations. Available at: http://www.natboard.edu.in/Accessed Dec 12, 2011. 7. World Health Organization, WHO-AIMS Report on Mental Health System in Uttarakhand, India,at: http://www.who.int/mental_health/uttarkhand_who_aims_report.pdf, Accessed on Dec 26,2010. 8. Kulhara P, Chakraborti S. Postgraduate training in India: Current status and Future Directions.In: Mental Health: An Indian Perspective (1946-2003) (ed.) Agarwal SP: Directorate General of Health Sciences & Ministry of Health and Family Welfare, New Delhi, p 215-218 9. First five year plan, Planning Commission, Government of India. Available at http:// planningcommission.gov.in/plans/planrel/fiveyr/welcome.html. Accessed on Dec 20, 2010. 10. Ninth five year plan, Planning Commission, Government of India. Available at http://planningcommission.gov.in/plans/planrel/fiveyr/welcome.html Accessed on Dec 20, 2010. 11. Report of the National Commission on Macroeconomics and Health. National Commission of Macroeconomics and Health, Ministry of Health and Family Welfare, Government of India, New Delhi, 2005. 12. Implementation of National Mental Health Programme during the Eleventh five year plan 2009, Ministry of Health and Family Welfare, Government of India. Available at: http://www.mohfw.nic.in/NMHP.pdf. Accessed on Dec 20, 2010 . 13. Annual report to people on health 2009-10, Government of India, Ministry of Health and Family Welfare, Government of India. Available at: http://www.mohfw.nic.in/Annual% 20Report%20to%20the%20People%20on%20Health%20_latest_08%20Nov%202010.pdf Accessed Dec 20, 2010. 14. National Council for Human Resource in Health Draft Bill 2009, Ministry of Health and Family Welfare, Government of India. Available at: www.mohfw.nic.in. Accessed Dec 20, 2010. 76 Psychiatry in India : Training & training centres Rajesh Sagar (Author for correspondence) Associate Professor Department of Psychiatry All India Institute of Medical Sciences Ansari Nagar, New Delhi, India-110029 & Secretary, Central Mental Health Authority Tel: 011-26588500-3644, 3236 E-mail: [email protected]

Raman Deep Pattanayak Senior Research Associate (CSIR) Department of Psychiatry All India Institute of Medical Sciences Ansari Nagar, New Delhi, India-110029 9 Role of Academic Centers in meeting the Mental Health needs of Indian Population

R. Srinivasa Murthy

Mental health programmes are at a critical phase in India. It will be soon 30 years, from the time the National Mental Health Programme (NMHP) was formulated in 1982. A whole generation of leaders who initiated a number of innovative approaches to mental health care will be soon be replaced by a new generation of mental health professionals. The country is also experiencing policy changes that aim for greater inclusion of the population in all programmes and services and an enhanced budgetary allocation for social welfare programmes.

The importance of 'Providing Mental Health Care' for all is reflected in the choice of the topic as the theme of the Annual Conference, ANCIPS, 2011. In the scientific programme, of ANCIPS, 2011, there are a number of scientific sessions directly addressing this topic. In addition to the theme symposium, there are symposiums on (i) Ministry of Health symposium on National Mental Health Programme (ii) Mental : historical perspectives (iii) Models of Sensitising Primary Care Physicians to Mental Health Care (iv) Community Psychiatry in India: from concept to reality(v) Role and responsibilities of institutions in providing mental health care to the community.[1]

Academic centres have an important role in the provision of mental health care to the total population (WHO,2006, Box 1) .[2]

BOX 1: Areas in which mental health professionals, working in the university centres, can play a role in the national programmes of mental health ( modified from WHO,2006)

l Technical advice and assistance in formulating the national mental health policy and programmes 78 Psychiatry in India : Training & training centres

l Representation on national and provincial multisectoral groups to monitor and coordinate the progress of the programme.

l Leadership role in the activities of the national programme, which can include:

l organization of sections of community psychiatry in the existing departments of psychiatry.

l activities related to the extension of mental health care services in the rural and urban areas (responsibility of providing care to specific catchment areas).

l development of suitable teaching/learning materials in local languages for the training of general physicians and other staff working in primary health care, and organization of workshops for training of trainers, in collaboration with the ministry of health.

l Orientation of the general public and non-governmental organizations to the programmes on promotion of mental health through meetings and lectures on radio and television and writings in the press, etc.

l Reorientation of teaching of all health personnel, such as psychiatrists, doctors, nurses, social workers and psychologists, with special emphasis on:

l inclusion of behavioural and psychosocial sciences in the curricula.

l inclusion of principles and activities of national mental health policy and programme as a regular part of teaching.

l practical training in community mental health linked with extension of services in the rural/urban areas. l Involvement in needs-based research to support the national programme and evaluation of the innovative approaches developed as part of the national programme. Murthy : Role of academic centres 79 In India, in the past six decades, academic centres have been in the forefront in providing national leadership in the areas of mental health.These centres have contributed to the human resources development, support to the development and implementation of the NMHP and created new knowledge through research. Currently, there are many challenges in the areas of mental health, ranging from the large treatment gap, poor utilisation of available services, poor implementation of the national programmes, changing demography of the population, growing problems of drug dependence and suicide. There is also the growing presence of private sector medicine, migration of professionals, and changing perceptions of mental health in the general population. In the commercial field, innovative approaches have been utilised to take goods and services to the people (eg. mobile phones, agricultural initiatives, consumer goods, PDS distribution, health insurance etc). These efforts have demonstrated both the need in the population for services and the feasibility of addressing them through innovative approaches.[3] There is a need for the academic centres to reposition their place in the country by reorienting their priorities and practices and reclaiming the leadership role. Specifically, there is need for (1) Optimization of resources to achieve maximum advantage to patients and through empowerment of people towards mental health (2) Training of professionals and non- professionals to meet the national needs (3)Innovative methods in management of mentally ill persons (4) Developing standard treatment guidelines for mental illnesses (5) Focussed multi-disciplinary research on priority conditions of national importance (6) Understanding social changes as it affects mental health of the population and identifying corrective interventions and (7) Supporting the voluntary organisations and state Governments to make mental health a priority in their activities. The current article presents an overview of the mental health needs and reviews the roles, academic centres have played in the past and identifies areas for future action. Challenges for mental health care in India One of the striking aspects of the current situation with regard to mental disorders in the country is the big treatment gap (eg. over half of all persons suffering from even severe mental disorders such as schizophrenia have never been treated). There is also poor utilisation of the available services as expressed in high drop out rates after initial contact with services and poor compliance with treatment. Both of these factors contribute to higher levels of disability and burden to the family and the community. The other aspect is the stigma about these conditions and violation of human rights of these individuals (eg. mentally ill in beggar homes, unlicensed centres for care of drug dependent persons, inhuman treatment of the ill persons). The state 80 Psychiatry in India : Training & training centres level and central level mental health programmes are not operating at the optimum level. The implementation of district mental health programme at the State and Country levels (as evaluated recently) are not serving their objectives mainly for want of adequate technical support and monitoring and evaluation mechanisms. In a way, there are plenty of resources for the mental health programme but poor outcome to the benefit of patients. The leadership provided by Academic centres to support the NMHP has not been adequate especially in the last one decade. The other distressing development is the continuing migration of trained professionals to western countries for lack of attractive opportunities within the country. Priority public health conditions like depression, psychosis, suicide, are not receiving the type of attention that can bring positive results at the level of states and the country. The other striking aspect is the wide variation in the available mental health resources across the states and union territories. At the national level, politically sensitive issues like farmers' suicide continue with no systematic explorations of causes and no solutions coming from mental health professionals. Past efforts to address national needs Academic centres during its six decades have shown that it is possible to address national needs. Academic centres have supported the human resource development in the country. Over the decades, new courses and professionals and non-professionals relevant to the national needs have been included in this agenda of creating human resources for the national needs. The role of academic centres in the formulation of the National Mental Health Programme and its implementation has been significant. For example, it was the community mental health initiatives by National Institute of Mental Health and Neurosciences(NIMHANS), Bangalore at the Sakalawara centre along with that of Postgraduate Institute of Medical Education and Research(PGIMER), Chandigarh at Raipur Rani during 1975-1982, that led to the formulation of NMHP in 1982. It is salient to note that the regular training of medical officers was started by NIMHANS in April 1982, 6 months before the formulation of NMHP (in August 1982). The initial experiences of NIMHANS and PGIMER were followed by other academic centres like Hyderabad, jaipur and Delhi. Subsequently, NIMHANS developed the Bellary District Mental Health Programme providing a feasible model for national level implementation. During the last decade, the efforts to modernise mental hospitals by systematic review of the conditions and suggesting changes has been an important contribution of NIMHANS.[4] In the area of research, academic centres at Bangalore, Baroda, Bikaner, Chandigarh, Goa,Calcutta, Lucknow, Madras, Madurai, New Delhi,Patiala & Vellore, have addressed priority topics in the field of mental health(community mental health, acute psychosis, schizophrenia, drug dependence, old age psychiatry, suicide). Murthy : Role of academic centres 81 Current National Priorities in mental health During the last six decades, the country has changed in a large number of areas. Relevant to the current review are the following: Currently private sector medicine is occupying greater space in the health scene of the country. This poses special challenges for the population groups who are poor and marginalised as they can not access the private sector services. In addition, the private sector will never be able to address the total needs of the population. There is a need for Academic centres to address the needs of the larger population. The other major change is the shifting demands of the general population. Health planners have recognised the need to cover the total population for all services. In addition, such an attempt at universal coverage, would require people’s involvement and empowerment of the population in health care in general and mental health in particular. This requires greater sharing of information and caring skills with the general population and ill persons and their families. Consequent to the above two developments, there is need for a different approach to training of professionals at academic centres. Development of leadership and professionals able to and willing to work with national programmes is an urgent need. Such a reorientation of the training at academic centres can not only create a group of professionals relevant to the country, but also hopefully limit their migration to other countries. One of the important roles academic centres played during the period of 1975-2000, was to support the national initiatives like the NMHP. However, the path breaking NMHP to DMHP implementation is in a poor state of implementation. There is an urgent need for the academic centres to re- establish their role in the NMHP-DMHP, especially in the monitoring and evaluation of the mental health care provided through these programmes.[5] There are major changes in the area of human rights of the persons who are disabled and mentally ill through legislative changes (eg. revisions of Mental Health act, 1987, Persons with disabilities Act,1995, The National trust Act, 1999). There is need of urgent action given the country's accession to international laws such as the United Nations Convention on the Rights of Disabled Persons (CRPD). Innovations in other areas In the area of commercial and private sector there have been major innovations both to create demand in the general public, and to take services to the people (often called as building from the bottom of the pyramid). Examples of success of these are the way telephones, especially mobile services have extended both in reach and utility to meet multiple needs of the 82 Psychiatry in India : Training & training centres population; the growth of personal care industry; increase in use of traditional systems of medicine by the general population, use of information technology for agricultural purposes. The DIGITAL GREEN initiative is illustrative of what can be achieved. The initiators of this noted as mentioned: ‘We found that when farmers identified with people who were demonstrating something on screen, they would ask what the name of the farmer was or seek other details on what they were doing. They would pick up audio and visual cues, and dialects too are critical here. Once they form the connection, we knew we had them 'hooked'.[6] One other example is the MOBILE HEALTH initiative of IIT, Madras.[7] Similarly, the PDS system in Chattisgarh state has been revolutionised by (I) expanded reach (ii) expanded number of beneficiaries (iii) better vigilance(iv) increased awareness in the population and (v) improved economic viability.[8] The initial success of health insurance by Star Health Insurance is another example. In this commercial, the focus was on low to middle income customers; also importance was given to mass scale micro-insurance, cost savings and better control of hospitals and fully in-house administration.[9] There is an opportunity waiting in the mental health for such innovations. Focussed initiatives for the academic centres The central theme for the academic centres should be the optimization of resources to achieve maximum advantage to the country at all levels.[2] The following are some of the examples of how this can be achieved. 1. Optimization of resources to achieve maximum advantage to patients reaching the services: In the care of persons with mental disorders, there are five challenges, namely, (i) early identification of distress/ disability by the ill persons/family members (ii) patients/families deciding to seek help from professionals; (iii) availability of accessible mental health services (iv) following initial consultation, regular contact with the service, following the advice about medicines, life style changes and crisis support (v) reintegration and rehabilitation into the family and community. In the past reaching the population with relevant information and maintaining a two way contact was a challenge. However, with the explosion of mass media and the availability of mobile phones within reach of most of the population, it is possible to rethink these issues. Academic centres, by making the information about the health conditions available in a way that individuals can care for themselves, be in contact through helplines and websites that are interactive, can Murthy : Role of academic centres 83 change a lot in the current problems of treatment gap, treatment delay and drop out rates. In addition, the physical visits to the hospital can be optimised to decrease the crowds in the OPD services. The need is to think of a big initiative to synthesise information, update the same and develop and run an interactive service. The academic centres being located in different states allows for academic centres to play an important role at the local level by developing materials that are relevant and applicable at the local/state levels. When this service becomes operative, it should be possible for the general public to visit the website/phone for help at different stages of their health needs. This will require rethinking the way we deliver health care. By making use of ICT technologies effectively we can increase coverage and improve adherence by empowering the patients in a manner never possible before. 2. Training of professionals and non-professionals to meet the national needs: Academic centres have pioneered the human resource development in the country and continuously developed training programmes to meet the needs of the country. However, as yet, the academic centres trainees do not have the type of identity that some of the Institutions like C.M.C.Vellore have in preparing professionals with a specific identity- the orientation and skills that are relevant to the national needs both in the public and private sectors. This goal has to come from the role models the teachers, the components of the training programmes (syllabus), choice of research activities and exposure to leaders of different disciplines, alumni working in different settings and stimulating the students with regard to national issues (as done, for example as a model, in the training of civil servants at the Lal Bahadur Shastri Academy, Mussorie). Professionals trained need to know that they have a specific purpose in the country and should be capable of being leaders in their area of work, whether working in the public sector, private practice or with voluntary organisations. 3. Innovations in the management of mentally ill and neurologically ill persons: Large numbers of persons with mental disorders in the country and the limited resources call for innovation in mental health care. As noted earlier, the different academic centres have pioneered this area. Some examples are the family nurse support to schizophrenics, school mental health, use of Yoga, Ayurveda, disaster mental health care, care of the elderly persons. There is much greater need for this area of work from all of the centres in the different parts of the country. The development innovations also requires systematic evaluation of these approaches in the form of peer review that would stand the scrutiny of the highest scientific standard. This is best undertaken by the multi- 84 Psychiatry in India : Training & training centres disciplinary staff of the academic centres. 4. Developing standard treatment guidelines for mental illnesses: The Indian Psychiatric Society in the last few years has worked towards developing treatment guidelines for the country. This is a very good beginning. Academic centres using its strength of large patient care load and both multi-disciplinary staff and students can develop the standard guidelines relevant to India and other developing countries. By this effort, the academic centres would be fulfilling a national need as well as improving the care programmes in their centres. The WHO strategy of the mhGap programme “mhGAP Forum” (Mental Health Gap Action Programme) needs to be systematically evaluated and translated into a programme that meets the national needs. The implementation of these programmes, ideally integrated into the NMHP-DMHP, needs to undergo a rigorous monitoring and evaluation. 5 Focussed multi-disciplinary research on priority conditions of national importance :During the decade of 1998's, the Indian Council of Medical Research, New Delhi, in collaboration with a large number of academic centres in the country, initiated 'Strategies for mental health research' and addressed important public health issues. These researches demonstrated both the feasibility and the value of collaborative research.[10] However, these initiatives have not been maintained in the last two decades. One of the main areas where the academic centres needs to take leadership is to place mental health in the public health priorities in India. It needs to seriously examine what it will take to scale up interventions, what is the cost-effectiveness of these and monitor the scale-up to show what difference it can make. The different academic centres could create think tanks on specific topics, either alone or in collaboration with other centres, to identify specific areas of research in mental health that are at the cutting edge and seek resources for these to demonstrate leadership in this area. The academic centres should be providing national leadership in a set of key areas that are of national and international importance. Academic centres need to be proactive. given the changing landscape for mental health both in India and globally. 6 Understanding social changes as it affects mental health of the population and identifying corrective interventions: India is experiencing one of the greatest rate and quantum of social changes which is challenging individuals, families, communities and social institutions in their capacities to cope with the changes. There is evidence of the fall out of these in the form of increasing substance abuse, growing suicide rates, increasing divorce rates, poor quality of life of elderly and disabled. There is need for multidisciplinary research both to understand and also to develop protective and promotive Murthy : Role of academic centres 85 interventions to address the rapid changes. Detailed qualitative and quantitative studies need to be undertaken in partnership with a range of disciplines traditionally not considered relevant in the Institute (such as economists, anthropologists, social scientists and policy makers) to address the fallout of these rapid social changes. Interventions for these mental health and related outcomes can then be systematically identified, implemented and monitored over time. 7. Supporting the voluntary organisations and State Governments to make mental health a priority in their activities: There is currently an explosion of half way homes, counselling centres by the voluntary organisations with great variations in the way different states are giving importance to mental health. Academic centres can provide technical support to both voluntary organisations and the state governments to make mental health and neuro-sciences their priority. In conclusion, academic centres have vital role in the development of mental health services in the country. They can build on their past efforts and strengths ( very vividly brought out, by the reports of the individual centres, in the special supplement) by developing measures to address the national needs. This is a unique challenge and opportunity for all academic centres. Acknowledgements: My sincere thanks to Prof. N.N,.Wig, Chandigarh, Dr. K.S. Raghavan, Hyderabad and Dr. Somnath Chatterji, WHO, Geneva for their critical suggestions of the initial drafts of this article. REFERENCES

1. Scientific Program: Conference Theme: “Providing Mental Health Care to All”.Retrieved on 27th Dec. 2011.www.ancips.com/scientific-program. 2. Disease Control Priorities Related To Mental, Neurological, Developmental and Substance Abuse Disorders. Mental Health: Evidence and Research:Department of Mental Health and Substance Abuse. World Health Organization,Geneva 2006.Retrieved on Dec 29 2011 from: http://www.dcp2.org/file/64/WHO DCPP%20mental%20health% 20book_final.pdf. 3. Mental Health Policy Project: Policy and ServiceGuidance Package, Executive Summary. World Health Organization 2001.Retrieved on Dec 29 2011 from: http://www.who.int/ mental_health/media/en/47.pdf. 4. Isaac MK. District Mental Health program at Bellary. Community Mental Health News 1988.NIMHANS Bangalore;11-12(April-Sep)8. 5. Sinha SK, Kaur J. National Mental Health Programme: Manpower development scheme of eleventh five year plan. IndianJPsychiatry 2011;53(3):261-265. 6. Deepa Kurupa. Starring Farmers, video goes 'grass-root' here-The Hindu, September 15,2010.Retrieved on Dec 29 2011 from: http://www.thehindu.com /todays-paper/tp- features/tp-opportunities/article646447.ece. 7. Building Mobile Health-Editorial, The Hindu, September 17,2010.Retrieved on Dec 29 2011 from: http://www.thehindu.com/opinion/editorial/article672982.ece. 8. Mishra U.How the PDS is changing in Chattisgarh.Forbes India Dec 11 2010. 86 9. Dharmakumar R.Star Health Insurance goes from the Hospital to the Bank.Forbes India Dec 15 2010. 10. Shah B, Parhee R, Kumar N, Khanna T, Singh R. INDIAN COUNCIL OF MEDICAL RESEARCH.Mental Health Research in India(Technical Monograph on ICMR Mental Health Studies):Division of Noncommunicable Diseases. Indian Council of edical Research New Delhi 2005.

R. Srinivasa Murthy Professor of Psychiatry(retd) C-301; CASA ANSAL Apartments, 18, Bannerghatta Road, J.P.Nagar 3rd Phase, Bangalore-560076. India [email protected] 10 Psychiatric Nursing: Past, Present and Future

N.V. Muninarayanappa, M. Bharti

INTRODUCTION: In 13th century medieval Europe, psychiatric hospitals were built to house the mentally ill, but there were not any nurses to care for them and treatment was rarely provided. These facilities functioned more as a housing unit for the insane. Throughout the highpoint of Christianity in Europe, hospitals for the mentally ill believed in using religious interventions. The insane were partnered with “soul friends” to help them reconnect with society. Their primary concern was befriending the melancholy and disturbed, forming intimate spiritual relationships. Today, these soul friends are seen as the first modern psychiatric nurses. [1] The 1790s saw the beginnings of moral treatment being introduced for people with mental distress. The concept of a safe asylum offered protection and care at institutions for patients who had been previously abused or enslaved. In the United States, Dorothea Dix was instrumental in opening 32 state asylums to provide quality care for the ill. Dix also was in charge of the Union Army Nurses during the American Civil War, caring for both Union and Confederate soldiers. Although, it was a promising movement, attendants and nurses were often accused of abusing or neglecting the residents and isolating them from their families. In Europe, one of the major advocates for mental health nursing to help psychiatrists was Dr. William Ellis. He proposed giving the “keepers of the insane” better pay and training so that more respectable and intelligent people would be attracted to the profession. In his 1836 publication of Treatise on Insanity, he openly stated that an established nursing practice calmed depressed patients and gave hope to the hopeless. In the 1840s, Florence Nightingale made an attempt to meet the needs of psychiatric patients with proper hygiene, better food, light and ventilation. Reports based on Florence nightingale's crude research suggested that the mortality rate had reduced and there was improvement in behaviour of 88 Psychiatry in India : Training & training centres patients to some extent. However, psychiatric nursing was not formalized in the United States until 1882 when Linda Richards opened Boston City College. This was the first school specifically designed to train nurses in psychiatric care. The discrepancy between the founding of psychiatry and the recognition of trained nurses in the field is largely attributed to the attitudes in the 19th century which opposed training women to work in the medical field. In 1913 Johns Hopkins University was the first college of nursing in the United States to offer psychiatric nursing as part of its general curriculum. The first psychiatric nursing textbook, Nursing Mental Diseases by Harriet Bailey, was published in1920. The first developed standard of care was created by the psychiatric division of the American Nurses Association (ANA) in 1973. This standard outlined the responsibilities and expected quality of care by nurses for mentally ill patients. Generally, the management of mentally ill was considered to be more challenging than other types of nursing care, because more than physical care, the task involved interpersonal skills, imagination, sensitivity, knowledge of human behaviour and interviewing skills. By the early twentieth century, psychiatric nursing training was well organised in the west. Psychiatric nursing became a speciality by the late nineteenth century in England and in other European countries by 1930. The registration of psychiatric nurses was done in UK by 1920. Degree courses in psychiatric nursing began in USA. Psychiatric nursing was included in the basic nursing curriculum by International Council of Nurses in 1961. Psychiatric Nursing Trends in India: In 4th century AD, the emperor Ashoka had built hospitals with 15 beds for mentally ill with two male and two female nurses. The role of nurses was to administer herbal medicine to psychiatric patients, in addition to meeting their basic needs. They were also keeping weekly records of psychiatric patients progress. The first was established at Mumbai in 1745 and the second at Kolkata in 1787, followed by Central mental Hospital Asylum at Yeravada in 1889 and the Thane Mental hospital in 1902. The central Lunatic Asylum was established at Ranchi in the year 1918. Nurses provided custodial care, in addition to attending the basic physical needs of patients. In addition nurses also helped to ensure a suitable environment, ventilation, sanitation and involved patients in recreational activities. [2,3] In 1930s 11 British nurses along with one matron were brought from UK to work in the Mental hospital at Ranchi, India. Later on three to six months N.V. Muninarayanappa, Bharti M. : Psychiatric Nursing 89 lectures were arranged for English speaking nurses at the end of which certificates recognized by the Royal Medical Psychological Association was awarded to them. To begin with these nurses helped patients in occupational and recreational therapies. Introduction of somatic therapy in 1917 gave nurses a definitive role in psychiatric care. Treatments like deep sleep therapy (1930), (1935), Metrazole shock therapy (1935), ECT (1937) and psychosurgery (1936) necessitated important role of nurses in treating the mentally ill. Somatic therapies such as ECT also made patients accessible to psychological methods of treatment. As there were few psychiatrists, nurses got involved in psychological treatment of patients in hospital wards. Individual therapy and group therapy were taught gradually to nurses in 1960. These techniques stressed the importance of the personality and behaviour of nurses as a factor in therapeutic interaction with patients. During 1930 – 1960 principles and practice of psychiatric nursing were derived from practical experiences of caring for psychiatric patients.[2,3] From the year 1943, the Madras government organised a three months psychiatric nursing course (subsequently stopped in 1964), for male nursing students at the Mental hospital, Madras (in lieu of Midwifery). The government of India sent four nurses to UK during the years 1948 and 1950, for training in Diploma in Mental Nursing. The Nur Manzil Mental Health centre, Lucknow, conducted four to six weeks duration orientation courses in psychiatric nursing in the year 1954. All India Institute of Mental Health ( presently called as NIMHANS), Bangalore started 1 year diploma in psychiatric nursing with the help of WHO consultant C.A.M. Verbeck in the year 1956 with 15 seat intake. From the year 1965 the DPN seats were increased to 30. Later Central Institute of Psychiatry, Ranchi and Lokapriya Gopinath Bordoloi regional Institute of Mental Health, Tejpur, Assam, also started conducting Diploma in Psychiatric Nursing.[4] In 1963, the then Mysore Government started a nine month course in psychiatric nursing for male nursing students, in lieu of midwifery at Mental hospital, Bangalore. In 1964-65, the Indian Nursing Council (INC) made it mandatory to include psychiatric nursing subject in nursing diploma and degree courses. Rajkumari Amrit Kaur College of Nursing, New Delhi started Masters level program in psychiatric nursing in the year 1976. PGIMER Chandigarh (1978), CMC Vellore, SNDT Bombay and CMC Ludiana also started offering Masters level program in psychiatric nursing. NIMHANS, Bangalore started offering M.Sc. Psychiatric Nursing from the year 1988. Subsequently Ph. D program for psychiatric nursing was started. National consortium for Ph. D in Nursing by INC in collaboration with Rajiv Gandhi University of Health Sciences with the support of WHO called for nursing professionals to register for Ph. D in nursing in five disciplines including psychiatric nursing from the year 2005.[4] 90 Psychiatry in India : Training & training centres Current Status of Psychiatric Nursing: Presently, the psychiatric nursing is viewed as a dynamic interplay between the nurse and the patient, which encompasses knowledge and skill application of the concepts of behavior, personality, the mind, psychopathology and most importantly the process of interpersonal relationships. It is directed towards both preventive and corrective impact upon mental disorders and their sequel and is concerned with promotion of optimal mental health for society, the community, and those individuals who live within it. The NIMH considers psychiatric and mental health nursing as one of the four core disciplines of mental health. Psychiatric nurses play vital roles in the assessment of needs of acute and chronic adult psychiatric patients, providing care to children and adolescents, providing support to the family members of mentally ill, educating both patients and their care givers regarding psychiatric disorders, medications; management of side effects, undesirable behaviors of chronic mentally ill at home etc. Nurses are working in de-addiction centers, rehabilitation and geriatric centers. They also play a key role in the areas of family therapy and community mental health service. Psychiatric nurses are participating actively in training of para-professionals, particularly guiding health workers at grass root level to integrate mental health components into primary health care delivery system and enable them to implement national mental health program. They are also participating in training of school and college teachers, and helping them to identify behavioral and emotional problems in children and adolescents and training them to provide counseling and referral services. Many psychiatric nurses are actively participating in research activities both in psychiatric hospital and community mental health care.[5,6,7,8] Future Issues of Psychiatric nursing: Psychiatric nursing is the essential component of the health care delivery system and they should receive their appropriate place in the system, particularly while delivering mental health care in hospitals and also in community mental health program. Majority of psychiatric care centres are entirely staffed with nurses who are having limited training and are inadequately equipped to play their role.[9] At present there are around 800 diploma holders in psychiatric nursing, and nearly 300 Master's degree holders in psychiatric nursing and ten doctorates in psychiatric nursing in India. This number is a fraction of the required number of psychiatric nursing manpower to meet the mental health needs of India. There is urgent need to enhance the number of psychiatric nursing training centres with focussed support from government.[10] N.V. Muninarayanappa, Bharti M. : Psychiatric Nursing 91 The role of psychiatric nurses need to be clearly enunciated in hospitals as well as in community mental health programs, school health programs, rehabilitation facilities and de-addiction centres. There is a need for creating job positions for psychiatric nurses to meet the mental health care needs at primary , secondary and tertiary care institutions, as well as creating position for psychiatric nurse at each states mental health authority and central mental health authority at centre.[11] Once the appropriate recognition and valid positions for nurses in the field of psychiatric nursing are achieved, the next step will be to develop and strengthen the psychiatric nurses with specialised fields of psychiatric care as advanced nurse specialist in areas of child mental health, de-addiction, psychiatric rehabilitation, community mental health and family therapy.[12,13] Psychiatric Nursing Training Institutions in India: Presently, there are 300 plus institutions (Govt. & Private) in India where specialized courses in psychiatric nursing at Doctoral, Post Graduate and Post Basic Diploma level are offered, through which 700 to 1000 nurses are prepared annually with advanced skills in psychiatric nursing (Refer- www.indiannursingcouncil.org for details). Among these some key institutions are:[14]

1. National Institute of Mental health and Neurosciences, Bangalore. 2. Central Institute of Psychiatry, Ranchi, Jharkhand. 3. Lokopriya Gopinath Bordoloi Regional Institute of Mental Health, Tezpur, Assam. 4. Govt. Institute Of Nursing at Ranchi Institute of Neuro-psychiatry And Allied Sciences , Kanke, Ranchi. 5. Maharashtra Institute Of Mental Health , Sassoon General Hospital Campus , District Pune.

Conclusion:

Psychiatric Nursing has evolved from the primitive level of custodial care to the present level where the nurses are able to identify the client's needs and plan and organise the care based on these needs. But the need of the hour is that the psychiatric nurses should strengthen and equip themselves with much more advanced skills which are required to cater to the growing needs of the present clientele in promotive, preventive, curative and rehabilitative aspects of care, thereby contribute in reducing the burden of cost of health care for both; the client and the care organizations. This can be achieved by providing user-friendly opportunities for nurses who wish to expand their 92 Psychiatry in India : Training & training centres therapy practice to include prescriptive authority, providing access to the three courses (pathophysiology, physical assessment, and advanced pharmacology) and supervised medication hours in a way that fits with the schedules of nurses who wish to work as therapists

REFERENCES

1. Agarwal S P et al. Mental Health: An Indian Perspective 1946-2003. New Delhi: Elsevier publishers. 2004:132-137. 2. Bhaskaran K, Satyanand D, Subramanyam P. Experience with the use of carbutamide in combination of insulin coma therapy. Indian Journal of Psychiatry 1960.2(2):63-68. 3. Davis RB, Davis AB. The first ten years: some phenomena of private psychiatric hospital. Indian Journal of Psychiatry 1965;2(4): 231-245. 4. Gail W. Stuart, Michele T. Laraia. Principles and Practice of Psychiatric Nursing. 8th ed. Missouri: Mosby publishers. 2008;2-5,11-12. 5. Gournay, K. & Brooking, J. (1994) Community psychiatric nurses in primary health care. British Journal of Psychiatry, 165: 231–8. 6. Gray, R., Parr, A., Plummer, S., et al. (1999) A national survey of practice nurse involvement with mental health interventions. Journal of Advanced Nursing, 30 (4): 901–906. 7. Lalitha, K.Mental Health and psychiatric Nursing: An Indian Perspective. VMG Book House,Bangalore:1-17. 8. Nagarajaiah, Parthasarathy R, Issac MK, Reddemma K. Psychiatric Nursing outside the hospital: some observations. The Nursing Journal of India 1993; LXXXIV(9): 203-204. 9. Nagarajaiah. Role of nurse in mental health research. NIMHANS Journal 1984; 2(1): 41-45. 10. Paquette, M. The future of advanced practice psychiatric nursing. Perspectives in Psychiatric Care, Jan-Mar, 2001: editorial. 11. Reddemma K, Nagarajaiah, Ramachandra. Integration of mental health with general care nursing. The Nursing Journal of India 1989; XXX(9):231-232. 12. Reddemma K. Psychiatric Nursing. The Nursing Journal of India 1982; LXXIII(5): 144-146. 13. Townsend Mary 2005, Essentials of Psychiatric Mental Health Nursing. 3rd ed. Philadelphia: F.A Davis company.2005: 3-5 14. www. indianursingcouncil.org

N. V. Muninarayanappa Prof. cum Vice Principal

M. Bharti Principal Employees State Insurance Corporation College of Nursing Indiranagar, Bangalore 11 Post Graduate Training: An Asian Scenario

Sujit Kar, J.K. Trivedi

ABSTRACT

Psychiatry is an emerging and rapidly evolving branch of medicine. It exists as a separate branch in medical curriculum. Due to vast advancement in the field of medicine and emergence of multiple super- specialties, the branch psychiatry carries enormous importance. Asia is one of the heavily populated regions in the world. Approximately 25% of world's population and approximately 20% of world's population suffering from mental disorders reside in South Asia region. But there is scarcity of psychiatrists in Asia. Psychiatric training is developing rapidly in Asia. Psychiatric education and training, whilst playing a pivotal role in addressing the burden of mental illness in Asia, is very variable in quality and quantity across the continent. This article aims at focusing the variability in post graduate training in Asia.

KEY WORDS: psychiatry, Asia, post graduate training, mental disorders

INTRODUCTION

Psychiatry is an emerging and rapidly evolving branch of medicine. It exists as a separate branch in medical curriculum. Due to vast advancement in the field of medicine and emergence of multiple super-specialties, the branch psychiatry carries enormous importance. Continuous research works, development of definite diagnostic & classificatory system has made the branch more stable. Psychiatry, as a separate subject is taught in the medical curriculum of many countries. Asia is one of the heavily populated regions in the world. Approximately 25% of world's population and approximately 20% of world's population suffering from mental disorders reside in South Asia region. But there is scarcity of psychiatrists in Asia. Different Asian countries have different teaching and training curriculum in psychiatry. 94 Psychiatry in India : Training & training centres

DEVELOPMENT OF PSYCHIATRY TRAINING GLOBAL SCENARIO

Mental disorders are highly prevalent across the world. Out of global burden of health related conditions, mental disorders constitute 13% of Disability Adjusted Life Years (DALY) [1]. A psychiatrist's role is very crucial in delivering mental health care to the community. The quality of mental health care service provided by the psychiatrist depends on his / her competency and the quality of training, he or she has undergone. Across the world, there is pressure on the countries for development and proper organization of mental health care delivery systems [2]. In past few decades, there have been major developments in psychiatric training across the globe. Psychiatry has been divided into several sub-branches like biological psychiatry, social psychiatry, community psychiatry, forensic psychiatry, child & adolescent psychiatry and many more branches. A survey conducted by World Psychiatry Association (WPA) and World Health Organization (WHO) revealed that psychiatric training facility is available in approximately 55% of developing (low income) countries whereas in developed countries it is 77% [3, 4].

As per the statistics of WHO & WPA (2005), information about psychiatric training is available from 74 countries, out of which approximately 50% of the countries have facility for training in Master's degree or Diploma in psychiatry. About 60% of these countries fulfill the minimum number of beds required for teaching. Each country has its own criteria of training and the criteria of psychiatric training vary from country to country. In approximately 85% of countries, a written curriculum is present for psychiatric training. Most countries have compulsory rotational training in medicine and neurology. Case conferences and seminars are the commonly used methods of training in about 50% of the countries. Evaluation and assessment of Psychiatric training is done at any point of time during the period of training or at the end of training by written and / or oral (viva) method. During or at the end of the training programme, the trainee has to face clinical examination followed by written test of essay type questions or multiple choice questions or patient interviews. In about 45% of countries, trainees have to undergo assessment by combination of external as well as internal examiners whereas in 33% countries only the internal examiner assesses the trainees. Very few countries have facility for super-speciality psychiatric training. Super- speciality training available are child psychiatry, addiction psychiatry and forensic psychiatry. It is also reported that trained psychiatrists of developing countries usually migrate to developed countries. The guidelines for postgraduate training in psychiatry are decided by different government bodies or medical or psychiatric councils [4]. Psychiatric training needs to be developed in all countries including the developing and third world countries. Countries with limited resources should initiate psychiatric training in collaboration with other regional countries. Different psychiatric Kar & Trivedi : PG training in Asia 95 training courses offered are:

I. Diploma in psychiatry II. Master's degree in psychiatry III. Ph D in psychiatry IV. Super- speciality fellowship training in psychiatry

Minimum requirements for training in psychiatry are:

1. Number of teaching beds 2. Facilities for rehabilitation and psychological testing 3. General infrastructure like biochemical testing, radiology and support of anaesthetists 4. Library facilities 5. Biostatistics 6. Access to ethics committee

The World Psychiatry Association has set a core curriculum for post graduate training in psychiatry. The curriculum is decided by a committee composed of representatives of different countries. The recommendations in the curriculum are [5]: l Basic sciences ( human growth and development, neurosciences, genetics, behavioral science, social science and psychopharmacology) l Diagnostic assessment l Basic knowledge (classification of psychiatric disorders, psychiatric disorders in detail) l Psychopathology in different ages (child & adolescent, adult and geriatric) l Emergency psychiatry l Core competencies (knowledge and skills) l Communicative / interviewing / diagnostic skills l Skills in liaison psychiatry l Culture sensitivity l Etio-pathogenesis l Growth and development l Risk factors (genetic /social & cultural / biological / environmental) l Social isolation and discrimination l Therapeutics l Somatic treatment / pharmacotherapy /psychotherapy l Emergency and crisis intervention l Social and community psychiatry / family dynamics and psychoeducation l Prognosis

l Short & long term course / predictive outcomes 96 Psychiatry in India : Training & training centres

l Prevention and mental health promotion

l Primary / secondary / tertiary prevention

l Mental health education / health promotion/ reinforcement of healthy behavior

l General aspects

l Teaching skills and methodology / research methodology and statistics

l Evidence – based medicine / psychiatry

l Cross – cultural psychiatry / religion and spirituality

l Ethics, legal aspects / forensic psychiatry

l Management and leadership development etc

General guidelines for post graduate training recommended by the WPA are [5]

1. The clinical training should start after completion of the medical doctor degree and compulsory rotatory internship. 2. Three years was the minimum training period required for completion of post graduate training 3. During the training there should be a minimum of 6 months rotational training in neurology & primary care / internal medicine and minimum 18 months training in general psychiatry (includes inpatient, outpatient, day hospital and rehabilitation services) 4. There should be exposure to emergency psychiatry, de-addiction psychiatry, rehabilitation psychiatry, forensic psychiatry and mental retardation 5. During entry into the training process, motivation and empathy need to be evaluated whereas at the exit the focus is to assess knowledge, patient care, communication skills & empathetic development 6. Oral and written evaluation should take place at regular intervals (preferably twice a year) and there should be a qualifying examination comprising of oral and written examination

In the training process the trainee has to present seminars, case conferences, journal clubs etc. The candidate (trainee) has to undergo training in ECT administration and different super-speciality branches of psychiatry.

CURRENT SCENARIO OF PSYCHIATRY TRAINING IN ASIA

Asia consists of different group of countries. Most of the countries are developing countries. Only a few countries are developed (e.g – Japan, Kar & Trivedi : PG training in Asia 97

Singapore etc) and few are undeveloped (e.g – Afghanistan, Bhutan etc). Mental disorders are distributed throughout Asia irrespective of the status of the country. But mental health care facility and psychiatric training are not available everywhere (e.g- Bhutan, Maldives etc).

In India, different courses are offered in psychiatric training. They are:

l Master's degree (duration 3 years)

l Diplomate of national board (duration 3 years) l Diploma in psychiatry (duration 2 years) l Super-speciality degree in psychiatry(DM) The guidelines proposed by World Psychiatric Association are followed in India. The governing bodies for psychiatric training and education are –

l The Medical Council of India, New Delhi, India l National Board of Examination, New Delhi, India In India, most institutes follow British pattern of training and making diagnosis. They follow ICD-10 for making a diagnosis, whereas few institutes follow American diagnostic tool DSM-IV for making diagnosis. Residents (trainees) attend clinics and treat patients in their very first year of training under direct supervision of senior resident. Clinical teaching is done mostly on bedside during ward rounds and it is mostly done by senior residents. Decision making ability gradually develops over time. During the 1st year of training the resident works under strict supervision of senior residents. Thesis is a very important component of curriculum in post graduation. It is done under the supervision of consultants and it needs to be submitted before commencement of the examination in 3rd year. When compared with the training provided by United States, Indian training is superior in providing knowledge of phenomenology, diagnostics and pharmacotherapy but it lacks adequate exposure to psychotherapy and research work. Only one institute in India (NIMHANS) provides 2 years speciality training in child psychiatry. Recently this institute has started super-speciality degree (DM) in child and adolescent psychiatry. C.S.M Medical University ( formerly King George Medical University) another leading institute of India, has also started a DM super speciality degree on Geriatric mental health from the year 2011. Both the super-speciality courses are meant for duration of 3 years. C.S.M. medical University, Lucknow has also started “P.G. Diploma in Geriatric Mental Health” and “Fellowship in Geriatric Mental Health”, which are meant for the duration of 2 years and 1 year respectively”.

In China, psychiatry residency training is a 5 year training programme. It is provided by large mental health hospitals and psychiatric departments of medical schools. China doesn't have any governing body or council to look after post graduate training programme in psychiatry. There is large variation 98 Psychiatry in India : Training & training centres in the standard of training provided. In most of the training centres, the first 4 years of post graduate training is mainly inpatient training which includes 6 months training in neurology, 3 – 6 months training in organic psychiatry, 1 – 3 months training in geriatric psychiatry. The last year of training is in the outpatient department and super-speciality clinics. During training, the residents have to attend regular classes, look after in / outpatients, attend super-speciality clinics and have to present seminars. The 5 years training mainly focuses on psycho-pathology, psychiatric diagnosis and pharmacological management. The residents have to face written and oral examinations at regular intervals (ideally at the end of each year). [6, 7]

In South Korea, the postgraduate psychiatric training is given over a period of 4 years. Korea is the first country in Asia to adopt American method of training. The training programme is well organized and standardized. In the 1st year of training the residents need to acquire basic knowledge in psychiatry and competency in inpatient care. In the 2nd year, the resident has to continue 1st year curriculum and acquire competency in outpatient care. In third year, the residents have to master the curriculum of 1st & 2nd year and are trained in super-specialities of psychiatry. The last year of residency includes development of clinical competency and supervising 1st, 2nd and 3rd year residents. The faculty members provide regular clinical group supervision. The residents have to publish at least one original article under supervision of faculty during their psychiatric training. [6, 7]

In Russia (former Soviet Union), the post graduate training in psychiatry is shorter and rigorous as compared to western countries. Department of Professional Education of Russian Federation, Ministry of Education of Russian Federation, Educational-Research-Methodical Centre for Continuous Medical Education, Russian Federation and Russian Medical Academy for Postgraduate Education are the governing bodies to provide psychiatric training in Russia. In Russia, much emphasis is given to biological therapy. Psychotherapy given in Russia is more reality oriented as compared to that of the west. [8]

In Cambodia, mental health care delivery is not fully developed due to many unfortunate tragedies. Post graduate training in Cambodia is governed by Department of Psychiatry, University of Health Sciences, Phnom Penh, Cambodia and Mental Health Sub-Committee at the Ministry of Health, Cambodia. The post graduate training in psychiatry in Cambodia comprises of several months of study of English, followed by 3 years of didactic instruction and on-the-job training. The training to the psychiatric residents is provided by Norwegian psychiatrists. The trainees spend 2 months in inpatient psychiatry in Thailand. Teaching programmes are organized several times a year. In patient care facility is not developed in Cambodia. [9] Kar & Trivedi : PG training in Asia 99

In Srilanka, the post graduate training curriculum recommends 3 years of training. Training programmes are well structured and comprehensive. But still trainees are sent for foreign training.

In Kuwait, there is no specific psychiatric training programme. [4]

In Pakistan, Pakistan Medical and Dental Council College of Physicians & Surgeons Pakistan, Karachi, Pakistan Psychiatric Society provides training in psychiatry. During the post graduate training in psychiatry, residents are trained in psychiatric disorders as well as in neurology and neuro-imaging (with respect to major psychiatric disorders such as schizophrenia, depression and obsessive compulsive disorder). Few specialized institutions provide training in forensic psychiatry.[4]

The following table enumerates the situation in this region:(source : Atlas, Psychiatric education and training across the world, 2005)*

INDIA PAKISTAN SRI LANKA NEPAL MALAYSIA THAILAND

MD /Diploma 189 18 4 to 6 4 15 to 20 32

PG training centres 59 12 6 2 3 12

Child psychiatry course 0 0 0 0 0 4

Duration of training 2 to 3 yrs 2 to 4 yrs 5 yrs 3 yrs 4 yrs 3 to 4 yrs

Brain drain 50% 50% 50% 10% 10% Rare

*As per the recently available data available from the official website of MCI, there are 398 MD and 129 seats in psychiatry which includes both permitted and recognized seats.

In 1987, Chairmen of the Japan Association of Department of Psychiatry of Medical Colleges (JACDPM) proposed a program for a postgraduate course. The Japanese Society of Psychiatry and Neurology (JSPN) formed the Committee on Psychiatric Education and Working Group on Accreditation Program (WGAP) which are the governing bodies for psychiatric training. This governing body recommends three years of post graduate training in psychiatry which has to be delivered by the department of psychiatry of different medical schools, mental hospitals, outpatient mental clinics or health centres. Residents are evaluated at the end of training period through oral and written examination [10].

CONCLUSION Psychiatric training is developing rapidly in Asia. Psychiatric education and training, whilst playing a pivotal role in addressing the burden of mental 100 Psychiatry in India : Training & training centres illness in Asia, is very variable in quality and quantity across the continent. The WPA has worked together with the World Federation for Medical Education and the World Health Organization to minimize the gap between psychiatry and the rest of medicine, promote a better understanding and care of mental illness and strive to introduce improvements to the medical education. Despite developments in post graduate training in psychiatry, the need of mental health care in Asian countries is still not met. The possible reason can be migration of psychiatrists to high income countries. Much more is needed, particularly for countries where the psychiatric training system is not fully developed. In these countries, psychiatric education can be developed by collaboration with neighboring countries.

REFERENCES

1. World Health Organization (2004). The World Health Report 2004: Changing History. World Health Organization. Geneva. World Health Organization (2001a). 2. The World Health Report 2001: Mental Health: New Understanding, New Hope. World Health Organization. Geneva. 3. World Health Organization (2005). Mental Health Atlas 2005. World Health Organization. Geneva. www.who.int/mental_health/evidence;atlas/index.htm 4. World Health Organization, World Psychiatric Association (2005), Atlas, Psychiatric education and training across the world, 2005. 5. World psychiatric association institutional program on the core training curriculum for psychiatry; YOKOHAMA, JAPAN, AUGUST 2002. 6. Zisook S, Bjorksten KS, Yoo T, et al: Psychiatry Residency Training Around the World. Presented at the AADPRT Annual Meeting. San Diego, Calif. March 9–12, 2006. 7. Sidney Zisook, Richard Balon, Karin S. Bjo¨rkste´n, Ian Everall, Laura Dunn, Krauz Ganadjian, Hua Jin, Sagar Parikh, Andres Sciolla, Tanuj Sidhartha, Tai Yoo; Psychiatry Residency Training Around the World; Academic Psychiatry 2007; 31:309–325. 8. Lerner V, Frolova K, Witztum E; Education and postgraduate education of psychiatrists in the Soviet Union and their integration into a new milieu. A view from the present to the past of former Soviet psychiatrists. Isr J Psychiatry Relat Sci. 2007; 44(3):219-24. 9. Daniel Savin; Developing Psychiatric Training and Services in Cambodia Psychiatr Serv 51:935, July 2000 © 2000 American Psychiatric Association. 10. Kojima T, Hosaka T; [Some resolutions in difficulties of postgraduate psychiatric education in Japan]. [Article in Japanese] Seishin Shinkeigaku Zasshi. 2003; 105 (2):221-6. Sujit Kar Senior resident, Department of Psychiatry, C. S. M. Medical University UP (Upgraded K. G. Medical University) Lucknow-226003 [email protected]

J.K. Trivedi Professor & Ex-Head, Department of Psychiatry, C. S. M. Medical University UP (Upgraded K. G. Medical University) Lucknow-226003 12 Psychiatric Training in Sri Lanka and its relevance to India

Harischandra Gambheera, Shehan Williams

ABSTRACT

Psychiatric training has to adapt to existing needs. The positive steps in this direction in Sri Lanka and the recent landmark achievements in undergraduate and postgraduate training are discussed. The lessons learnt and the directions for the future can be shared with neighbouring countries like India, which has similar challenges in the context of a shared socio-cultural milieu.

INTRODUCTION Modern psychiatry had its origin in Freudian times. Its practice has evolved, taken diverse forms and changed considerably over time. The advent of psychotropic medicines in the 1950s further changed the landscape of psychiatry. Western psychiatry has thus taken the upper-hand and its practice is well entrenched in both India and Sri Lanka. The challenge however is to ensure that this speciality meets the needs of the population. Training priorities in psychiatry should thus address these needs. Diverse needs The needs however are diverse and may range from basic counselling and guidance skills to treatment and rehabilitation of major psychoses1. Traditionally psychiatrists have also taken on the treatment and rehabilitation of alcohol and substance misuse, sexual disorders and others in the neuropsychiatric borderland, such as dementia. Training has to address skills which are beyond the scope of average psychiatric curricula. The rich cultures of India and Sri Lanka bring with it, certain attitudes and beliefs in relation to psychiatric illness. Psychiatric practitioners have to deal with these issues sensitively and effectively, with the benefit of the patient in mind. Some traditional practices are indeed harmful to the well being of the patient and can result in delays in receiving 102 Psychiatry in India : Training & training centres treatment, resulting in an increased burden of morbidity and at times even significant mortality. Undergraduate training Introducing mental health care into primary health care settings is the practical and accepted mode of bridging the 'treatment gap' in low and middle income countries with resultant better health outcomes2. In this sense, imparting adequate training in mental health to all medical undergraduates should be a priority. Sri Lanka has perhaps achieved landmark success in this effort with the introduction of psychiatry as a final year specialty in most medical schools in the island. Previously as in most of India, psychiatry was taught in the third and fourth years with all other medical subspecialties with little emphasis on its importance. The teaching and assessment was minimal, and most medical graduates could qualify with little or no knowledge of psychiatry. This led to serious limitation in the knowledge of psychiatry amongst the medical profession in Sri Lanka. Therefore even the doctors in Sri Lanka were prejudiced regarding mental illnesses and mental health services. Their capability of recognizing a psychiatric disorder was greatly limited and they were reluctant to refer patients to mental health professionals due to the prevailing stigmatized attitude towards psychiatric illnesses and their management methods. The current programmes in all the leading medical schools in Sri Lanka have up to eight weeks or more of full time exposure to different aspects of psychiatry and mental health , and the undergraduates are assessed extensively on par with the other final year specialties – Medicine, Surgery, Obstetrics and Gynaecology and Paediatrics. Most medical schools also have a behavioural sciences strand from the first year of medical training which focuses on holistic care, imparting empathy and sensitive communication with all patients and their carers. In addition to imparting essential knowledge, these measures also contribute to a positive attitude towards psychiatry among most medical graduates qualifying in this new stream with hopeful minimization of stigma within the profession3. Post graduate training MD Psychiatry The Post graduate Institute of Medicine (PGIM) of University of Colombo started in 1980 and conducts a 5 year course leading to MD (Psychiatry). Those who successfully complete this programme are certified as specialists in psychiatry. Any medical officer who passes the selection examination conducted by the PGIM is eligible to enter the training programme in Psychiatry. The training programme that runs for three years prior to the MD (Psychiatry) Gambheera & Williams: Psychiatric training in Srilanka & India 103 examination, includes training in general adult psychiatry as its major component and short periods of exposure in subspecialties such as child and adolescent psychiatry , addiction psychiatry , forensic psychiatry and old age psychiatry. Trainees successful at their MD (Psychiatry) examination have to undergo two more years of training as Senior Registrars under direct supervision of a consultant psychiatrist. One year may be in an approved centre overseas. A Senior Registrar will be certified as a specialist in psychiatry once they have completed these requirements and also submitted a research dissertation. Core knowledge Developing the curricula to produce worthy specialists in psychiatry in the context of India and Sri Lanka involves identifying the core components of this training. This should not be confined just to the knowledge of psychiatry as laid down in textbooks or the diagnosis and treatment of mental disorder. It will have to encompass a wide repertoire of skills and all round versatility. It will have to equip the clinician with the necessary knowledge, skills and attitudes that make the psychiatrist into a leader, teacher, researcher and clinician. Diploma in Psychiatry A large proportion of the senior registrars sent for overseas training however never returned to Sri Lanka4. Thus the psychiatrist per population ratio remained low with a presence of 1: 500,000 to 1000,000 on most occasions. In this backdrop it was decided to train a middle grade doctor with limited competency who would be less attractive for recruitment in high income countries. The compulsory period of overseas training up to that point was also made optional in the hope that fewer trainees would opt to go abroad and be tempted to stay back in high income countries. After much deliberation with several stake holders and objection from some mental health professionals themselves on legitimate fears of dilution of the psychiatric training, a one year training course leading to a Diploma in Psychiatry was started by the PGIM. A major portion of the training included was general adult while they were also exposed to sub-specialties such as child and adolescent, addiction and community psychiatry for a limited number of sessions, mainly for the purpose of recognition. Training 'fit for purpose' in establishing community structures A mental health policy drafted by the Sri Lanka College of Psychiatrist has been approved by the Government of Sri Lanka for the first time in 20055. The basic objective of the policy is to decentralize the Psychiatric services that have been centralized in large mental hospitals in Colombo and establishment of a community mental health service. According to the policy 104 Psychiatry in India : Training & training centres of Sri Lanka the district has been considered as the basic service unit. A minimum of one Acute Psychiatric Inpatient Unit (APIU) should be based in District General Hospital which is the biggest health impatient establishment in a district. Apart from the acute inpatient unit there should be a rehabilitation unit based in each district. Each district is divided into several Medical officers of Health (MOH) areas depending on the population. There is a small district hospital situated in each of these MOH areas. The Policy is to establish Primary Community Mental Health centres (PCMHC) in every district Hospital in each MOH area. A community mental health team comprising of a Medical Officer of Mental Health (MOMH), Community Mental Health Nurses and a Community Support Officer will be attached to each PCMHC. A medical officer who successfully completes the Diploma training programme will be usefully appointed as the Medical Officer of Mental Health in the community team. The Diploma in Psychiatry training programme has been in existence only for the last three years and has not yet produced enough diploma holders to be appointed to all MOH areas. Therefore, steps have been taken to appoint medical officers as Medical Officers of Mental Health after three months of training in Psychiatry at National Institute of Mental Health of Sri Lanka. This programme will be conducted until all the PCMHC is filled by Diploma holders. Currently the Sri Lanka College of Psychiatrists provides continuous professional development opportunities to those with a Diploma in psychiatry. Training of allied specialists As envisaged in the national mental health policy, the training of other mental health professionals has to now take priority in Sri Lanka. Foremost among them is the need to train psychiatric nurses and psychiatric social workers with particular focus on the community. These professionals can play a critical role in timely, effective and appropriate services to those with mental disorders6. Unlike in the West, the ratio of psychiatric beds for the population has always been low. There have not been widespread mental hospitals and most patients have been cared for in the community by their families7. Therefore a paradigm shift from institutional to community care is not necessary. The services in the community have to concentrate on strengthening the families to care for those with mental disorders8. India perhaps has taken the lead in training a significant cadre of allied mental health specialists. Such a move however is just being initiated in Sri Lanka. This no doubt will be a significant step in supporting the carers and bridging Gambheera & Williams: Psychiatric training in Srilanka & India 105 the 'treatment gap'. CONCLUSIONS The approach to training in psychiatry has to be multi-pronged9. Doctors have to be trained adequately from their undergraduate days. Post graduate training should tackle the unique range of skills necessary for a psychiatrist practicing in India and Sri Lanka. Flexible attitudes to training middle level competencies will have to be adopted. The development of allied mental health specialists should be a priority. REFERENCES 1. Nisha Dogra and Khalid Karim. Diversity training for psychiatrists. Advances in Psychiatric Treatment (2005) 11: 159-167 2. Integrating mental health into primary care: a global perspective. Authors:World Health Organization / World Organization of Family 2008 http://www.who.int/mental_health /policy/services/integratingmhintoprimarycare/en/index.html 3. Sartorius N, Gaebel W, Cleveland HR, Stuart H, Akiyama T, Arboleda-Flórez J, Baumann AE, Gureje O, Jorge MR, Kastrup M, Suzuki Y, Tasman A. WPA guidance on how to combat stigmatization of psychiatry and psychiatrists. World Psychiatry. 2010; 9(3):131-44. 4. Malik Hussain Mubbashar and Asma Humayun. Training Psychiatrists in Britain to Work in Developing Countries. Advances in Psychiatric Treatment 1999; 5: 443 - 446. 5. The Mental Health Policy of Sri Lanka: 2005-2015. Ministry of Healthcare and Nutrition 2005. 6. Atlas: Nurses in Mental Health 2007. World Health Organisation 2007. 7. Saeed Farooq and Fareed A. Minhas. Community psychiatry in developing countries — a misnomer? Psychiatric Bulletin, 2001; 25: 226 - 227. 8. K. Linsley, R. Slinn, R. Nathan, L. Guest, and H. Griffiths. Training implications of community-oriented psychiatry. Advances in Psychiatric Treatment, 2001; 7: 208 - 215. 9. Atlas: Psychiatric education and training across the world. World Health Organisation 2005.

Harischandra Gambheera National Institute of Mental Health Colombo, Sri Lanka [email protected]

Shehan Williams Department of Psychiatry Faculty of Medicine University of Kelaniya, Sri Lanka

13 Teaching & Training in Psychiatry: Pakistani Perspectives

Muhammad Nasar Sayeed Khan, M. Afzal Javed

ABSTRACT

This paper describes a general outline of undergraduate & postgraduate teaching & training programmes in psychiatry, in Pakistan. The details of the curriculum, course contents and examination are given about different postgraduate programmes in Psychiatry.

Background information

Pakistan is the 9th most populous country in the world, though area wise it ranks thirty-fourth among the thirty-seven low-income countries. It is the fourth most populous Asian country after China, India & Bangladesh, & is located along either side of the historic Indus River, following its course from the valleys of the Himalayas down to the Arabian Sea. Pakistan’s 796,095 square kilometers of territory include a wide variety of landscapes, from arid deserts to lush green valleys to snow covered mountains. Agriculture accounts for about a fifth of the economy and employs more than half of the workforce. Social development has remained slow, and inequality between social classes, genders and rural and urban areas has led to widespread poverty. In addition, the latest invasion of Afghanistan by the USA resulted in a fresh influx of 200,000 refugees, mainly women and children1. Pakistan has a total population of 157, 935000; with urban population of 34%, literacy rate of 49% & 35% of the population below the poverty line (UNICEF, 2006). GDP per capita is $2,151, with life expectancy at birth as m/f : 62/63, infant mortality as 102/1000 and total health expenditure per capita comes to around $48 2. Pakistan at present is amidst multiple political, social and economic crisis. This has an impact on general health care systems that is worsening with each passing year. Like many low income countries, health is not a priority and mental health is getting even less importance in policy and practice. The total number of physicians in the country is 128,073 which includes 18,633 108 Psychiatry in India : Training & training centres specialists (PMDC. 2006).3 The magnitude of mental illness is alarming 4 and the total number of qualified psychiatrists (about 300) for a population of more than 160 millions clearly shows the extent of the problem. Similarly the allied mental health professionals and support facilities are also less than satisfactory with 125 psychiatric nurses, 480 psychologists, 600 social workers and the number of alternate practitioners is about 12,000. There are currently four mental hospitals in the country, while another 20 units are attached to the medical colleges in the government sector. Medical colleges in the private sector offer nearly the same number of psychiatric units5. The variety of health care services and standards vary among different government sector medical colleges & this gap widens among the private sector medical colleges3. Despite opening of new medical colleges, the medical education and specifically the psychiatric teaching & training still face a number of challenges. PSYCHIATRIC TEACHING & TRAINING: Undergraduate training: After ten years of primary & secondary schooling and further two years of college education, those with nearly eighty percent marks apply for a place in a medical college. The entry to the medical education is very competitive & comprises of an entrance test. The medical course lasts for five years in Pakistan followed by internship (House Officer) ranging from 1-2 years in different institutions. In the first two years of medical education (pre-clinical years) students are taught the subjects of anatomy, physiology, biochemistry and behavioral sciences. During the remaining three years they are taught Pharmacology and therapeutics, forensic medicine and toxicology, surgery, medicine, pathology, community medicine, obstetrics & gynecology, otolaryngology and pediatrics. Students train on hospital wards in the clinical years where they spend approximately 500 hours of clinical attachments per year. The students are examined through four professional examinations including theory papers (short essay questions, MCQ‘s mostly one best answers and long essay questions) and clinical examinations including the OSPE(On Spot Practical Examination), long cases and short cases. Psychiatry and behavioral sciences are recognized as an important part of the curriculum by the Pakistan Medical and Dental Council (PMDC). However, there is a lack of uniformity over undergraduate psychiatric curriculum in different medical schools. The behavioral science is usually taught in the first two years and is examined in the third year. The number of teaching hours are variable as that range from 25-50, however specified as 50 hours for the subject by the PMDC. In the final year, students spend four weeks of placement in Psychiatry and Khan & Javed: Psychiatric teaching & training in Pakistan 109 also receive ten to twenty five theoretical lectures in their final year. They are examined in their final exams, in the subject of psychiatry through two compulsory questions, which is part of a paper in medicine. Psychiatry is unfortunately not considered a preferred career by many medical graduates.

A recent survey6 of medical students in Karachi concluded that, nearly 32% students believed psychiatrists are not respected and 42% believed that they earn less money than other specialists. More than half (54%) of the students were reluctant to choose psychiatry as a career. Clinical students held positive views about psychiatry than pre-clinical students.

Postgraduate Training: Pakistan Medical & Dental Council (PMDC) requires postgraduate qualification for the practice of psychiatry as a specialist. Those with major diplomas can take up academic positions in teaching hospitals and others with minor diploma can practice psychiatry privately or even in the district general hospitals. Postgraduate medical training in Pakistan is regulated by the College of Physicians and Surgeons of Pakistan (CPSP). The college offers membership (MCPS) and fellowship (FCPS) exams in psychiatry. The College of Physicians and Surgeons of Pakistan is also responsible for accreditation of training institutes, and of setting curricula for different specialities. Out of all the registered health care specialists, nearly eighty percent are trained by the College. By March 2010 the college had awarded 279 FCPS diplomas and 54 MCPS diplomas to psychiatrists. 7 Some universities offer postgraduate qualifications as well. 8

MEMBERSHIP EXAMINATIONS OF COLLEGE OF PHYSICIANS & SURGEONS OF PAKISTAN (MCPS): The Member of college of Physicians and Surgeons (MCPS) is a two year programme. 188 candidates have passed MCPS in Psychiatry from 1965. This diploma was stopped few years ago but has now been restarted in 2008. The basic requirement for entering is the same as Fellowship (FCPS), however, the candidates can appear in the theory papers and later in the TOACS examinations after two years of clinical structured training programme. 4

FELLOWSHIP AND MEMBERSHIP EXAMINATIONS OF COLLEGE OF PHYSICIANS & SURGEONS OF PAKISTAN (FCPS): The FCPS is the highest qualification offered by the College of Physicians & Surgeons of Pakistan. This course consists of four years training and three set of examinations which are outlined below. PART 1 FCPS: The eligibility criteria for the part one exam includes; MBBS or equivalent 110 Psychiatry in India : Training & training centres qualification registered with the PMDC and one year house job (internship in the USA) in an institution recognized by the CPSP or PMDC. The house job does not need to be in Psychiatry. The exam is held two times a year. Theory examinations are held in ten different cities. There are a few overseas centers as well. Examinations are conducted in the English language. The examination consists of two theory papers, each consisting of one hundred MCQs. Each paper of FCPS Part-I (MCQ type) will be divided into three well defined sections of Anatomy, Physiology and Pathology including other allied basic medical sciences. A candidate would be required to secure a minimum percentage in each of the three sections separately besides passing in aggregate.

INTERMEDIATE MODULE:

The candidates have to undertake two years training in a recognized institute to appear in the Intermediate Module Examination. This consists of a two written papers having Short Essay Questions and a Viva examination comprising of twelve OSPE stations. The contents are usually the basics of psychiatry and detailed curriculum is available at the college of Physicians and Surgeons of Pakistan website.9

PART 2 FCPS:

After another two years of training the candidates are eligible to appear in the part two of the FCPS examinations. The candidates have to register for training with a tutor approved by the college in an accredited department of psychiatry. The tutors have the responsibility to supervise training in accordance with the college standards. Tutors are psychiatrists with a higher degree and at least five years of experience as a teacher and a consultant in a medical college. There is prescribed training for tutors in teaching and research methods before they are registered as tutors. The training is arranged by the College of Physicians and Surgeons of Pakistan, in collaboration with WHO and reviewed regularly with current updates 10,11.

The candidates need to submit a logbook, proof of attendance of workshops and proof of acceptance of research dissertation or alternatively two publications in national journals in order to be able to sit for the final exams. The candidates should have attended workshops in information technology, research methodology and dissertation writing and communication skills. Candidates are expected to have seen patients from the following disciplines: general adult psychiatry (100 outpatients and 100 inpatients), psychotherapy (20), child psychiatry and learning disability (50), substance abuse (25), geriatric psychiatry (15), organic psychiatry (15), forensic psychiatry (10), liaison psychiatry (15) neurology (20) and psychometrics (20). Psychiatric rehabilitation and community psychiatry cases are optional. Khan & Javed: Psychiatric teaching & training in Pakistan 111 The final examination is a structured examination & consists of two theory papers & a clinical examination. Both papers have ten short essay questions of a problem solving nature. The clinical examination consists of one long case, two short cases and a viva-voce to examine candidate’s theoretical knowledge.12

DPM Some universities offer postgraduate qualifications as well. Punjab University offers Diploma in Psychological Medicine (DPM) The DPM is recognized as a minor diploma by the Pakistan Medical & Dental Council. During the past five years, 119 doctors were admitted to the DPM course from all over the country, 12 female and 107 male. Forty per cent have passed the DPM Part II examination and another 30% have passed Part I only. The government of Pakistan has decided to appoint these DPM psychiatrists at district headquarter hospitals, and later at Tehsil Hospital, to provide psychiatric services to psychiatric patients and drug dependent persons on their doorstep8. Another diploma, Diploma in Psychiatric Practice (DPP) was started as a joint initiative in collaboration with universities from Egypt and London.

MD A research degree, Doctor of Medicine (MD) is also being offered by some Universities. However there are not many trainees enrolled for this degree as FCPS is preferred for higher training in Pakistan. Once a doctor has been awarded with the Fellowship of College of Physicians and Surgeons, he can apply for the post of a Senior Registrar or even an Assistant Professor in a medical college. They can also work as consultants in district general hospitals. An assistant professor is also a consultant psychiatrist in the attached university hospital. Assistant professors and associate professors receive supervision and support by the professors. In the absence of a proper system of support and supervision for the junior consultants, this is the only possible support that can be offered13.

SUMMARY & CONCLUSION: Although the major teaching hospitals have established separate departments of psychiatry, in most of the cases they are not well equipped especially in terms of manpower. For an example there are six public hospitals attached to the Medical Colleges in Lahore and all have established Psychiatric Departments; however there are only one or two consultants available. The Private Medical colleges have even less number of consultants 112 Psychiatry in India : Training & training centres and usually due to the financial reasons they hire only one Assistant Professor to run the Psychiatry Department (only to fulfill the requirement of the PMDC), that too without any other support services (psychologist or a social worker). The number of Psychiatrists in Pakistan is very low and many of them are going abroad especially to the west where they are being offered an attractive package and lifestyle. It is not surprising that there are a large number of Pakistani psychiatrists in the United Kingdom, United States, Canada, Australia and New Zealand apart from those in Middle East, Africa and South East Asia. It seems that soon we shall become a psychiatrist exporting region like our neighbor India, thus deepening the already existing scarcity of psychiatrists13. There is also an acute shortage of allied mental health professionals. Research is still not a priority with low representation in local accredited journals and even lower in international journals. Though there has been an increase in lay and scientific write-ups recently, it is still far from satisfactory state. Papers are generally written for getting promotions and standards are ignored. The Journal of Clinical Psychiatry was started in the 1990s but has consequently disappeared. The first journal of Pakistan Psychiatric Society (JPPS) was started in the year 2003. After discontinuation for a number of years, it has now restarted and is being published regularly. Funding for training is a major issue in Pakistani health system; the government pays for a limited number of candidates allocated to each department in an institution. There have been major changes in the health service in Pakistan over the last few years and the emphasis has shifted from tertiary care to primary and secondary care. However, due to lack of careful planning and financial restraints, funding for the teaching hospitals has reduced. The teaching hospitals are less willing to pay the salaries of the trainees. This is particularly true for new trainees who do not have long standing posts as medical officers (equivalent to Senior House Officers in the UK). Some of the trainees therefore fund themselves. Recently the College of Physicians and Surgeons have put a ban on having unpaid trainees in the training centers. This may result in further reduction of training posts14. We are still far behind in achieving the standards in psychiatric training due to lack of manpower and resources. Although the current work of College of Physicians & Surgeons is exemplary, we still need improvement in our training systems both at undergraduate & postgraduate levels so that we can attract more professionals in this speciality. There has always been a trend to follow & copy the curriculum of the West, but there is a growing interest among local professionals that we should learn more from the regional countries and get some consensus in our training programmes. It is also desirable to offer Khan & Javed: Psychiatric teaching & training in Pakistan 113 better incentives for the mental health professionals in order to avert brain drain. An effort for providing a favorable environment to the public to help in promoting sound mental as well as physical health is imperative15.

REFERENCES

1. www.who.int/countries/pak/en/ date accessed: 24th June, 2006. 2. UNICEF. State of the world’s children, New York, USA 2006: 96-111. 3. Actionaid (2002). http://www.actionaid.org.uk/wps/content/documents/ new_pakistan_2432004_113938.pdf 4. Gadit A. A & Khalid. N. In State of Mental Health in Pakistan — Service, Education and Research. Hamdard University Hospital, Karachi, Pakistan. 2002. 5. Niaz U, Hassan S, Hussain H, Saeed S. Attitudes Towards Psychiatry in Pre-Clinical and Post- Clinical Clerkships in Different Medical Colleges of Karachi. Pakistan J Med Sci: 2003; 19(4): 253-63. 6. Farooq, S. Psychiatric training in developing countries. British J Psych 2001; 179: 464. 7. Naeem F, Ayub M. Psychiatric training in Pakistan. Med Educ Online [serial online] 2004;9: 19. 8. Ijaz Haider, Diploma in Psychological Medicine (DPM) at Postgraduate Medical Institute, Lahore. Psychiatric Bulletin (1995);19:446-447. 9. Mowadat H Rana, Saeed Farooq, Sohail Ali and Iqbal Afridi; A outline of structured training programme(STP) for FCPS in Psychiatry(Intermediate Module) JPPS: 2008; 5:2: 58. 10. Davies T, McGuire P .Teaching medical students in the new millennium. Psychiatric Bul 2000; 24: 4-5. 11. Table from http://www.med-ed-online.org 12. Khan MM. The NHS International Fellowship Scheme in Psychiatry: robbing the poor to pay the rich? Psychiatr Bull 2004; 28: 435-7. 13. Khan MM. The International Fellowship Scheme. Letter to Editor. Psychiatr Bull 2004;28:433-4. 14. Gadit AA Out of pocket of expenditure for depression among patients attending private community psychiatric clinics in Pakistan. J Med Health Pol Econ 2004;7:23-8. 15. Afridi, M Iqbal. Mental health priorities in Pakistan. J pak Med Assoc. 2003; 58: 5: 225-226

Muhammad Nasar Sayeed Khan Associate Professor and Head Department of Psychiatry and Behavioural Sciences, Services Institute of Medical sciences Lahore-Pakistan, [email protected]

M. Afzal Javed Pakistan Psychiatric Research Centre Fountain House, 37- Lower Mall Lahore, Pakistan [email protected]

14 Psychiatry in Nepal: Training and Training Centre and it’s Relevance to India Tapas Kumar Aich, Deepak Giri ABSTRACT First psychiatric outpatient service in Nepal was started in 1961 at Bir Hospital, Kathmandu. In 1985 first and the only mental hospital in Nepal started functioning at Patan in Kathmandu valley. First Community Mental Health Project was started in the year 1983 at Lalitpur district by United Mission to Nepal (UMN), an international NGO dedicated to the development of mental health services in Nepal. Year 1997 saw the adaptation of ‘Mental Health Policies and Strategies’ by the Ministry of Health, Government of Nepal. Drafting of Mental Health Legislation was done in the year 2000. Out-patient mental health services in Institute of Medicine (IOM), Tribhuvan University-Teaching Hospital (TU-TH), at Kathmandu was started in 1986. A three year MD Psychiatry programme was initiated in 1997 by the department. In 1998 M. Phil course in ‘Clinical Psychology’ and in 2002 B. Sc in ‘Psychiatric Nursing’ was started at the same center. Nepal is better placed than her big neighbor India in relation to implementing psychiatry teaching and training in MBBS course. A student has to attend 40 hours of theory classes in psychiatry and has to gain 160 hours clinical exposure in psychiatry during his/her final year clinical rotation. Additionally, he would get 10 days posting each in psychiatry during his ‘junior internship’ and ‘internship’ period. Indian psychiatrists have played a significant role in imparting postgraduate training in psychiatry to a number of medical graduates from Nepal, who, later on contributed significantly to the growth of psychiatry and psychiatric training in Nepal. They also played active role in establishing postgraduate departments of psychiatry in both government run as well as private medical institutes in Nepal. Key Words: Psychiatry in Nepal, Training centre, Relevance to India 116 Psychiatry in India : Training & training centres PSYCHIATRY IN NEPAL: DEVELOPMENTAL MILESTONES IN BRIEF1,2 In 1962 late Dr. Bishnu Prasad Sharma became the first psychiatrist of Nepal. In 1963 mental health services were started formally in Bir Hospital with both in-and-out-patient psychiatric services. In 1970 first private psychiatric nursing home ‘Temple of Health’ was started (now known as ‘Aryogya Mandir’). In 1974 Dr. Desraj Bhandari Kunwar became the second psychiatrist of Nepal. Psychiatric services were started in Tri Chandra Military Hospital, Kathmandu in 1976 (now named as Birendra Army Hospital). In 1983 department of psychiatry at Birendra Police Hospital in Kathmandu was started, with the help of 2 expatriate psychiatrists, available under United Mission to Nepal (UMN) Mental Health Programme. In the same year first Community Mental Health Project was started at Lalitpur district by United Mission to Nepal (UMN), an international NGO dedicated to the development of mental health services in Nepal. Dr Sarah Acland, was the director of the UMN Mental Health Project from 1990 to 20003. A 50 bedded separate mental hospital was created after closing the existing psychiatry department of Bir Hospital in 1984. Later in 1985 mental hospital was shifted to its current location in Lagankhel, Kathmandu. In 1990 Center of Victims of Torture (CVICT) was established at Kathmandu. Psychiatric Association of Nepal (PAN) was formally made its inaugural appearance in the same year 1990. Year 1997 saw the adaptation of ‘Mental Health Policies and Strategies’ by the Ministry of Health, Government of Nepal. Drafting of Mental Health Legislation was done in 2000 in collaboration with representatives from Ministry of Health, Government of Nepal, Psychiatric Association of Nepal (PAN), United Mission to Nepal (UMN) and Department of Psychiatry, IOM, TU- TH with technical assistance of WHO and summated to ministry of health for necessary action4-6. Centre for Mental Health and Counseling-Nepal (CMC- Nepal) was registered as a NGO in 2003, under the aegis of the United Mission to Nepal (UMN). Table.1: MENTAL HEALTH: HUMAN & OTHER RESOURCES (CURRENTLY AVAILABLE IN NEPAL): DEPARTMENT OF PSYCHIATRY, INSTITUTE OF MEDICINE (IOM), TRIBHUVAN UNIVERSITY-TEACHING HOSPITAL (TU-TH)2,8-10: Out-patient mental health services in Institute of Medicine (IOM), Tribhuvan University-Teaching Hospital (TU-TH), at Kathmandu was started in 1986 following collaboration between TU-TH and United Mission to Nepal (UMN) mental health programme. By 1987 twelve bedded psychiatric in-patient unit started functioning at TU-TH. Later eight bedded de-addiction unit was added Aich & Giri: Psychiatric training in Nepal & India 117 to psychiatric inpatient set-up, thus making it to a current strength of 22 beds with the department. Besides, the department has linked-up with the 50 bedded Mental Hospital set-up at Lagankhel, Kathmandu and 22 bedded psychiatry unit in a general hospital set-up of Nepal Army Hospital in Kathmandu for teaching, training and other academic purposes of their MD residents. In the same year first psychiatric nurse joined her duty at TU-TH and first community mental health programme was initiated at Bhaktapur district by mental hospital in collaboration with World Health Organization9. Institute of Medicine initiated its various mental health projects in collaboration with UMN-MHP in 1989. In 1982 Dr. Dhurba Man Shrestha became the first Nepalese psychiatrist to complete three years MD course from AIIMS, New Delhi, India. Subsequently, Dr. Nirakar Man Shrestha in 1985 and Dr. Mahendra Kumar Nepal in 1986 completed their MD in psychiatry from the same institute, AIIMS, New Delhi, India. Dr DM Shrestha and Dr NM Shrestha joined back their government job in Ministry of Health, while Dr MK Nepal joined as faculty in the department of psychiatry, TU-TH. All three of them contributed significantly for the further development of psychiatry in Nepal, both at government as well as via various national and international NGOs working in the field of mental health. Dr Nepal, as head of the department of psychiatry, IOM, TU-TH, specifically influenced the policy makers in the development and implementation of undergraduate and postgraduate psychiatry teaching and training programmes in Nepal, during subsequent years. A three year MD Psychiatry programme was initiated in 1997 by the department of psychiatry, Institute of Medicine (IOM), TU-TH, Kathmandu. In 1998 M. Phil course in ‘clinical psychology’ and in 2002 B.Sc in ‘psychiatric nursing’ was started by the same center. A brief sketch of teaching and training activities of Department of Psychiatry, IOM, TU-TH is narrated below: i. UNDERGRADUATE PSYCHIATRY PROGRAMME: A separate theory paper of psychiatry consisting of 16 marks and a separate clinical and practical examination in psychiatry consisting 20 marks has been included in internal medicine as integrated course in MBBS curriculum, which bears 10% of total marks in internal medicine. It was initiated by the curriculum advisory committee of TU-TH, Mental Health Unit of WHO and UMN Nepal. Later on it was modified accordingly by the Department of Psychiatry and Mental Health, IOM, TU-TH, Mental Health Project (MHP), MHP and linkage programme. In the USA, about 60 hours of teaching in ‘behavioral sciences’ are there in the first year of undergraduate studies. In the third year, 30 118 Psychiatry in India : Training & training centres

hours are devoted to practical teaching of psychiatry and in the fourth year, there is a full-time posting of 8 weeks of ‘psychiatry clerkship’. In Great Britain, 80 hours are devoted to the ‘behavioral science’ course during basic medical science teaching. During the clinical course, students first learn interview skills and psychiatry history taking once a day per week for 36 weeks and then attend a full-time ‘psychiatry clerkship’ for 3 months. This is usually followed by a university examination as in other subjects. In India, the MBBS syllabus prescribed by the Medical Council of India devotes only 20 lectures to psychiatry and a two-week posting of 3 hours/day in psychiatry. Psychiatry is still taught as an allied discipline of medicine. This is in spite of recommendations of various committees, including one by the Medical Council of India (MCI) itself, to make psychiatry a separate subject with increased allocation of time11. Nepal is better placed than her big neighbor India in relation to implementing psychiatry teaching and training in undergraduate course (MBBS) in medicine. A student has to attend 40 hours of theory classes in psychiatry and has to gain 160 hours clinical exposure in psychiatry, which effectively turns out to one month clinical posting in psychiatry ward/OPD during their final year clinical rotation. Additionally, they get 10 days posting each in psychiatry during ‘junior internship’ and ‘internship’ period. Department of Psychiatry has submitted a proposal to the University (TU-TH) to separate undergraduate psychiatry examination from Medicine, when a student will have to appear for an independent theory as well as clinical examination in psychiatry.

ii. MD PSYCHIATRY PROGRAMME: This programme was started in April of 1997 as 3 years training course with the sanction to enroll 2 students in every year. It was initiated by Mental Health Project (MHP), and MHP-linkage programme chaired by Dr MK Nepal and Dr Abdul Khalid. Dr Deshraj kunwar, Dr VD Sharma, Dr KC Rajbhandari, Dr Sishir Regmi and others had significant contribution in initiating the course. Training and teaching pattern that is being followed here is that being adapted and modified from pattern being followed at AIIMS, New Delhi, India. Dr Abdul Khalid from India, who was hired on yearly basis from July 1997as a long term consultant faculty for the MD courses, for the MD courses, left Nepal on 13th June 2000. Three students had joined the course as first year resident. Two of them were regular and one student came from Bhutan in spirit of cooperation within SAARC region. First batch of MD psychiatry, which included Dr Saroj Ojha Aich & Giri: Psychiatric training in Nepal & India 119

and currently holding the post of Associate Professor of Psychiatry in the same institute, passed out in the year 2000.

A Compilation of Thesis titles of Postgraduate students of MD Psychiatry & M. Phil in Clinical Psychology Programme in Department of Psychiatry, IOM, TU-TH:

iii. THE BIRTH AND DEVELOPMENT OF MENTAL HEALTH PROJECT (MHP) FOR DEVELOPMENT OF PSYCHIATRY IN NEPAL12,13: Mental Health Project (MHP) was eventually established following discussion between psychiatrists from IOM and Redd Barna-Nepal, an International NGO working in Nepal, for development of psychiatric awareness. In 1987, the MHP was duly established with advisory committee of 5 members - chaired by Dean of Institute of Medicine (IOM), Head of psychiatric unit of IOM, Dr MK Nepal, Project Coordinator and 2 implementers Dr. Chris Wright, a psychiatrist attached to United Mission Nepal and Mrs. N Pokhrel, a psychiatric nurse. iv. MHP AND LINKAGE PROGRAMME FOR DEVELOPMENT OF PSYCHIATRY IN NEPAL13: It was established by MHP programme with the help of UMN Nepal and chaired by Dr MK Nepal with members Dr VD Sharma, Dr Sishir Regmi, Mrs Rita Moilanen, Mrs Kanti Tiwari, Mrs Chandrakala Sharma from MHP and Dr Sarah Acland, Mrs Gyanu Sharma & Mrs Raija Kiljunen, from United Mission Nepal. v. OTHER ACTIVITIES IN THE FIELD OF PSYCHIATRY BY DEPARTMENT OF PSYCHIATRY IOM, TU-TH: 1. Training14: With collaboration of NGO CMC Nepal, the department has been training health workers to empower their knowledge and also supervise their work at different levels of the community. Training to health worker in mental health per year is as follows: Medical officer – 14a C AHW/AHW – 40 (C AHW: Community Auxiliary Health Worker; AHW: Auxiliary Health Worker) Nursing (on request from different NGOs & health institution) – 8 to10 2. CMC clinic7:The Department with the help of NGOs organizes CMC clinic at 16 Primary Health Care (PHC) centres in different districts. 120 Psychiatry in India : Training & training centres

3. Research Activities and Publications2,15-17: First issue of Nepalese Journal of Psychiatry made its appearance in 1999 under the editorship of Professor MK Nepal. Currently, Psychiatric Association of Nepal (PAN), under the presidentship of Professor V D Sharma, has taken up the responsibility of timely publication of Nepalese Journal of Psychiatry and made it as its official journal. Multiple research papers have been published as a result of research work carried out in the department, both in national and international journals till date. 4. Conductance of conference: Under the leadership of Professor MK Nepal Psychiatric Association of Nepal (PAN) successfully conducted 2nd SAARC Psychiatric Conference on November 2006 at Kathmandu, Nepal. OVERVIEW Department of Psychiatry, IOM, TU-TH, Kathmandu is too young to be considered as an ‘iconic institute’ in relation to psychiatric teaching and training. But still in its brief stay in the field of psychiatric training and teaching in Nepal, it has made a significant impact in creating leaders and building new trained manpower in the field of psychiatry. Dynamic leadership of Professor MK Nepal was the key factor in the significant growth of the department in shortest time span. Besides Department of Psychiatry, IOM, TU-TH, Kathmandu postgraduate course (MD) in psychiatry is currently being run at BP Koirala Institute of Health Sciences (BPKIHS), Dharan, Universal College of Medical Sciences (UCMS), Bhairahawa and Manipal College of Medical Sciences (MCMS), Pokhara. Indian psychiatrists collaborated and acted in unison with their Nepali counterparts in the development of psychiatry in Nepal, at least during its initial years of development. Contribution of Indian psychiatrists in the development of psychiatry in Nepal has been discussed and elaborated in a different article18. REFERENCES 1. Upadhyaya KD. Current situation of mental health service in Nepal and some priorities to improve it. In Souvenir: 15 years of PAN: past, present and future; 3rd National Conference of Psychiatrist Association of Nepal 2006, 13-23. 2. Sharma VD. Editorial. Mental health in Nepal. Nepalese J Psychiatry 1999, 1(1): 3-4. 3. Acland S. Report on mental health camp at Gandruk village, Kaski district. Kathmandu, United Mission to Nepal, 1998. 4. Shrestha NM. National Mental Health Policies, Strategies and Action Plan. Mental Health Manual for Medical Doctors. Government of Nepal & WHO, 2005. 5. Shrestha NM. The annual report of mental health status of Nepal 2007-08. Ministry of Health and Family Planning, Government of Nepal, Kathmandu 2007. 6. Upadhaya KD. Proceedings of National Seminar on Implementation of National Mental Health Policy: Accelerating the Rate and Meeting the Challenges. Kathmandu 1999. Aich & Giri: Psychiatric training in Nepal & India 121

7. Shrestha RL. Annual Report 2007-2008: Centre for Mental Health & Counseling – Nepal. Kathmandu, 2008. 8. Chhetri AM, Jareg E, Sinha RN. Evaluation of the Mental Health Project in Nepal [Redd Barna- Nepal]. Kathmandu, 1994. 9. WHO and Ministry of Health and Population Nepal. WHO-AIMS Report on Mental Health System in Nepal. Kathmandu, Nepal, 2006. 10. Regmi SK, Pokharel A, Ojha SP, Pradhan SN, Chapagain G. Nepal mental health country profile. Int Rev Psychiatry 2004 16(1-2):142-9. 11. R Srinivasa Murthy, S Khandelwal. Undergraduate training in Psychiatry: World perspective. Indian J Psychiatry 2007 49(3):169-174. 12. Shrestha DM, Pach A, Rimal KP. A social and psychiatric study of mental illness in Nepal [United Nations Childrens Fund, Nepal]. Kathmandu, 1983. 13. Chhetri AM, Jareg E, Sinha RN. Evaluation of the Mental Health Project in Nepal [Redd Barna- Nepal]. Kathmandu, 1994. 14. S Sherchan. Training Manual for Primary Health Care Workers on Mental Health. In: Annual Report 2007-08. Centre for Mental Health and Counselling- Nepal (CMC-Nepal). Mental Hospital, Lagankhel, Kathmandu, 2008. 15. Ojha SP, Pokhrel P, Acharya RP, Pandey KR, Bhusal CL, Marhatta MN. Socio-psychological study among injectable drug users in Kathmandu valley. J Nepal Med Assoc 2002, 41(141): 235-40. 16. Ojha SP, Pokhrel A, Koirala NR, Sharma VD, Pradhan SN, Nepal MK. Profile of first 100 inpatients in deaddiction ward of TU-Teaching hospital, Nepal. J Nepal Med Assoc 2003 42(145): 32-35. 17. Chapasgain G, Rajbhandari KC, Chandra K, Sharma VD. A study of symptom profile of depression following myocardial infarction. J Nepal Med Assoc 2003, 5(2): 92-94. 18. Aich TK. Contribution of Indian psychiatry in the development of psychiatry in Nepal. Indian J Psychiatry 2010;52:S76-9.

Table.1: MENTAL HEALTH: HUMAN & OTHER RESOURCES (CURRENTLY AVAILABLE IN NEPAL): 1. Psychiatrists (Nepalese, working in Nepal): 53 2. Clinical psychologist: 12 3. Psychiatrist nurses: M.Sc. 2 Bachelor (B.Sc.) 12 Diploma 28 4. Psychiatric beds: Government 94 Medical Institutes 246 Private Nursing home 25 NGO/INGO 70 TOTAL 435 5. PG Training: IOM, Kathmandu 2-3 PG students/year BPKIHS, Dharan 2-3 PG students/year 122 Psychiatry in India : Training & training centres UCMS, Bhairahawa 1PG student/year NMC, Birgunj 1-2PGstudents/year Manipal, Pokhara 1PG student/year 6. M. Phil. in Clinical Psychology: 1-2/year (IOM, Kathmandu) 7. M. Sc. Psychiatric Nursing: 2/year (BPKIHS, Dharan) 8. Diploma in Psychiatric Nursing: 4/year (IOM, Kathmandu) 9. Psychiatric Social worker: Nil 10. Occupational therapist: Nil

Table.2: A Compilation of Thesis titles of Postgraduate students of MD Psychiatry & M. Phil in Clinical Psychology Programme in Department of Psychiatry, IOM, TU-TH:

1. Dr Saroj Prasad Ojha. Emotional and behavior problems in physically disabled children and adolescents. 2000. 2. Dr Anupam Pokhrel. A phenomenological study of a patient in stupor and stupor like state. 2000. 3. Dr Mohan Raj Shrestha. An open randomized comparative study of efficacy and tolerability of amitriptyline and sertraline in major depression. 2001. 4. Dr SN Pradhan. Attempted suicide –a study of socio-demographical variable, method employed and associated mental disorder. 2001. 5. Dr Ghanshyam Chapagain. A study of depression in MI. 2001. 6. Dr CP Sedain. An exploratory study of depressive disorder in patient with GI carcinoma. 2002. 7. Dr NR Koirala. Presenting symptoms of depressed patients at PHC. 2002. 8. Dr Lumeshwar Achariya. A sociodemographical & clinical profile of depression following CVA. 2002. 9. Dr Sailendra Raj Adhikari. Prevalence of emotion and behavioural problem among school going children. 2003. 10. Dr Namrata Rawal. A study of psychiatric consequences among patients with RTA. 2004. 11. Dr Binu Champakasssery Balan. Gender difference in unipolar depression–A comparative study. 2004. 12. Dr Manisha Chapagain. Study of prevalence of post-mortem depression and impact of psychological intervention on it. 2004. 13. Singh Bahadur Henjan. A study of anxiety depression and suicidal ideation among HIV infected people. 2004. 14. Dr VD Sharma. Cognitive dysfunction in adult schizophrenic patients and their first degree relatives. 2005. 15. Dr Rabindra Kumar Thakur. A study of dissociative disorder– phenomenology and other correlates. 2005. Aich & Giri: Psychiatric training in Nepal & India 123 16. Dr Jaganath Subedi. An open randomized comparative study of efficacy and tolerability of Imipramine and fluoxetine in patient presenting with panic attack. 2005. 17. Dr Jai Bdr. Kul Bdr. Kharti. Prevalence of depression among geriatric patients attending OPD of TUTH. 2005. 18. Dr Bharat Goit. A study of executive function, memory, attention and concentration. 2006. 19. Dr Bijaya Kaul. Cognitive dysfunction in first degree relation of patients suffering from cannabis induced psychosis. 2006. 20. Dr Sarad Tamrakar. An open randomized comparative study of efficacy and safety of risperidone and haloperidol in schizophrenia. 2007. 21. Dr Roshan Pokhrel. A study of cognitive function in normal adult Nepali population. 2007. 22. Dr Leepa Baidhya. Prevalence of psychiatric co-morbidity in patients with tension headache. 2007. 23. Dr Sunil Kumar Shah. An open randomized comparative study of efficacy and safety of risperidone and olanzapine in schizophrenia. 2008. 24. Dr GR Bhantana. Study of frequency of sexual abuse among patients presenting with dissociative symptoms. 2008. 25. Dr Siquafa Zafreen. An open randomized comparative study of efficacy and safety of quetiapine and haloperidol. 2009. 26. Dr Bibhusan dahal. Prevalence of symptoms of anxiety and depression among patients admitted in de-addiction ward TUTH. 2009. 27. Dr Nishita Pathak. Prevalence of symptoms of depression and anxiety among patients maintained on methadone programme. 2009. 28. Ms. Rekha Kumari Jalan. Neuropsychological dysfunction in schizophrenia. 2001. 29. Ms. Nandita Sharma. Mothers awareness of adolescent stress: Relation between mother’s awareness and adolescent adjustment. 2003. 30. Mr. Prem Bharati. Neuropsychological dysfunction in BPAD. 2005. 31. Mr. Rajan KC. Adjustment and self concept of dissociative disorder patient. 2009.

Tapas Kumar Aich Professor of Psychiatry Universal College of Medical Sciences, Bhairahawa, Nepal [email protected]

Deepak Giri PG Resident Institute of Medicine Tribhuvan University –Teaching Hospital Kathmandu, Nepal

15 Psychiatric training in the UK and its relevance to India

Dinesh Bhugra, Gurvinder Kalra, Nilesh Shah

ABSTRACT

United Kingdom and India not only share a common history, but also a competing amount of dynamism, talent, and expertise across all sectors, including medicine. As far as psychiatry is concerned, the UK has seen a substantial number of Indian psychiatrists migrating into the country. Initially this interest was related to higher training when fewer places were available for training in psychiatry in India. However a decade or so ago for political imperatives, trained psychiatrists from India were appointed to various posts in the UK. These psychiatrists have played a major role in the evolution of psychiatric training and psychiatric curriculum in the UK. Today psychiatric training in UK has undergone changes by leaps and bounds and all of these have a major impact on the psychiatric training programs back home in India. This article discusses the relevance of UK psychiatric training system in the Indian scenario. Training in various institutions in India has been heavily influenced by training patterns in the UK. In this paper we describe similarities and differences and assess how things can be carried forward in the shrinking world as a result of globalization.

Keywords: UK, India, psychiatric training

INTRODUCTION Historically as a result of the British Raj several developments occurred in India in the field of education, communication, travel and language. Even after India gained independence in 1947, close ties between the two countries have led to exchange of ideas and personnel. From the justice system to medical schools and sports such as cricket , UK has influenced the Indian systems in a way that no other country has been able to. When it comes to education and specifically medical education, the two countries have a lot 126 Psychiatry in India : Training & training centres in common. For several decades textbooks used in undergraduate and post- graduate training were the ones followed in the British system. Furthermore there have been close collaborations through initiatives like the British Council to more recent programmes such as the UK India Education and Research Initiative (UKIERI) that aim to improve the educational links between India and the UK.1 TRAINING IN THE UK Psychiatric training in the UK is of 6 years; the first three years is core training and the last three, advanced training. Training posts are approved for the purposes of training as part of a training scheme. Training has three broad components of clinical, academic (including research and teaching) and personal development. Since 2005 the training follows a competence-based curriculum which was developed by the Royal College of Psychiatrists and had to be approved by the Post-graduate Medical Education and Training Board (PMETB) in 2005 itself.2 The role of PMETB was taken over by the UK wide regulating body for medical doctors, the General Medical Council (GMC) in March 2010. There have been several major changes in training recently. Till 2005 the Royal College of Psychiatrists approved training; this role was then taken over by PMETB and now the GMC. Whereas the College carried out site visits, PMETB and GMC approve training based on submissions but visits can be triggered if concerns are raised on training matters. The approval of training occurs at the level of a training programme, which is defined as a series of posts that together enable an individual doctor undergoing training to acquire the competencies which will enable them to complete their training in order to receive the award of a Certificate of Completion of Training (CCT), the UK specialist qualification. Following this award the trainee's name is added to the specialist register maintained by the GMC and only those who are on the specialist register can work as consultants and practice as specialist consultants. The UK is geographically divided into Deaneries which are run by the local Postgraduate Dean who run training programmes in the UK. They are responsible for delivery of training which is provided by the employers. Each Deanery has a post-graduate school in a speciality; thus the deans have to work in close partnership with the heads of Postgraduate School of Psychiatry, the Royal College and employers (NHS hospital Trusts). Recently debate has started about the relationship between service delivery and training. Hospitals deliver all specialty training programmes using their education contract. To learn more about the structure and delivery of training please read the College guide to specialist training (OP69) and other useful documents available at http://www.rcpsych.ac.uk/training/specialtytraining guides.aspx. Bhugra & Kalra et al: Psychiatric training in the UK & India 127 As already noted above, training programmes are delivered in two separate blocks – The first block is core psychiatry training for 3 years which normally leads to passing the MRCPsych exam (membership of the Royal College of Psychiatrists). Once the trainees have passed the examination they then become eligible to apply for and be appointed to an advanced trainee position(second block). This occurs in one of the 6 recognized psychiatric specialities which are General and Community, Child and Adolescent, Forensic, Psychiatry of Learning Disability, Psychotherapy, Old Age psychiatry. In addition three sub-specialties are recognized : Rehabilitation psychiatry, Addictions and Liaison Psychiatry as part of the General and Community psychiatry. Advanced training is for 3 years although in exceptional circumstances trainees are allowed to do dual training in which case the length of training may be extended to a further year. As mentioned above this leads to the award of the CCT. The Royal College of Psychiatrists oversees the process of recruitment to each of these blocks. The eligibility criteria for application for each level of training are described in detail in the person specification document. Trainees must meet these if they are to be considered for entry to a training programme. In core training the trainee rotates around the scheme and each placement is for six months. First placement is always in general adult psychiatry. In the first three years the trainee will be expected to go through a year of adult training, six months of developmental psychiatry either in child psychiatry or psychiatry of learning disability and another six months in a specialist placement such as forensic psychiatry, psychotherapy or other specialities. All advanced training level placements are for a year each. Every three months the trainees give feedback to their tutors or educational supervisors and at the end of term report on their placement. With the introduction of competency based training the trainees have to undergo regular Work Place Based Assessments (WPBA) and be signed off before they can appear for the examination. These methods were introduced to ensure standardization of assessments and training.3 Membership examination has 3 theory papers which can be taken in any order and followed by a structured CASC (Clinical Assessment of Skills and Competence) with stations where the role of the patients is played by actors with very well designed and validated scripts. Each station is examined by one examiner who observes the trainee performing a specific task which can include physical examination. Details of eligibility criteria are available on the College web site. The MRCPsych examination is also available for trainees overseas. Hong Kong is one centre and others are being developed including one at NIMHANS, Bangalore. The Department of Health sets the broad policy of training and numbers required for training and the postgraduate deaneries are responsible for 128 Psychiatry in India : Training & training centres delivering and monitoring medical specialist training in their regions. The College website provides up-to-date information on training and assessments. The Department of Health web site also provides information on education and training called Modernizing Medical Careers – MMC. TRAINING IN INDIA AND A COMPARISON TO THE UK Psychiatric training in India occurs at two levels, the undergraduate and the post-graduate level. At the undergraduate level, students are exposed to psychiatry through a handful of lectures and clinics, where they get an overview of dealing with psychiatric patients. Some of them may develop an interest in the subject at this stage and take up psychiatry as a career at the postgraduate level by either opting for an M.D. (degree- 3 years) or a D.P.M. (diploma- 2 years). Except for the longer duration and dissertation in M.D., there is basically no difference between the two courses. The postgraduate medical education is looked after by the Medical Council of India (MCI), which prescribes various standards of postgraduate medical education, including psychiatric education. Although the MCI governs the education system at the upper level, various Universities have the control of conducting exams etc. as opposed to the centralized system in UK. Autonomous institutes like NIMHANS (Bangalore), AIIMS (New Delhi), and CIP (Ranchi) conduct their own examinations. There is yet another degree of Diplomate of National Board (D.N.B.) which is under the aegis of the Ministry of Health and Family Welfare (MOHFW). DNB has a centralized examination system like the UK, consisting of theory papers and a practical exam. The candidate may have to appear for the practical exam anywhere in the country and not necessarily in the centre where he or she has been trained. The centralized theory exam system is definitely a plus point but the practicum is a bit dicey considering that India is a multi-lingual nation; a student trained in a Hindi speaking north-Indian state may face difficulty when appearing for a practical exam in a Tamil speaking south-Indian state. A translator is provided as a solution to this, but the student may not be well aware of the socio-cultural milieu of the new region, considering the importance that cultural psychiatry is gaining these days. This is a significant observation compared to the UK, which although a multi- ethnic and multi-cultural country, still has English as the main spoken language (with different accents though). This then brings us to the de-centralized system of examinations wherein each individual University holds its own examinations with practical held in their own home-colleges or the same city. As with WPBA system, if done locally there may be seen some degree of nepotism and manipulation of grades unless national standards are agreed and followed. Early results from the UK indicate that assessors find it very difficult to criticize trainees. In the Indian context similar problems may emerge. Having a centralized theory exam and a de-centralized practicum seems to be a decent solution to this quandary. Bhugra & Kalra et al: Psychiatric training in the UK & India 129 From day one, a student in any of the post-graduation courses is exposed to both outpatients and inpatients and is expected to participate in care and management of patients, using both psychopharmacology and psychotherapy. Depending on the Institute, the student may be exposed to child guidance clinics, geriatric and substance use patients etc. Sharma (2010)4 recommends that for psychiatric postgraduate training and assessment, a minimum of six months of clinical rotation in Neurology and Primary Care, three months in consultation and liaison psychiatry and three months in community-based psychiatry should be encouraged. At present different institutes have their own rotation systems with no uniformity. Various specialties in psychiatry are developing apace in India with Child & Adolescent, and Geriatric psychiatry being ahead of other specialties. In India, only two fellowships, one in Geriatric (at CSMM University)5 and the other in Child and Adolescent Psychiatry (CAP) at NIMHANS, Bangalore,6 currently exist. Forensic psychiatry is also another new and upcoming field in India.7 Psychiatric training in psychopharmacology and psychotherapy is also an interesting area in the two countries. With the UK relying mainly on patent drugs, the trainees there may have less experience with various drugs, whereas in India, with most of the generics available, the trainees get to use wider range of drugs, including the older drugs, like the tricyclics and the typical antipsychotics and hence get to see most of the side effects, considering the sheer patient load in the country. On the contrary, UK trainees may have a better exposure to training in psychotherapies, an area which is neglected in India, except for a few centers. RECOMMENDATIONS: A FUTURE AHEAD Kalra and Bhugra (2010)8 point out how Indian psychiatry has been largely influenced by the European system and specifically by the psychiatric practice in the UK. With the two nations sharing a long history, it is time they also share the training expertise and develop mutually helpful systems of higher psychiatric education. The new training structure in the UK has transformed psychiatric training emphasizing evidence based competencies in the workplace in addition to achievements in periodically held examinations.9,10 With more students getting interested in taking up psychiatry as a career in India, it becomes even more important to make comprehensive reviews in the current training programs in the country.11 The major focus area needs to be on promotion of partnerships between the Centers of Excellence in the UK and India, development of more collaborative projects, student exchanges and work placements. Development of specialist short courses in various psychiatric sub-specialties, shared curriculum, staff exchanges would be of immense help in shaping the knowledge base in either nation and would be 130 Psychiatry in India : Training & training centres an impetus to the interesting cross-cultural aspects of psychiatry. Regular periodic short training programs by specialists in the UK delivered in India would help the training system in the country reach new heights. REFERENCES 1. UKIERI, Working together in Education. 2010. Available from www.ukieri.org [last accessed on 13 December 2010]. 2. Bhugra D. The new curriculum for psychiatric training. Adv Psychiatr Treat 2006;12:393-6. [doi: 10.1192/apt.12.6.393]. 3. Bhugra D, Malik A, Brown N (eds). Workplace-Based Assessments in Psychiatry. London, RCPsych Publications, 2007. 4. Sharma S. Postgraduate training in psychiatry in India. Indian J Psychiatry 2010;52:S89-94. [doi: 10.4103/0019-5545.69219]. 5. Department of geriatric mental health. Available from http://www.kgmcindia.edu/ departments/geriatric_index.htm [last accessed on 20 December 2010]. 6. NIMHANS. http://nimhans.kar.nic.in/aca_admission/prosp201112.pdf [last accessed on 20 December 2010]. 7. Shah LP. Forensic psychiatry in India: current status and future developments. Indian J Psychiatry 1999;41(3):179-85. 8. Kalra G, Bhugra D. Mutual learning and research messages: India, UK, and Europe. Indian J Psychiatry 2010;52(7 Suppl 3):S56-63. [doi: 10.4103/0019-5545.69211]. 9. Bhugra D. Training – all change? Advances in Psychiatric Treatment 2005;11(6):381-2. [doi: 10.1192/apt.11.6.381]. 10. Bhugra D. Psychiatric training in the UK: the next steps. World Psychiatry 2008;7(2):117-8. [PMID: 18560514]. 11. Rubin EH, Zorumski CF. Psychiatric education in an era of rapidly occurring scientific advances. Acad Med 2003;78(4):351-4. [PMID: 12691960].

Gurvinder Kalra Northern CCU, North-Western Mental Health, Preston, Melbourne, Victoria 3072, Australia [email protected]

Nilesh Shah Professor & Head, Dept. of Psychiatry, L.T.M.M.C. & L.T.M.G.H., Mumbai 400 022, India

Dinesh Bhugra Professor of Mental Health and Cultural Diversity, Department of Health Service and Population Research, Institute of Psychiatry, King's College London, De Crespigny Park, London SE5 8AF, UK 16 Psychiatric Training in USA and relevance to India

Anand K. Pandurangi

Introduction

In the United States of America (USA), graduate medical education (GME) is highly advanced. Over 8700 specialty programs and 4700 subspecialty programs provide an enriched, resourceful and satisfying environment to 109,000 trainees in 130 medical-surgical specialties for systematic and dedicated learning to emerge as qualified physician specialists and pursue excellence, creativity, and innovation in patient care, education, research and service1. It is no wonder that the USA attracts many aspiring individuals from all over the world to develop careers and fulfill professional dreams. As global dynamics shift, the USA finds an excellent partner in India which shares its core values, especially the pursuit of higher education. The Indian physician diapsora which has migrated to the USA over the last 50-years has excelled in this pursuit and now occupies a critical and leadership position in the USA, both in service and academics. With increasing globalization and emerging India-US partnerships in education, science, healthcare and technology, the time is right to examine the GME system in USA and its relevance to India and Indians. This article attempts to provide an overview of GME in the USA with specific reference to Psychiatry and discusses the relevance to Psychiatry GME training in India, and continued opportunities in the USA for Indian medical graduates, including research training and research collaborations.

Psychiatrists of Indian Origin

The American Association of Physicians from India (AAPI, www.aapiusa.com) estimated that in 2009, there were over 50,000 physicians of Indian origin in the USA and the Indo-American Psychiatrists Association (IAPA, www.myiapa.com) estimates over 5000 such psychiatrists. These groups constitute roughly 7.5% and 12.5% of all physicians and psychiatrists in the USA respectively. The Accreditation Council for Graduate Medical Education (ACGME, www.acgme.com) lists 184 general psychiatry residency training 132 Psychiatry in India : Training & training centres programs in the USA in 2009-10, and the American Psychiatric Association (APA, www.psych.org) counts 6200 graduate trainees in these programs. Roughly 34% of all graduate psychiatry trainees (residents) were international medical graduates, of which trainees who identified themselves as of Asian Ethnicity has varied between 20 and 27% in the last 10-years according to the APA Resident Census data. Although the exact number of trainees of Indian origin is not known, it has varied between 7% and 20% over the last 40-years with a median around 8% in the earlier years and 13% in the recent years. Although the cumulative number of psychiatrists of Indian origin trained in the USA is unknown, based on various data sources from the above listed organizations, the author estimates it to be between 6000-7000. The large majority of these have become permanent residents in the USA and as noted above, over 5000 psychiatrists of Indian origin are currently practicing in the USA. The remainder have returned to India, are practicing psychiatry in different countries, changed specialties, and retired or expired.,2,3,4, 5

Residency Training (Graduate Medical Education – GME) in USA

The primary organization responsible for graduate medical education in the USA is the ACGME, a private and non-profit organization that was created in 1981 as an independent accrediting organization. Its forerunner was the Liaison Committee for Graduate Medical Education, established in 1972. The ACGME’s mission is to improve health care by assessing and advancing the quality of resident physicians’ education through accreditation. The ACGME Board has broad representation from various entities related to medical education and healthcare and includes two resident members, three public members, and a federal representative appointed by the Department of Health and Human Services. The ACGME has 28 Residency Review Committees (RRC) to oversee specialty-specific training6.

The ACGME recognizes the increasingly global nature of medical education and in its 2008-09 annual report, noted that the world is getting “flatter and smaller” each day. Many around the world approach the ACGME for the development of GME programs of excellence in their own countries. The ACGME Board approved a pilot program of international accreditation in Singapore and the creation of ACGME International, to test the feasibility of international accreditation and lay the groundwork for more extensive international relationships for accreditation, as well as opportunities for international experiences for American residents within ACGME-accredited programs.6

The ACGME currently measures a program’s potential to educate by determining compliance with its announced guidelines: (1) Does the program comply with the Requirements, (2) Does the program have Pandurangi: Psychiatric training in the USA & India 133 established objectives and an organized curriculum, (3) Does the program evaluate its residents and itself. However, there is a gradual transition in emphasis from structure-and-process components to emphasis on outcomes. Assessing the actual accomplishments of a program requires a different set of questions including: (1) Do the residents achieve the learning objectives set by the program, (2) What is the evidence the program provides for this, and (3) How does the program demonstrate continuous improvement in its educational processes. As part of the outcomes project, the ACGME has set out Core Competencies to be achieved by resident during their training. The six general competencies are: Patient Care, Medical Knowledge, Professionalism, Systems-based Practice, Practice-based Learning and Improvement, Interpersonal and Communication Skills6, 7.

The ACGME sets out the Common Program Requirements that are then supplemented by the specialty-specific RRC. The elements of a program that are reviewed for accreditation are shown in Table I

Institution Sponsoring/ Participating/ Letters of Primary Institution Training Sites Agreement

Program Personnel Program Director Program Faculty Program Staff Program Resources Clinical Resources Facility Resources Medical Information Access Appointment of Residents Resident Transfers Fellows Other Trainees Educational Program Curriculum Learning Methods Scholarly Activities Evaluation Resident Evaluation Faculty Evaluation Program Evaluation & Feedback Improvement Resident Supervision Direct, Indirect Duty Hours On-call Activities Professional Growth Fatigue Moonlighting Experimentation Innovation Psychiatry GME: In 2009-2010, there were 184 programs offering GME in General Psychiatry with 6200 residents enrolled. The general psychiatry training program in the USA is 48-months long with four 1- year long training periods referred to as PGY 1 through PGY 4. Psychiatry specific requirements and guidelines are published by the RRC for Psychiatry. It is beyond the scope of this article to document all the recommended and required learning methods, knowledge, skills and competencies. Mention of the major items is made below. For full details of both the common program requirements and the psychiatry-specific requirements8, the reader is referred to http://www.acgme.org/acWebsite/navPages/nav_400.asp.

Patient care skills and competencies elaborated by the Psychiatry RRC include: 134 Psychiatry in India : Training & training centres 1. Obtaining a comprehensive set of information through history, examination, and tests 2. Formulating a bio-psycho-social diagnosis and differential diagnoses 3. Developing and implementing a comprehensive treatment plan 4. Working with an interdisciplinary team of professionals 5. Developing knowledge and skills in various treatment modalities such as pharmacological and psychotherapeutic including individual psychotherapies, and family and group therapies, electroconvulsive therapy, and psychosocial, rehabilitative therapies 6. Providing psychiatric consultation.

Training durations are specified as follows: 1. 4-months of primary care medicine 2. 6-18 months of inpatient psychiatry experience 3. Minimum of 1-year continuous experience in an outpatient setting 4. 2-months of child and adolescents 5. 2-months of neurology 6. 1-month geriatric psychiatry 7. 1-month of addiction psychiatry 8. 2-month of consultation-liaison experience. 9. Training in forensic psychiatry, emergency psychiatry, and community (public) psychiatry is required but no specific duration is specified.

Various settings and contexts for developing the various skills are suggested. The RRC specifies the minimum requirements while allowing flexibility to programs to mix and match the various experiences and substitutions in a way as to optimize the learning experience for the resident.

The medical knowledge component for psychiatry is further elaborated to include: (1) History of psychiatry and its relation to the evolution of Medicine, (2) Major theoretical approaches to understanding the doctor-patient relationship, (3) A comprehensive set factors that influence the physical and psychological development, adaptation and maladaptation throughout the life cycle. (4) Fundamental principles of epidemiology, etiologies, diagnosis, treatment and prevention of all major psychiatric disorders in the DSM including biological, psychological, social, cultural, iatrogenic factors Pandurangi: Psychiatric training in the USA & India 135 affecting prevention, incidence, prevalence, course and treatment of such disorders. (5) Co-morbidities, and neuropsychiatric conditions, (6) Laboratory and psychological testing, (7) Legal aspects of psychiatry, (8). American culture and sub culture. The development of this knowledge occurs through didactic and other formats of instruction which include regular lectures, seminars, and reading assignments.

Scholarship includes research literacy and critical appraisal, and research opportunity through projects.

Practice based learning to become competent in investigating and evaluating care of patients, appraisal and assimilation of evidence, and striving to improve patient care, to include self evaluation, and life long learning, use of information technology, and participation in education of patients, students, self, peers, and other professionals. Professionalism includes responsiveness to patients and others, respect, compassion, integrity, accountability, sensitivity, and ethical practice. System based practices including health delivery systems and integration, cost and cost effectiveness, promotion of health, prevention of illness, interdisciplinary function, documentation, discharge and transition. Resident evaluations include mock examinations, simulations, tests and examinations, and formative and summative evaluations7,8.

Examinations and Certification

The American Board of Psychiatry and Neurology, Inc (ABPN) is the primary certifying organization9. It is a nonprofit corporation that was founded in 1934. Its mission is to develop and provide valid and reliable procedures for certifications and maintenance of certification in psychiatry and neurology. Between 1935 and 2010, the ABPN has certified over 50,000 physicians in general psychiatry10. Overall passing rates in recent years are around 80% for first time test takers. The ABPN sets the standards for knowledge and skills required for certification, constructs and administers examinations to evaluate these, and monitors, evaluates, and improves the standards and procedures of the certification process.

Board Certification: To be certified in general psychiatry, candidates must currently pass a two part examination. From the fall of 2011, a new single Psychiatry Certification Examination is being implemented, and the current format is being phased out9. Currently, a candidate is eligible to take the examination upon successful completion of the 4-year general psychiatry training program. The Part I examination tests both the topical and clinical knowledge of the candidate and his/her understanding of the various aspects of good clinical practice. It is a computer based examination and consists of 136 Psychiatry in India : Training & training centres 250-questions in the multiple choice format to be completed over a maximum of 8-hours. Upon successful completion of this part, the candidate may take Part II of the examination. The part II examination is held 3-4 times a year at a central location and consists of two segments. In one segment, the candidate is presented four case vignettes including one video clip by an examiner in 1:1 setting, followed by questions focused on phenomenology, diagnosis, treatment, and prognosis. Each case is presented and questioned over 12-minutes. In the second segment, the candidate interviews a live patient who has volunteered and consented to be interviewed in the presence of two examiners for 30-minutes. The candidate obtains the critical elements of the patient’s psychiatric, psychosocial and medical history, and conducts a mental status examination. After the patient is examined, the candidate presents a summary of the case including a bio-psycho-social formulation, and diagnosis and differential diagnoses. The two examiners observe and assess the candidate for the following:

l Physician-patient relationship l Conduct of psychiatric interview l Organization and presentation of data l Phenomenology, diagnosis, and prognosis l Etiologic, pathogenic, and therapeutic issues (biologic, psychologic, and social)

The new single certifying examination will be a computer-based examination involving clinical vignettes, basic psychiatry, and neurology and neuroscience questions that may be completed over a 9 & ½ hour period. The first such examination will be offered in the fall of 2011. The ABPN will require that residents demonstrate mastery of the clinical skills listed above as verified by their training program to be eligible for the certifying examination. These skills are to be assessed in the context of three or more live patient evaluations conducted in the presence of an ABPN-certified psychiatrist. Training programs may elect to assess additional competency components, e.g., differential diagnoses and treatment planning. Evaluation must be completed on ABPN-approved clinical skills verification forms9.

Maintenance of Certification (MOC)11

The mission of the MOC Program is to advance the clinical practice of psychiatry by promoting the highest evidence-based guidelines and standards to ensure excellence in all areas of care and practice improvement. Diplomates are responsible for their own self-assessment activities, continuing education credits, and practice improvement plans, and they can choose the learning tools that will best address their perceived needs, expand their expertise, and enhance the effectiveness and efficiency of their practice. Pandurangi: Psychiatric training in the USA & India 137 All ABPN time-limited certificates are valid for 10 years. The ABPN MOC program includes four components: (1) Professional Standing, (2) Self- Assessment and CME (30 CME credits per year, 300 credits over the 10-year cycle), (3) Cognitive Expertise, (4) Performance in Practice.

Observerships and Externships: A significant impediment for trainees aspiring to obtain GME in the USA is the requirement that the individual have 3-months of “hands-on” clinical experience, in addition to the ECFMG certification. Yet, such experience is not easy to obtain due to the requirements of close supervision by faculty, risk and liability concerns, and expenses. There are several IMG friendly programs that do provide such experience and a list of such programs may be obtained from the AAPI12.

Cultural and Other Adaptation: An issue unique to international medical graduates including those from India who pursue GME in the USA is that of learning the American and local culture, history, language, dialects, semantics, idioms, communication, cultural protocols and sensitivities as well as the medical culture, community and system expectations, methods and systems of care delivery. Daunting as this list is, it is still not an exhaustive list of the challenges of acculturation, accommodation, and adaptation that confront the freshman graduate trainee. The reader is referred to the articles annotated by Nyapati Rao and colleagues13on both psychiatry specific, and generic articles on these topics.

Psychiatry Subspecialties and Fellowship Training: A major advantage of the training opportunities in the USA is the vast number of sub-specialty training that is available. In addition to General Psychiatry the following subspecialties related to Psychiatry are recognized by the ABPN: Addiction Psychiatry, Child and Adolescent Psychiatry, Forensic Psychiatry, Geriatric Psychiatry, Hospice & Palliative Medicine, Pain Medicine, Psychosomatic Medicine, and . As of 2009, there were the following programs in the various sub-specialties with number of residents shown in parentheses: Addictions=45 (57), C & A=124 (810), Forensic=44 (81), Geriatric=58 (64), Psychosomatic=48 (58). The ABPN and RRC provide detailed guidelines for the curricula and training for these programs1.

There are various subspecialties without formal ABPN recognition that one may pursue through fellowships. These include administrative psychiatry, anxiety disorders, biological psychiatry, brain imaging, cognitive behavior therapy, community psychiatry, electroconvulsive and other brain stimulation therapies, mood disorders, , psychiatric and behavioral genetics, psychoimmunology, psychopharmacology, public psychiatry, rehabilitation, research, schizophrenia, transplant psychiatry, etc. Fellowships are typically funded as PGY-5 or higher year of training by the 138 Psychiatry in India : Training & training centres local GME funds, state funds, foundation and/or research grant dollars. The duration is variable and typically last between 1-3 years. Fellowships are typically advertised in the Psychiatry News, published by the APA14. The APA maintains an exhaustive data bank of fellowships that is accessible to potential applicants and others. Research fellowships may be available to those without formal US residency training and/or non-physician doctoral and post doctoral candidates. The formats of training, skills to be achieved and learning methodologies are too varied and fellowship specific, and beyond the scope of this article.

Dual and Triple Board Certifications: A limited number of programs offer training to become eligible for multiple specialization and develop inter disciplinary careers and practices that are broad in scope. These include (1) adult and child psychiatry, (2) psychiatry and neurology, (3) psychiatry, child psychiatry and pediatrics, (4) psychiatry and medicine, and (5) psychiatry and family practice.

Prominent Programs: During the immigration of the first wave of the Indian physicians between 1965 -1980, most obtained residency positions in the larger cities such as New York and Chicago. Although the opportunities have expanded significantly since then, these cities continue to offer most number of residency positions to IMGs. Major university programs tend to be very competitive. The recent top-25 programs based on NIH funding for research are listed below in Table II15.

Institution City State

1 UNIVERSITY OF PITTSBURGH SCHOOL OF MEDICINE PITTSBURGH PENNSYLVANIA 2 UNIVERSITY OF PENNSYLVANIA SCHOOL OF MEDICINE PHILADELPHIA PENNSYLVANIA 3 YALE UNIVERSITY SCHOOL OF MEDICINE NEW HAVEN CONNECTICUT 4 DUKE UNIVERSITY SCHOOL OF MEDICINE DURHAM NORTH CAROLINA 5 UNIVERSITY OF CALIFORNIA SAN DIEGO SCHOOL OF MEDICINE LA JOLLA CALIFORNIA 6 WASHINGTON UNIVERSITY SCHOOL OF MEDICINE SAINT LOUIS MISSOURI 7 JOHNS HOPKINS UNIVERSITY SCHOOL OF MEDICINE BALTIMORE MARYLAND 8 MOUNT SINAI SCHOOL OF MEDICINE NEW YORK NEW YORK 9 UNIVERSITY OF TEXAS SOUTWESTERN MEDICAL CENTER DALLAS TEXAS 10 UNIVERSITY OF MARYLAND SCHOOL OF MEDICINE BALTIMORE MARYLAND 11 DAVID GEFFEN SCHOOL OF MEDICINE AT UCLA LOS ANGELES CALIFORNIA Pandurangi:Psychiatric training in the USA & India 139

Institution City State

12 UNIVERSITY OF MICHIGAN MEDICAL SCHOOL ANN ARBOR MICHIGAN 13 STANFORD UNIVERSITY SCHOOL OF MEDICINE STANFORD CALIFORNIA 14 UNIVERSITY OF WASHINGTON SCHOOL OF MEDICINE SEATTLE WASHINGTON 15 UNIV OF COLORADO HEALTH SCIENCE CTR SCHOOL OF MEDICINE AURORA COLORADO 16 UNIVERSITY OF CALIFORNIA SAN FRANCISCO SCHOOL OF MEDICINE SAN FRANCISCO CALIFORNIA 17 EMORY UNIVERSITY SCHOOL OF MEDICINE ATLANTA GEORGIA 18 COLUMBIA UNIVERSITY COLLEGE OF PHYSICIANS & SURGEONS NEW YORK NEW YORK 19 UNIVERSITY OF NORTH CAROLINA SCHOOL OF MEDICINE CHAPEL HILL NORTH CAROLINA 20 MEDICAL UNIVERSITY OF SOUTH CAROLINA COLLEGE OF MEDICINE CHARLESTON SOUTH CAROLINA 21 UNIVERSITY OF CINCINNATI COLLEGE OF MEDICINE CINCINNATI OHIO 22 UNIVERSITY OF IOWA COLLEGE OF MEDICINE IOWA CITY IOWA 23 UNIVERSITY OF MIAMI SCHOOL OF MEDICINE CORAL GABLES FLORIDA 24 UNIVERSITY OF ILLINOIS COLLEGE OF MEDICINE CHICAGO ILLINOIS 25 NEW YORK UNIVERSITY SCHOOL OF MEDICINE NEW YORK NEW YORK

Research Training and Opportunities:

Although the focus of this article is on residency training, mention must be made of research training, visiting fellowships, research funding and collaboration opportunities in the USA for international psychiatrists. The Fogarty International Center16 an arm of the National Institutes of Health located in Bethesda, Maryland, USA is the principal facility and program through which these activities are conducted, although the location of the investigator may be at any academic site in USA or elsewhere depending on the nature of the program or collaboration. As of September 2007, there had been 303 Indian researchers on the NIH campus, including Visiting Fellows, Visiting Scientists, Volunteers, and Guest Researchers. The majority of these researchers were Visiting Fellows at NIH for 2-5 year assignments. Although many of these Visiting Fellows returned to India after their experiences at NIH, a substantial percentage did not repatriate. The Government of India and the Fogarty International Center have been working together to attract 140 Psychiatry in India : Training & training centres visiting Fellows back to India17.

US-India Fund: For over three decades, the United States and India have had a robust cooperative relationship in Science and Technology (S & T). In large part, this relationship was fueled by the U.S.-India Fund and its predecessor, the P.L.-480 program. Since 1987, the NIH has administered over 35 research projects and workshops in a wide variety of biomedical research topics. The USIF Program ended in 1998. However new memoranda of understanding have been signed between NIH and India's department of biotechnology (DBT) to continue and expand S & T initiatives. Although much of the focus and funding in recent years has been towards vaccine development, maternal and child health, contraception, and prevention and treatment of HIV, a major initiative on brain disorders to include mental health and neurological and addictive disorders has been initiated in 200818.

Separately, NIMH (USA) has recognized the importance of creating more research opportunities in global mental health, in areas such as: novel approaches to care; clinical trials, integration of primary care and mental health care, access to longitudinal datasets; population genetics; large epidemiologic studies; identify the protective effects of support systems, research on cell lines, tissue repositories, experimental animal models, and probe libraries. Another issue is training. Medical students and those in related fields are expressing tremendous interest in global health, including global mental health. NIMH might consider its overall training strategy in global mental health for US institutions, particularly as it relates to areas of strategic importance. In addition, NIMH might consider building capacity in other countries by assisting in the training of their scientific workforce. Both training efforts could be addressed in collaboration with the Fogarty International Center19. Recent examples of highly productive training, mentoring and collaboration include Dr. Linda B. Cottler, a grantee of Fogarty's International Clinical, Operational, and Health Services Research and Training program,20 and the genetics training program with Drs Nimgaonkar and Deshpande as project directors in USA and India respectively.21

The Indo-US Science & Technology Forum (www.Indousstf.org)22 offers another platform for research training and research. Established under an agreement between the Governments of India and the United States of America in March 2000. This is an autonomous, not for profit society that promotes and catalyzes Indo-US bilateral collaborations in science, technology, engineering and biomedical research through substantive interaction among government, academia and industry. Pandurangi: Psychiatric training in the USA & India 141 Conclusion: The psychiatry GME programs including training, certification and administration the USA offer rich and successful models for the development, enrichment and specialization of GME in India. Psychiatry programs in USA have trained and continue to train considerable number of physicians of Indian origin who contribute to patient care, education and service, predominantly in the USA with a small number repatriating to India. The educational and research institutions in USA offer substantial training and collaborative opportunities for Indian psychiatrists, and new programs are being created with the support of the leadership of both countries, making the future looks very promising.

REFERENCES

1. Accreditation Council for Graduate Medical Education (www.acgme.org) http://www. acgme.org/acWebsite/dataBook/2009-2010_ACGME_Data_Resource_ Book.pdf 2. American Medical Association Physician Master File, Chicago, Il (www.ama.org) 3. American Association of Physicians of Indian Origin Newsletter 2009-2010, Chicago, Il www.aapiusa.org 4. American Psychiatric Association Resident Census data 1968-2010, APA, Rosslyn, Virginia, (www.psych.org) 5. Indo-American Psychiatrist Association (IAPA) Newsletters 2009-2010 (Forum), Philadelphia, PA www.myiapa.org 6. ACGME Annual Report 2008-2009. ACGME Inc., 2010 7. Program and institutional requirements for psychiatry available at http://www.acgme.org /acWebsite/RRC_400/400_prIndex.asp 8. Psychiatry programs structure, requirements, guidelines, projects and resources, etc http://www.acgme.org/acWebsite/navPages/nav_400.asp 9. American Board of Psychiatry and Neurology, Inc. www.abpn.com 10. ABPN Certification Statistics http://www.abpn.com/cert_statistics.htm 11. ABPN MOC Psychiatry http://www.abpn.com/moc_psychiatry.htm 12. AAPI Clinical Observership program. http://aapiusa.org/education/observership.aspx. 13. Rao, N.R., Kramer, M., Saunders, R., et al: An Annotated Bibliography of Professional Literature on International Medical Graduates, Acad Psychiatry 2007, 31:68-83 14. Psychiatry News, APA. http://pn.psychiatryonline.org/site/misc/about.xhtml 15. The Official Ranking of US Psychiatry Departments (Based on NIH funding 2005). http://www.residentphysician.com/Psychiatry_rankings.htm 16. The Fogarty International Center. http://www.fic.nih.gov/ 17. The Fogarty International Center. South Asia Program. http://www.fic.nih.gov/programs/ regional/South_asia/). 18. FIC Global Health Matters, 2008, 7, 2. 19. National Advisory Mental Health Council. Minutes of the 220th Meeting, February 12-13, 2009, Department of HHHS, PHS, NIH-NIMH 20. FIC. Global Health Matters, September - October, 2008, Volume 7, Issue 5. 142 Psychiatry in India : Training & training centres 21. The Indo-US Programme for Genetics and Psychoses. V Nimgaonkar, P.I.-US, SN Deshpande, P.I-India. http://indouspgp.info/ 22. The Indo-US Science & Technology Forum. www.Indousstf.org

Anand K. Pandurangi Professor of Psychiatry Virginia Commonwealth University P.O. Box 980710 Richmond, Virginia, 23298 USA [email protected] 17 Psychiatry Training in Australia and its relevance to India

Russell D'Souza

ABSTRACT

Introduction: This paper introduces the Australian Mental health operations including an overview of the man power and the influence of the legal act in clinical practice and training.

Methodology: There is an examination of the general broad bird’s eyeview of the Australian Psychiatry training program with a mention of the recent changes. This is followed by an overview of the broad principles and operations of the Indian Psychiatry training program. Then, a consideration of the Australian training and its relevance to Indian training is elicited considering the well regarded and demonstrated Indian Psychiatry Training but with some thoughts of areas of training that might be relevant to further enhance the quality and applicability of the skills of the Indian trained psychiatrist.

Conclusions: Australian training program while still deficient in some areas particularly in meeting the requirements of the changing population, from changed migration patterns, has areas that can be relevant to the Indian training, which is generally well regarded internationally. This is demonstrated in the significant Indian trained psychiatrists providing care and making their mark in all the areas of psychiatic practice in the major developed countries.

Psychiatry training in Australia has evolved from the British Training programs as most of the early psychiatrists were British trained. Over time and with the Royal Australian and New Zealand College of Psychiatrist taking the role of training from the earlier university based qualification, the training has evolved to the local requirements and in the format with some similarities of the Royal College of Psychiatrist of UK.

Currently, there are about 2400 practicing consultant psychiatrists in 144 Psychiatry in India : Training & training centres

Australia, 80% of whom are in private practice. In terms of training, there are close to 700 trainees (registrars) with approximately 100 qualifying each year[1]. Training takes place all over the country but, as with many other aspects of Australian life, is largely confined to a small number of larger cities dotted around the coast of the mainland.

The Federal and State infrastructure that Australia bases much of its organisation on is also reflected in its Mental Health Act legislation. There is no nationwide Mental Health Act. Each state has its own Act (albeit largely similar) and board of medical registration for practitioners. This has just moved to a national registration program.

Australian training

Usually a doctor who wants to specialise in psychiatry must first complete 2 years as a medical officer after obtaining the MBBS degree. Important to note that the MBBS degree has a significant component of psychiatry placement, training and examination in each of the years of undergraduate medical training. This can be in any broadly medical/surgical post provided it has been approved by the state board. The would-be trainee applies to the Royal Australian and New Zealand College of Psychiatrists (RANZCP) training program in any of state branches directly and will undergo a selection process involving an interview before being accepted and recognised by the College as a trainee. Once accepted, it is down to the individual to search for a suitable accredited 5-year training program of a hospital or health service scheme to join. Entry onto such schemes is again by interview; however, in practice the two interviews (College and scheme) will often be merged to form one general entry interview. The training program followed this model, however in the last 5 years there have been changes made.

Overall the first year is regarded as probationary. Trainees will spend 12 months in two 6-month placements; usually in general adult psychiatry. Towards the end of the first year, various assessments are made. First, a formal report of the trainee's progress together with a detailed patient case history of 3000-5000 words needs to be submitted. The next 2 years or so are designed to enable the trainee to meet the criteria specified in the 'Certificate of Eligibility for Section 1 Exam' [2]. This consists of further 6-month posts in psychiatric specialities such as old age, child & adolescent, consultation/liaison, etc. At the end of each post, a detailed case report must be submitted — six in total including the year one case. These will need to be approved before being deemed acceptable by the College.

In addition to case reports, requirements for psychotherapy training need to be met. Including at least two cases of short-term and one of long-term (>6 months) cognitive—behavioural therapy and dynamic psychotherapy. Also at D’Souza: Psychiatric training in the Australia & India 145 least five sessions of marital/family/group work need to be undertaken. Training and work in Indigenous mental health is required. The individual trainee must organise and log these.

Also during the third year, a general medical examination (GME) is attempted. Its purpose is to underline the importance of a good working knowledge relating to physical medicine in everyday psychiatry. It consists of a clinical long case followed by a viva in the presence of two physicians. This has been dropped and included as one of the stations of the Observed structured clinical examination. This year is said by many trainees to be the most taxing of the 5-years. During this time the trainee must ensure that all the requirements for the 'Certificate of Eligibility' are present and up-to-date. Then, towards the end of this fourth year he/she can take the Section 1 exam. This exam is structured, consisting of both written and clinical elements. There are two written papers. The first is a series of short answer questions on neurosciences and theory followed by an essay paper covering broader clinical topics. These have been revised to consist of multiple choice questions.

The oral exam is taken approximately 4-6 weeks following the written. This section of the exam is divided into 2 days. Day 1 consists of two long cases (each with two examiners). There is a presentation and discussion. Day 2 is reserved for the so-called 'consultancy viva'. Here, a variety of clinical scenarios and vignettes are presented and the candidate is asked to comment on, or manage them. Provided both clinical days are passed then no further exams need be taken along the path to consultancy — the trainee can now progress to the fifth and final year of training.

In 2005, following a review, these have been changed to day 1 consisting of a long case with two examiners and day two consisting of OSCE stations with two examiners at each station. The next year is referred to as the elective year. Having passed all the exams, case histories and other training requirements, the trainee — now referred to as a 'senior registrar' embarks on the final phase of training before being granted Fellowship of the College. The purpose of this year is to enable the trainee to make career and speciality choices — the types of posts available to senior registrars reflect this.

The major requirement of this year is a 10,000-25,000 word dissertation, which will be submitted to the College for approval. It can be a literature review, a piece of original research, a clinical topic or a service development/evaluation paper. Normally, candidates complete this towards the end of their fifth year. If approved, the College bestows fellowship (FRANZCP) upon the trainee. Once fellowship is granted, the senior registrar is regarded as a consultant psychiatrist and is eligible to practise 146 Psychiatry in India : Training & training centres independently, either privately or in the public system.

In addition to being part of a training scheme, university based post graduate degree course and other courses related to the theory and practice of psychiatry are run. These courses vary from state to state and culminate in a qualification such as a Master of Psychological Medicine (MPM). The course is structured in a way to mirror the 5-year registrar training scheme dealing with phenomenology and a variety of clinical topics at the outset progressing onto neurosciences and methodology in later years.

Indian training

Psychiatry training in India broadly follows from undergraduate training where psychiatry training is dismally low in comparison to the undergraduate program in Australia; the Medical Council of India guidelines show that students are required to participate only in a 2-week programme of clinical postings, excluding a number of theory lectures. The staff teaching the undergraduates is relatively junior and not fully trained in teaching methodology, curriculum planning and use of teaching aids[3]. Those interested in gaining experience can work as junior residents (equivalent to senior house officer) in 6-month posting in various district hospitals and medical colleges. Postgraduate training in psychiatry, like most other specialities, is on a 3-year residency system with an exit exam leading to the degree of Doctor of Medicine (MD); 2-year diploma courses are run by a small number of institutions. There are around 300 training places annually for psychiatry, this is low considering the standard requirements of psychiatrist to population and the demand for psychiatric care in such a large population. Training posts are spread across various state medical colleges and there are also a few central institutions that offer postgraduate training, namely: the National Institute of Mental Health and Neurosciences (NIMHANS) in Bangalore; Post Graduate Institute of Medical Education and Research (PGIMER) in Chandigarh; All India Institute of Medical Sciences in Delhi; and Central Institute of Psychiatry in Ranchi. Training in these institutions, including some centres in Mumbai and Chennai, are highly regarded. Standards of training are not centrally monitored and thus vary across institution although training standards in some institutions are high. Trainees rotate through out-patient and in-patient and on-call placements. In some institutions trainees undertake a comprehensive training programme covering placement in out-patient and in-patient services, addiction, liaison psychiatry, psychotherapy, child psychiatry, forensic psychiatry, community psychiatry[4] and neurology. The MD thesis, which every trainee has to complete in order to achieve his or her degree involves a research project, which the trainee plans, executes and writes up under the guidance of a supervisor from within the same department. Unlike in Australia the exit D’Souza: Psychiatric training in the Australia & India 147 exam for the degree of MD is not conducted by one central institution but is conducted by the trainees' local institution. The examiners consist of two faculty members from within the department and two external examiners from other academic departments of psychiatry within the country. Further training after the MD degree as a senior registrar for a period of 3 years leads to eligibility for consultancy. Many doctors do not opt for senior registrar training, but go into private practice or work as a psychiatrist in a district hospital. In some hospitals it is not deemed necessary to complete senior registrar training to become a consultant. However, senior registrar training is essential if the trainee plans a career in academics or plans to join a teaching institution. Sub-specialities in psychiatry are not yet developed (except at some central institutions) and hence nearly all senior registrar posts are currently in general psychiatry. However, many psychiatrists develop their own areas of special interest during training.

Australian training and its relevance to Indian Training

There are positive aspects of the Indian training scheme in that it is structured with a clear time frame of 3 years, with emphasis on compulsory research in the form of a MD thesis. However, one of the clear differences and needs is the lack of uniformity in the training offered by various institutions, with training in some institutions comparable to the leading institutions in the world and training in others that are wanting in many areas [5]. Having a central organisation stipulating, monitoring and continuously evaluating training will be necessary to address this difference. There appears to be a paucity of supervisors/consultants with formal consistent training and expertise in various forms of psychotherapy[6,7]; this again will be an area that can be monitored and addressed by a central organisation and only a few centres provide sub-speciality services for training. Thus there is need to evolve a consistent national programme of training. The main organisation of Indian psychiatrists — The Indian Psychiatric Society could be involved in the process of developing, monitoring and evaluating psychiatry training program and services planning.

Psychiatry is an evolving speciality in India[8]. The bulk of current training is in general psychiatry and liaison psychiatry. There are currently approximately 3500 psychiatrists in India. A significant number are in private practice. There is still a considerable number of mental hospital systems that house patients with chronic mental illness. Community psychiatry is not yet well developed in all regions, although pilot schemes like the Raipur Rani project in Punjab[9] have shown its feasibility. Community psychiatry services function in Karnataka under the aegis of NIMHANS, Bangalore[10] and a few other areas. These could serve as a model for further development of community services across the country which will offer training positions for registrars. 148 Psychiatry in India : Training & training centres Community psychiatry training position is a mandatory part of the training experience scheme in the Australian training program.

Although there is a Mental Health Act, its use is virtually non-existent as opposed to the Australian system where the mental act and legal knowledge are an important part of clinical psychiatric care. The probable reasons for the Indian systems less reliance on the mental health law are cultural; family members often persuade patients to seek treatment and the advice of the doctor is often seen as binding. Similarly, the strength of social networks and involvement of the family in the management of the patient can to some extent compensate for the lack of community care.

There are important differences with respect to Indian and Australia in the epidemiology, manifestations and outcome of mental illness, which influence the practice of psychiatry in India [11]. The Australian training does not cater to knowledge to traditional medicine and religious beliefs which play a large part in the treatment seeking patterns of patients in India and also to the indigenous Australian patients. It has also been suggested that the practice of psychotherapy, as in the Western world, has to be adapted to Indian cultural beliefs [6].

While Psychiatry is an evolving speciality in India, there is an organised and well-proven postgraduate training programme from the demonstrated evidence; however, the number of training places and psychiatrists is low compared to Australia and to even keep up with the population requirements. Training in sub-specialities of psychiatry remains an area that needs attention will benefit from investment. Services are both hospital and private sector based. In terms of providing psychiatric care, there is a need for a more coherent and involved policy from the government in collaboration with national bodies such as the Indian Psychiatric Society.

Australian training program while still deficient in some areas in particular in meeting the requirements of the changing population needs from changed migration patterns, has areas that can be relevant to the Indian training, which is generally well regarded internationally. This is demonstrated in the significant Indian trained psychiatrists providing care and making their mark all areas of psychiatry practise in the major developed countries.

REFERENCES

1. Henderson, S. Focus on psychiatry in Australia. Br J Psychiatry 2000;176: 97-101. 2. RANZCP. Training and Examination By Laws for Fellowship 2000. 3. Alexander, P. J. & Kumaraswamy, N. Impact of medical school experiences on senior medical students interested in psychiatry. Indian J Psychiatry 1995;37: 31-34. 4. Kapur, R. L. Mental health care in rural India: a study of existing patterns and their D’Souza: Psychiatric training in the Australia & India 149 implications for future policy. Br J Psychiatry 1975; 127: 286-293. 5. Kuruvilla, K. A common minimum programme needed in postgraduate training in psychiatry. Indian J Psychiatry 1996; 38:118-119. 6. Neki, J. S. Psychotherapy in India. Indian J Psychiatry 1977;19:1-10. 7. Sharan, P. "Do what you must...?" Indian Journal of Social Psychiatry 2000; 16: 10-15. 8. Srinivasamurthy, R. & BURNS, B. J. Community mental health. Proceedings of the Indo-US Symposium,Bangalore: NIMHANS 1992. 9. Trivedi, J. K. Importance of undergraduate psychiatric training. Indian J Psychiatry 1998 ; 40: 101-102. 10. Varma, V. K. & Das, M. K. Mental Illness in India: epidemiology, manifestations and outcome. Indian Journal of Social Psychiatry 1995;11 (suppl. 1):16-25. 11. Wig, N. N., Srinivasamurthy, R. & Harding, T. W. A model for rural psychiatric services — Raipur Rani experience. Indian J Psychiatry1981; 23:275-290.

Russell D'Souza Director of Clinical Trials and Bipolar Program Northern Psychiatry Research Centre Melbourne University 185 Coopers Street, Epping Victoria 3076 Australia [email protected]

18 Psychiatric training in Australia and India: Similarities and differences

Mohan Isaac, Mathew Samuel

ABSTRACT

While Australia and India are two countries which are vastly different on so many dimensions, there are many similarities in the overall organization and delivery of mental health services in the two countries. This paper briefly describes the way post graduate training is psychiatry is currently organized in Australia by the Royal Australian and New Zealand College of Psychiatrists which is the principal body that represents psychiatry and psychiatrists in Australia and New Zealand. Some aspects of post graduate training in psychiatry in India is mentioned to highlight the similarities and differences between the two countries.

Australia and India are two countries which are vastly diverse on so many dimensions. The socioeconomic, demographic and developmental indicators are largely different in the two countries. However, both countries are vibrant multicultural, multi party democracies with an independent judiciary and a fiercely free press/media. Both countries are currently governed by a coalition of political parties. As in most Western European countries and countries such as the USA and Canada, mental health system in Australia is fairly well resourced in terms of funding support and professional human resources. For example, while the number of trained psychiatrists in India is less than 0.4 per 100,000 population, it is more than 13 per 100,000 population in Australia. This paper deals with only post graduate specialist training in psychiatry and will not dwell on issues related to psychiatry training in undergraduate medical education.

The training of psychiatrists in Australia occurs in the context of a mental health system which follows the well established multi-disciplinary team approach to management of psychiatric disorders and which is supported by 152 Psychiatry in India : Training & training centres a variety of ancillary mental health support services. There are obvious differences in historical evolution, policy and legislative framework as well as availability of financial and trained human resources and a variety of other socio-cultural factors in the mental health service delivery between Australia and India; differences in the way psychiatric training is structured, organized and delivered in the two countries are very striking; however there are interesting similarities too of issues, themes and problems.

Psychiatric training in Australia

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) which is the principal body that represents psychiatry and psychiatrists in Australia and New Zealand is responsible for the accreditation and assessment of training in psychiatry in these two countries. The binational RANZCP, through its Board of Education aims to ensure high quality psychiatric training in both the countries. At the end of satisfactory completion of all the required training components and various assessments, the trainee is awarded the Fellowship of the College – Fellow of the Royal Australian and New Zealand College of Psychiatrists (FRANZCP). The Board of Education of the College is assisted by three important Committees namely the Fellowship Attainment Committee, the Committee for Training and the Committee for Examinations. At the state level, the psychiatric training is co-ordinated by College's Branch Training Committees. The trainees in psychiatry who are designated as “Registrars” are represented in the College by the Registrar Representative Committee which is recognized by the Board of Education as the principal representative organization for the trainees. It takes up training and examination related issues and advocates for the trainees at the College. In addition, there is another organization called the Australian and New Zealand Association of Psychiatrists in Training (AZNAPT) which also advocates for trainees.

The RANZCP Fellowship training programme consists of a total of 5 years of training - an initial (minimum) 3 years of basic training followed by an additional (minimum) 2 years of advanced training. The goals of the training and assessment programme are to ensure that trainees develop attitudes and skills and gain knowledge required to fulfill the multiple roles that psychiatrists undertake such as medical expert and clinical decision maker, communicator, collaborator, manager, health advocate, scholar and above all a professional.

The process of selecting trainees is aimed to determine whether applicants have the necessary qualities, skills and experience to become psychiatrists. The selection process adheres to equal opportunity principles and is designed to be open, transparent and impartial. The criteria for selection Isaac & Samuel : Psychiatric training in Australia and India 153 include: eligibility for registration as a medical practitioner and evidence of good standing with Australian and/or New Zealand Medical Boards and satisfactory completion of internship and at least one year of full time general medical training. Each applicant is assessed based on his written application and curriculum vitae, referee report and performance at the interview conducted by selection committee. The members of the selection committee generally take turns to ask several questions or approach to a clinical vignette. The selection is based on the following criteria (which have a determined weightage): above average performance academically, above average performance from past employment history, good level of competence in general medicine, experience working in psychiatric setting, proven ability to work in teams, an understanding of psychological factors in medicine and psychiatry, good interpersonal and communication skills and other useful experience and skills such as work in rural areas, language skills, work with indigenous people and people of different cultural background and other useful interests. Following selection into the training programme, trainees are required to register with the college and pay an initial registration fees. Annual training fee for each year of training are also payable to the college as the training progresses.

The training is based on an eclectic and broad “bio-psycho-socio-cultural” model. The first year of the three years of basic training is spent in adult general psychiatry and the focus is on acquisition of knowledge and skills in phenomenology, interviewing, clinical assessment and principles of management planning. The trainee completes 10 observed interviews with the supervisor. During the second and third years of training, the focus is on the development of knowledge and skills in clinical management and team work. During this period, the rotations include 6 months in child and adolescent psychiatry, 6 months in consultation and liaison psychiatry, 3 months in old age psychiatry (or assessment of 10 patients), assessment of 10 patients from addiction psychiatry, rural training for a minimum period of 15 days, psychotherapy practical experience, ECT training, experience with consumers and carers, indigenous mental health training, psychological methods case history and first episode case history. The trainee also attends the mandatory academic programme (lectures, tutorials, workshops). The basic training is assessed by: i) Summative assessment by the supervisor ii) 2 Case histories of people managed personally by the trainee under supervision of people presenting to the mental health system for the first time and in whom the predominant mode of intervention is psychological iii) A written examination (which may be attempted at any point during the basic training) which assesses the trainees knowledge of theoretical and scientific underpinnings of psychiatry as well as clinical and ethical issues in psychiatry. iv) A clinical examination with assessment based on: a) an Observed Clinical Interview and presentation (OCI) and b) an Observed Structured Clinical 154 Psychiatry in India : Training & training centres

Examination (OSCE), across a range of psychiatric disorders.

Following successful completion of the clinical examination, the trainee can progress to the advanced training for 2 years which involves supervised experience in general clinical psychiatry or an approved programme of advanced training. Advanced training requires successful completion and documentation of 7 core advanced training experiences which include skills development in leadership and management in psychiatry, CME activities and experience in the application of consultation skills in psychiatry. On completion of the two years of advanced training the candidate becomes eligible for nomination, for election to the Fellowship of the College. Each aspect of required training has specific educational objectives, which are detailed in various training documents. All these documents as well as detailed account of the information provided above and regulations, bye laws, curriculum, log book and further information on training and assessment related issues disseminated by the college through position papers, practice and ethical guidelines, newsletters etc are easily accessible from the RANZCP website (www.ranzcp.org) 1,2

Psychiatric training in India

While the broad guidelines for post graduate training in all medical disciplines including psychiatry are laid down by the Medical Council of India, training as well as assessments are carried out in India by various medical colleges and institutes which come under a large number of different Universities across the country. The predominant professional organization of psychiatrists in the country namely the Indian Psychiatric Society has either very minimal or no role or influence in formulating and implementing guidelines, curricula and standards. There is no central coordinating or controlling body or mechanism to oversee the training and examination process in the whole country. Although there is a National Board of Examinations under the Ministry of Health and Family Welfare, Government of India, this board has limited influence in guiding post graduate medical education including psychiatry. As a result, there are varying standards of training and assessments across institutions, universities and states in the country. There is no standard rigid pattern of training. Most of the training at most of the training centres is largely focused on adult general psychiatry, with limited training of varying periods in sub specialty areas of psychiatry. The overall training is multi-tiered with trainees obtaining a diploma after completion of two years of successful training and prescribed examination, a degree (MD in Psychiatry) after completion of three years of successful training and examination. The full complement of training required to become a post graduate teacher in psychiatry consists of three years of initial training (Junior Residency) followed by another three years of advanced Isaac & Samuel : Psychiatric training in Australia and India 155 training as a Senior Resident. During the past three to four decades, little has changed in the overall structure and delivery of training in psychiatry in India3,4. However, the overall training programme has stood the test of time and is well proven now. People who have received their primary training in psychiatry in India have been able to adjust to clinical and mental health service situations in various developed countries with great ease and have been able to successfully complete qualifying examinations without much additional training. The clinical competence one gets in assessment and management of all types of psychiatric disorders due to the sheer large numbers of people who have to be assessed and managed under supervision by trainees at all training centers in the country contribute to this clinical competence. There is a need to review the current training programmes across the country and consider developing a uniform national pattern of training and examination to be co-ordinated by a national body.

REFERENCES

1. The Royal Australian and New Zealand College of Psychiatrists, 2010, www.ranzcp.org accessed on 20- 12-2010 2. Stratford J. How does Australia train its psychiatrists? Psychiatric Bulletin 2002; 26: 73-74. 3. Isaac M, Murthy P, Kewalramani M. Guidelines for post graduate training in India, Chennai, Indian Psychiatric Society, 2002 4. Das M, Gupta G, Dutta K. Psychiatric training in India, Psychiatric Bulletin 2002; 26: 150-153.

Mohan Isaac Professor of Psychiatry The University of Western Australia Perth, Australia. L6, W Block, Fremantle Hospital 1 Alma Street, Fremantle WA 6160 Australia. E-mail: [email protected]

Mathew Samuel A/Clinical Director, Mental Health Fremantle Hospital and Health Services Fremantle, Australia.

19 Community Mental Health Service: An experience from the East Lille,

France

Jean Luc Roelandt, Nicolas Daumerie, Laurent Defromont, Aude Caria, Paula Bastow, Jugal Kishore

ABSTRACT

Over the past 30 years in the Eastern Lille Public Psychiatric sector, there had been progressive development of set up in community psychiatry. This innovative set up conforms to WHO recommendations. The essential priority is to avoid resorting to traditional hospitalisation, and integrating the entire health system into the city, via a network involving all interested partners: users, carers, families and elected representatives. The ambition of this socially inclusive service is to ensure the adaptation and non-exclusion of persons requiring mental health care and to tackle stigma and discrimination. It gives a new perception to psychiatry that is innovative and experimental, and observing human rights, i.e., citizen psychiatry. This experiment also provides lesson to India for effective implementation of its national mental health program.

Keywords: Community Mental Health, Citizen Psychiatry, Lille, France, India

Introduction

For thirty years, every effort has been made to integrate Psychiatry into the field of medicine, and Mental Health into the health field. Mental health has become everyone's business: psychiatry and social exclusion specialists and non-specialists are united in fight against mental disorders. Information about diseases and treatments, prevention and psychosocial rehabilitation are part of the patients' rights and society's duties. This mix of all sectors is termed as “citizen psychiatry” 1,2, based on the “five principles”, which were developed over time: 158 Psychiatry in India : Training & training centres 1) Human and civic rights are inalienable. Psychiatric disorders can never invalidate them. 2) Justice and psychiatry, prison and hospital, imprisonment and care must no longer be confused. 3) Society, and therefore Mental Health services, has to adjust to patients' needs, not the other way round. 4) Citizen Psychiatry supersedes the strategy of French sectorization, in force since 1945, as it promotes the closure of medical and social exclusion places like asylums and large institutions. 5) Fight against stigmatization and discrimination is essential: raising the population's awareness in order to modify the prejudices of danger, misunderstanding and incurability against people with mental problems and facilitating access to care.3

The application of these principles to the functioning of a healthcare service implies changes in fundamental practice that can be summarized as follows:

1) Change of paradigm: Psychiatric services should no longer have partners but be a partner. 2) Liaison of the psychiatry sector with mental health participants: users, families, towns' health and social leaders. 3) Coordination of responses to the population's needs in healthcare requires the involvement of local elected officials, in order to give coherence to a global and non segregated position, between health, social and cultural services. 4) Involvement and integration of users and families in healthcare and its management.

Socio-demographic context of the psychiatry sector in East Lille

The psychiatry sector of East Lille covers an area of 2653 hectares in the south-eastern area of the metropolis of Lille, i.e. 6 towns of the Eastern suburb, which has a population of 86,000 inhabitants living in the urban zone. Eastern Lille Suburbs comprises the following towns: Faches-Thumesnil, Hellemmes-Lille, Lesquin, Lezennes, Mons-en-Barœul and Ronchin

The E.P.S.M (Former Psychiatric hospital of Armentières renamed Etablissement Public de Santé Mentale, Lille Métropole, i.e., Public Mental Health Institute Lille Métropole) Lille-Métropole, whose administrative headquarters are located in Armentières 25 km West of Lille, is in charge of Jean Luc Roelandt et al: Community Services in France 159 the service administrative management. This area is close to the Nord-Pas-de- Calais region of France, in which 4.2% of the population is of foreign origin and has more unemployment (15.6% vs. a national average of 11.1%). Health statistics show an abnormally high death rate, the shortest life expectancy in France and an under resourced health system. The Nord-Pas-de-Calais region is, historically, having big asylums and 4 big hospitals located in around Lille, whose psychiatry units started to integrate themselves closer in to the community 10 years ago.

In 1998, the psychiatry service of Eastern Lille suburbs, Public Mental Health Institution, Lille Metropole (EPSM Lille Métropole) was promoted as a pilot site for community mental health by the mental health division of World Health Organisation (WHO). Since 2001, it has recognized the French WHO Collaborating Centre for Research and Training in Mental Health (WHOCCRTMH) for its community mental health program. WHOCCRTMH is one of the founding members of the International Mental Health Collaborating Network (IMHCN), created in 2001 in Birmingham, for the promotion of international cooperation in the field of pilot experiences in community mental health.

History

In 1977, there was shift in the management of mentally ill subjects in one of the sectors. The leadership decided to change the treatment modality in adult psychiatry sector. From the 6 units in the Mental Hospital at Armentières hosting over 300 chronic mentally ill people, about 60 “restless” people from the whole region and the Loos Lez Lille prison, were restricted to the regional units for compulsory treatment, and 15 tuberculosis patients.

To help the transformation, a private non-profile Medico-Psycho-Social Association (AMPS: Association Médico-Psycho-Sociale) was created early in 1977, which gathered all good will of that time to change the asylum system and to develop psychiatric sectorization. In conjunction with the hospital of Armentières, the AMPS gathered the elected officials of the 6 towns in the sector, care professionals, social partners and people interested in the implementation of the sectorization policy in East Lille. To begin with, it brought about the opening of the Maison Antonin Artaud (medico- psychological centre) and favored the free acquisition of the premises by the municipality of Hellemmes. It acted as the lever for all the subsequent development that was carried out.

The first mission of the AMPS was to raise the population's awareness about mental health issues and the importance of integrating people suffering from mental health problems into the City. Numerous meetings were organized in the neighbourhood. Then, research was carried out to study more precisely 160 Psychiatry in India : Training & training centres the stereotypes of “mental illness” and “madness” and the stigmatization of “mentally ill” or “mad” people. This research work, supported by the Nord- Pas-de-Calais Regional Council early in 1979, enabled the implementation of a policy of integration and public education. The project was able to develop common ground for psychiatry team and local artists, keeping as an objective of rooting out the negative image of madness and mental illnesses by the population in the towns of the sector. Several cultural and artistic programs were organized together by the psychiatry teams and municipal authorities.

In 1982, AGORA (Greek word for an open "place of assembly"), a centre of housing and deinstitutionalization, specializing in the rehabilitation of long term patients, was created. Its employees were paid by the AMPS. This experience initiated first contacts with social landlords, for the setting up of an associative and 'therapeutic flat', then for access to dispersed associative housing facilities.

These thirty years of common work within the association and with health and social authorities enabled the changes, and this constitutes the psychiatry sector of the Eastern suburb of Lille today. The change occurred in 2 essential steps:

The first step (1975-1995) was the shift from the psychiatric hospital to the community, by the development of sectorization with the help of the global budget. In 1975, 98% of the budget was devoted to full- time hospitalisation (i.e. 300 beds in Armentières).

The second step (1995-2006) consisted of decentralising and opening the psychiatry service by integrating team professionals in the health, social and cultural services of the towns. This integration increased the partners' participation (users, families, professionals and elected officials) in the decisions of the psychiatry service. The overall objective is that the psychiatry team goes out of its ghetto and thus professionals become “nice to know” by the population. Structures cannot be set up without the local elected officials' legal agreement. The overall philosophy is one of care and support. The practice is open and multi-faceted.

In 2009, 80% of professional staff was assigned to the city, while 20% remained assigned to full-time hospitalisation (26 beds, 9 are occupied in average). Today's care structures of the East Lille sector are, thus, spread within the cities, over a dozen different places, and always in contact with one another, which facilitates the patient's moves between each unit. These supported places are either rented most of the time or put at the disposal of patients by the towns, and are located closest to the treated population. Jean Luc Roelandt et al: Community Services in France 161 In 2010, following the positive development in France of the mental health local council (National Program 2008-2011) where the AMPS has been transformed into a mental health local council (MHLC) gathering the 6 municipalities of the eastern Lille mental health services territory. The MHLC provides a discussion platform for 6 towns' mayors, citizens, users of mental services, families, artists, cultural services, low income housing services, curators, social services, sanitary services, and psychiatric services.

Similarly, prevention and information education communication activities are planned with the involvement of all stakeholders.

Caring Places: Accessibility and Continuity

Consultations

The psychiatric consultation centre “Maison Antonin Artaud” is located in a municipal house in Hellemmes. This place also hosts social receptions of the Unité Territoriale de Prévention et d'Aide Sociale d'Hellemmes (Territorial unit of prevention and social help / General Council) and the support service for gypsies.

The Van Belleghem medico-social centre is located in a Communal Centre of Social Action (in Faches-Thumesnil). This centre also hosts consultations for Maternal and Child Welfare, the Alfred Binet child psychiatry centre, sports medicine and social services. Psychiatric consultations are available within the Sports-Medical Centre located in the premises of the swimming pool in Ronchin. They are also available in the premises of the Territorial unit of prevention and social action of Hellemmes and Mons-en-Baroeul, which deals with elderly people and children (Maternal and Child Welfare) and is in charge of the follow-up of people in a precarious situation in the towns being served. Finally, they are available in the Medical House (Maison Médicale) of Mons-en- Baroeul, where one of the offices is rented to the sector team.

In all these places, consultations are offered. Besides psychiatrists of the sector, psychologists, psychomotility therapists and psychoanalysts offer diverse techniques such as psychoanalytic, cognitive-behavioural or systematic therapies.

Any person wishing to have a mental health care in that service, automatically see his/her general practitioner first, who provides an introductory liaison letter. These people are welcomed within 24 hour by a nurse of the sector, who assesses the situation and the emergency level, according to the attending physician and the result of the nurse assessment. If need be, the user is seen on the very same day by a psychiatrist. For cases that are judged as non urgent, an interdisciplinary meeting is organized twice a week, in 162 Psychiatry in India : Training & training centres order to provide user with better guidance and care.

Services of inclusion and care activities integrated in the City

Centres of therapeutic activities are called services of inclusion and care activities integrated in the City. A devoted team organizes inclusion and care activities in all artistic, sport and cultural places in the 6 towns of the sector and in the Frontière$ centre.

Altogether, 48 different activities are offered per week, with 60% of them taking place in 21 places outside the service (association, social centre, maison folie, media library, retirement home, sports facilities, etc.).

In this system, activities are made upon medical prescription and reviewed regularly with users. They are all carried out in municipal structures, in conjunction with the local associative network, and are led by professional artists, sports professors (49 hours of weekly time paid by the EPSM Lille- Métropole). These activities include Plastic arts workshop, aesthetics workshop, media library, sports, dance, music, singing and video activities, as well as psycho bodily activities (body awareness “vécu corporel”, stimulation, aquarelax).

Also, a therapeutic workshop has been developed at the FRONTIERE$ Centre in Hellemmes. This artistic centre in the inner city is co-located with a contemporary art gallery, financially being supported by the Regional Direction of Cultural Action (Direction Régionale de l'Action Culturelle), which organizes monthly exhibitions. The planning is meant to be diverse, as it opens towards inhabitants' leisure and daily life. No matter where they take place, activities are above all designed as a springboard to support the users' integration into local life and to give them the tools to break their social isolation. These activities include the possibility to have one's meal in municipal restaurants or in a municipal room where meals are being delivered by a caterer.

The psychosocial rehabilitation teams (apartment service, activities service, work placement service), lead inclusion activities and are also in charge of home visits, scheduled nurse interviews, and socio-educative guidance in conjunction with the City's services. Whether at home or in a unit, the multidisciplinary team offers a personalized follow-up with adapted intensity and frequency, in conjunction with a psychiatrist in-charge. Over 500 patients benefit from this type of support every year.

Full-time hospitalization

The historic part of the local services, the Jérôme Bosh Clinic, a full-time in- Jean Luc Roelandt et al: Community Services in France 163 patient unit, remains located in EPSM Lille-Métropole at Armentières. This in- patient service will be transferred to the Lille General Hospital in the near future (2012). In these fully renovated premises, 20 patients can be hospitalised and benefitted from the intensive care program. In 2006, the mean occupancy was 10 beds out of 20 for a mean length of stay of 8 days. During hospitalization, besides medical, psychological, nurse and socio- educational interviews, the patient benefits from artistic therapeutic activities (plastic arts, video, and music) and from bodily support (psychomotility, hydrotherapy, relaxation, dietetics, and aesthetics). The unit is completely open (doors are not locked, a person at the entry is in charge of watching entries and exits), and whatever the kind of placement is, it could be compulsory by legal order or by a third person request or free will of user. Patients have access to the information applicable to them, including their medical treatment. They also attend meetings between carers and users, twice a week. There is a close articulation with the teams of the sector, which establishes first contact with the patient during hospitalization, to consider his/her discharge. Some hospitalized people are also taken to the FRONTIERE$ Centre, in order to benefit from therapeutic activities, and meals in the Concorde room (in a municipal town), with patients in day care.

Alternatives to hospitalization

Therapeutic host family as an alternative to hospitalization: Therapeutic host families as an alternative to hospitalization were established in 2000 and there are currently 12 beds already available. In this case, the patient in an acute situation is sent to the family either directly, after a consultation, or secondarily after a hospitalization, for some days or some weeks. The instructions given to families are to host the person, not to cure him/her. A nurse and the social and medical team take care of support during home visits (management of treatment, link with therapeutic activities and consultations with the sector, in order to develop the individual project). Support is similar to that offered within the full-time hospitalization unit located in the hospital: medication, hydrotherapy and therapeutic activities carried out in the city in consultation centres and the towns' activity centres.

Families are paid up to 1036 euros per patient per month by the EPSM Lille- Métropole. They are an integral part of the psychiatry sector team. They provide attention and support which are important for patients. In family stays as an alternative to hospitalization, the average length of stay is 21 days. The host family in this way is therapeutic through the family dynamics complemented by the professional team and thus, enables personalised care of good quality.

Intensive care integrated in the City as an alternative to hospitalisation: This unit of 164 Psychiatry in India : Training & training centres 10 beds organizes reinforced follow-up of people who need it, during a repeatable period of 8 days. This follow-up takes into account the close circle of supporters and the patients' needs for a brief time, and for a reinforced follow-up (nurse interview, psychiatry, psychological consultations, relaxation, activities, etc.). This mode of intervention involves all carers (private nurses, general practitioner, local pharmacist, etc.) and all the person's de facto caregivers (family, friends, circle, etc.). It is the same team, along with the psychiatrist on call in the sector, which can be mobilized within 24 hour for people in the need of the service. It responds to post emergency situations, in order to guarantee total continuity of care and guidance to the patients.

Reduction in stays and admissions for full time hospitalizations related to host families and development of home care treatment is given in Table 1.

Table 1:

Paradigm shift from full time hospitalisation to home care treatment in Lille, France

For 86 000 inhabitants 1971 2002 2010

People in care 589 1677 2572

Ambulatory care (number of acts) 0 23478 48315

Admission to hospital / acute beds 145 444 360

Compulsory treatments 145 (100%) 99(22%) 87(24%)

Mean lenght of stay (in days) ± 213 14,5 6,5

Number of days of hospitalisation 77 640 4248 2490

Number of people admited in host families (AFTAH) 87 63

Number of people admited in home care treatment (SIIC) 234

Inclusion and rehabilitation: “DARE TO CARE”

The aim of the social inclusion program of WHO was to include and integrate care of mentally ill person within social groups and the regularization of the administrative, financial and social situation of the user. Mental health service at Lille has adopted WHO theme “Dare to Care” (WHO 2001) and other Jean Luc Roelandt et al: Community Services in France 165 recommendations4,5 by developing and combining these three components in order to reach the overall objective: housing; employment; leisure, arts and culture.

1. Housing

Associative apartments: Access to associative apartments spread in the social fabric of the town is one of the major components of inclusion work. An “apartment committee” gathers the members of the Medico-Psycho-Social Association (AMPS: Association Médico-Psycho-Sociale), the representatives of public housing offices (HLM: Habitation à Loyer Modéré), social landlords, caregivers, the representatives of users and family associations and trustees. This committee decides on the allocation of apartments located in the public housing stock. The president is a locally elected official. The AMPS covers the deposit; the patients cover the rent and the general expenses, with the help, if need be, of the trustee or the guardian and the team. The caring and socio- educational team is in charge of medical and socio-educational follow-ups. The therapeutic program comprises regular consultations with the psychiatrist in charge, the treatment taken, nurse interviews and schedules of therapeutic activities. Since the creation of the Committee, 150 apartments have been put at the disposal of patients, mostly as a co-tenancy of two or three people, with the presence of one student per apartment, who is hosted ex gratia to share the tenants' lives.

Currently, 57 apartments are supported by the “apartment committee” and 95 people, who accepted a contract of social inclusion and care, are being benefitted from this method of housing allocation. They are follow up by a specific mobile team, all days of the week i.e., 7X24 hrs.

Résidence André Breton: This associative and therapeutic residence is another form of access to accommodation, again within the framework of the public housing system. It is located in Faches Thumesnil and comprises six sheltered apartments and a large therapeutic apartment which hosts six people with severe handicap. The residence is completed by 5 social accommodation facilities entirely managed by the municipality. This accommodation is made possible by the constant presence of hospital staff (care assistants, health education assistants, education assistants and hospital service agents). Each patient is the tenant of his/her apartment. It is a genuine alternative to the concentration of the severely handicapped in specialised homes, which is a new form of handicap segregation. Assistance is given to the person who enables a good mix of the population, rather than segregation.

Housing to avoid very long term hospitalization

The Résidence Ambroise Paré, located in a block of low-rent accommodation, 166 Psychiatry in India : Training & training centres comprises two studios, one of which is occupied by a student, one 3-room apartment occupied by two user residents, and a 4-room apartment housing a student and 2 residents. This scheme is part of a social program of low rent accommodation approved by the municipality of Lille and social landlords.

The Résidence Samuel Beckett is a former centre for housing and social rehabilitation, for patients from the sector, settled here as a first step to change the service (discharge of patients who have stayed in hospital for a long time). This centre, which is owned by the municipality of Fâches Thumesnil, hosted the hospital day-activity and the regional centre for the setting up of basketball boards in the cities. Today, the structure, which is put at disposal by the EPSM Lille-Métropole, hosts:

an apartment accommodating a therapeutic host family, providing an alternative to hospitalization, with a user host for a mean period of six months, that corresponds to the rehabilitation period. The family also insures supervision duties in exchange of free accommodation.

A second 5-room apartment, next to the first one, which is a therapeutic, associative, social and transitional hosting place, for patients who are medically stabilized and in transit for sheltered accommodation, a private or social apartment, a retirement home or any other accommodation facility. A student is also accommodated with the beneficiaries.

There is a housekeeper in the transitional apartment premises. The educational team is there during evenings and weekends. It observes and assesses the people's self-sufficiency and ability to live alone or in a shared apartment and to manage their daily life on their own. The sector nursing staff is in-charge of the visits and monitors therapeutic treatments.

2. Economic rehabilitation

Partnership with the Centre d'Adaptation à la Vie Active (CAVA - Centre for adaptation to working life): The CAVA located in Fâches-Thumesnil, is an association through the French law of 1901 (Association de Handicapés de Fâches Thumesnil: Association of disabled people of Fâches Thumesnil), which is a part of the field of inclusion through economic activities. Its purpose is to promote access to the job market for people with major difficulties of social and professional exclusion (recipients of minimal social income, long-term unemployed people). It has 20 places via a contrat d'Accompagnement dans l'Emploi (C.A.E.) (supervised work placement) or via a contrat d'avenir. The partnership with the sector leads to:

The provision of 15 places within a specific setting, reserved for users referred to the centre by a sector psychiatrist. The aim is to “reboot” Jean Luc Roelandt et al: Community Services in France 167 professional abilities (working patterns, professional relationships, team working, etc.). Patients are referred to the centre either directly or after an assessment by the occupational therapist of the therapeutic workshop in the Frontière$ Centre, which was set up within the CAVA premises during 2006.

The implementation of a socio-professional inclusion scheme for the disabled (DISPHP: Dispositif d'Insertion Socioprofessionnelle en direction des Personnes Handicapées), which offers applicants a personalized and tailored course of socio-professional inclusion. This comprises successive steps: first, in training centers, in order to define the person's professional level and to validate it through work experience. Then, according to identified abilities and needs, the person is referred to qualifying training, possibly to a sheltered environment or, for most people, to the ordinary environment, via a contrat d'accompagnement dans l'emploi (CAE) (supervised work placement), within municipalities, local communities or partner associations.

The establishment of vocational rehabilitation integrated in the city: Following a three-year study carried out by a committee of experts, an experimental project was created, led by the municipality of Lezennes in the framework of the AMPS, composed of representatives of users and family associations, and associations of professionals in the field of economic inclusion. It is “integrated in the city” insofar as it is devoid of any production unit; all handicapped workers practise their professional activity within municipalities, local communities and partner associations, via the Work Centre. It enables people who are unable to integrate normally into the ordinary environment and who can however, find their place in conditions adjusted to their handicap.

Therapeutic work: In 2006, a new project to this scheme was added: “therapeutic work”, whose purpose is to renovate and to furnish associative apartments, which needed furnishing or improvements to the living spaces. It is based on the principle of voluntary service and self-help by and for users, and it is led by a workshop supervisor, and an occupational therapist, assisted by an artist. It is a first step towards the return to employment, through the help of active groups.

3. Art, culture and leisure

The Frontiere$ Centre: The Frontiere$ Centre initiates artistic activities, in the framework of a hospital /culture partnership, which was created 18 years ago. It started with the rehabilitation of the J. Bosch Clinic, a former unit for compulsory treatment, by the patients who had stayed there, with the help of an architect. A scale model of the Centre was presented during a cultural week Pavillon 11 – Procès de la folie in 1984. At that time, the mental health department sector Lille-Métropole wanted the Centre to be located in the 168 Psychiatry in India : Training & training centres city. This was impossible because of local political and medical pressures, which wanted employment linked to “madness” to remain at the site in Armentières. The sector was a part of the “Health, Culture and Musical practice in institutions” mission, organised in 1983-84 by the French Ministry of Culture and the French Ministry of Health. Since then, 49 hours of cultural work per week have been implemented by the EPSM Lille-Métropole for artistic activities. Full-time artistic participation was created two years ago. For over a year, an arts professor has been hired by the E.P.S.M. Lille- Métropole. All cultural structures of the sector, or the city of Lille, are entrusted with these activities; groups are led by artists and supervised by nurses. For activities carried out by the school of body practice in Villeneuve d'Ascq and the Dance association in Lille, groups are organized by these institutions and users and resident users are gathered in these artistic schools.

Art has the particular faculty of establishing equality between patients and non-patients for artistic production. It allows evaluation and social acceptance. Contemporary art at least, the spearhead of our work in the sector, like mental disorders, requires interpretation, it cannot be understood immediately. The integration of artists into the psychiatric sector contributes to the production of imaginative works: its creativity reaches beyond the stigmatization that people with mental disorders suffer from. As is suggested in this brief description, it is not Art Therapy: The purpose is not to “cure through art”, but rather to enable non-stigmatisation thanks to art and contact with artists.

NETWORK: NO LONGER HAVE PARTNERS, BUT BE A PARTNER

In addition to the multiplicity of care facilities and their integration into the urban framework, the originality of the East Lille sector is its diversity of links established with the different partners, within a real network.

The elected officials: The elected officials lead this partnership and are committed to social inclusion by making available- housing facilities, consultation places, municipal rooms for catering and therapeutic activities. By making use of their networks of relationships, they open doors and smoothened difficulties in order to provide their fellow citizens, suffering from mental illness, with a real place in the community.

Social institutions: Social institutions are other essential partners: social workers, a communal center of social action and the general Council are often included in the support, and guarantee people's rights. Using these services, in collaboration with educational associations ensures housing provision and solutions to problems of financial resources and rehabilitation. Jean Luc Roelandt et al: Community Services in France 169 The cornerstone of this collaboration can be illustrated by the sharing of the General Council's premises in the Centres for Prevention and Social Action of Mons en Baroeul and Hellemmes, for psychiatric consultation. In addition, special links have been established via formal agreement with the associations in Lille devoted to the homeless, in collaboration with 6 other general psychiatry sectors. This service has been the promoter and partner of a mobile team concerned with Mental Health and homelessness, called DIOGENE, which meets homeless people in the area of Lille, and can refer them to a public psychiatric facility if need be.

Cultural institutions: The National Lille Orchestra, the theatrical association QUANTA, the Nieke Swennen company, independent artists, plastics technicians, photographers and musicians have made it possible to offer therapeutic activities that are fully integrated into the local cultural landscape. Going to a concert, creating a ballet and taking part in an exhibition preview are new experiences for some patients, and a factor facilitating better contact with others and with the real world. The Frontiere$ gallery was managed for years by the artist Gérard Duchêne, and is now being run by David Ritzinger. Its window onto the street displays this alliance between care and art.

Users and family groups: Users and ex-user groups are favored partners, which are considered as “experience experts” in the field of Mental Health. These associations, members of the FNAPSY (Fédération Nationale des associations d'ex- patients en psychiatrie, i.e., National Federation of associations for psychiatry, ex-patients), develop a program of representation and training for users. They are actively associated to the research programs. Representatives from UNAFAM (Union Nationale des Amis et Familles des Malades psychiques (National Union of Friends and Families of people with psychiatric disorders i.e., national union of families and friends of mentally ill people) sit on the Commission for allocating accommodation, and are called upon more and more to take part in events organized by the sector and in its projects.

Mutual self-help groups (GEM: Groupes d'Entraide Mutuelle), meeting and self-help centres managed by users, have become essential partners for rehabilitation and for the fight against social isolation. They were created in 2005 through government funding (French Mental Health Plan 2005-2008) and run by users themselves in autonomy most of time. In 2009, 280 groups were in activity, out of which half of these groups were piloted 100% by users NGOs. These groups certainly do fight against isolation, yet they tend, above all, to become bridges allowing users to progressively leave the psychiatric care system. 170 Psychiatry in India : Training & training centres Health partners in the towns

Last but not least, another long-standing partnership has been established with the other local care providers. First of all, general practitioners in the urban districts in the sector, who are essential collaborators in all follow-up, are involved. They enable the referral of a patient to a CMP (medico- psychological centre) consultation and receive regular reports for each consultation or hospitalization. Outside hospitalization, the GPs are the only prescribers for patients, nominated by the consultant psychiatrist. The frequency of exchanges in mail, phone calls and meetings enable constant discussion on the way a patient should be catered for, given that, as family doctors, GPs are closest to the patients' daily life.

Several pharmacists are also part of this partnership, so that medication can be delivered to chemist's offices, in accordance with the need for proximity and routine observance of prescribed treatments.

Private Nurses are also often called upon to visit patients' homes, providing medications and for nursing and hygiene care, on medical prescription.

Very close links have been established with the Meeting and Crisis Centre (CAC: Centre d'Accueil et de Crise) in the regional university hospital in Lille. This unit takes in patients during an acute state of distress up to 72 hours. When a patient from the sector is hospitalized, a contact is made by the sector team, which routinely goes to the CAC to decide with the patients and the referring physician as to how the patient is to be supported in the sector, with a view of continuity between this emergency unit and short to medium term care in the sector. Usually it leads to intensive follow-up in the city and/or to care in a host family.

Role of the international and national network of good practices in psychiatry in the reorganisation of the psychiatry service in East Lille (EPSM Lille Métropole)

How did the psychiatry sector of East Lille, and by extension of its referral institute EPSM Lille Métropole, benefit from International Network and continued to be included it in its future plans? We owe this mainly to experiences drawn from the international network, training visits organized by the hospital for the whole staff of the East-Lille service in different European and national sites, consequently introducing new practices to Lille which seemed interesting and positive for the support of the population in the towns of our sector:

6-9 l The studying of all good practices in Trieste in 1976 led to their implementation in east Lille suburb in 1977.

l Host families as an alternative to hospitalization (one family= one Jean Luc Roelandt et al: Community Services in France 171 bed), during a conference with all alternative global experiences in Trieste in 198610 (example taken from Madison USA 1998) led to implementation of same in Lille in 2000.

l Home care 7 days a week with a mobile team: seen in

l Birmingham in 2000 and same was implemented in Lille in 2005.

l Totally open psychiatric wards were seen in Merzig, 1997 and in Trieste, 1995 and same was implemented in Lille in 1999.

l Nurses in the front line for welcoming patients, using appropriate tools: seen in Mauritania in 2001 and same was implemented in Lille in 2003 in the whole sector.

l Crisis centres for 72 hour Centre Hospitalier Universitaire de Lille (University Health Centre), 2001.

l Operational networks with the attending physicians

l Oviedo, 2002 and was implemented in Lille in 2003 with a network of GPs.

l Cooperatives to access work seen in Trieste in 2003 and similarly, were set up in Lille in 2007 in an experimental program with municipalities.

l Clubs and volunteers in Quebec 1987, in Luthon and Monaghan 2005 and same were implemented in Lille in 2005 thanks to the law about Self-help groups (GEM: Groupements d'Entraide Mutuelle).

l Peer support program has been witnessed in Canada 2008, USA 2009, and UK 2009 and same are being planned for Lille in 2011

The East Lille Mental Health sector is one of the founding members of the International Mental Health Collaborating Network, created in 2001 in Birmingham. In its collaboration a pilot programs in Community Mental Health for the promotion of international cooperation has been started in Lille. The IMHCN “Mental Health and citizenship” International NGO was founded in Lille in 2006. 11

The Future of Citizen Psychiatry

It is perfectly possible to implement the WHO recommendations4,5 in France by centralizing services for emergencies and stabilizing patients for short stay and rest of the mental services can be given through outpatient or community based health centers. Instead mental health services in Lille are truly integrated into the community with the active support of locally elected representatives.11-14 For that purpose, it is essential to go beyond hospital- centrism and to clearly shift from “psychiatry hospital services” to “individual health and social services”, in the person's living environment.15-16 Networking 172 Psychiatry in India : Training & training centres is essential for this paradigm shift.

For thirty years, the psychiatry service of East-Lille has evolved from the isolationism of Armentières to the Eastern suburb of Lille, fully integrated in the urban fabric, becoming more complex and more flexible. With the municipalities and the EPSM Lille-Métropole, we have set up all the structures. We only have to transfer the beds of the former psychiatric hospital, which have been almost empty since then, into a caring structure for the city; the ideal would be a general hospital. This is planned for 2012 as a 10 bed unit, close to the CHR (Regional Hospital Centre) of Lille. The integration of Mental Health into general health psychiatry in medicine is almost achieved, and it is logical to change the last psychiatric beds into a general hospital.

The integration of the mental health services into the city at proximity of citizens after a preparative work is also a powerful anti stigma strategy.17 The re-localisation of in-patient beds closer to the affected population will definitely mark the end of psychiatric imprisonment and isolation in asylums. This is 21st century psychiatry, which started thirty years ago, a psychiatry in favour of users, integrated in the community, that is to say, for the people.

Community Mental Health Service in India and training need

Unlike the West, in India, mental health care is delivered by outside institutions, means already de-institutionalized care. Family is a key resource in the care of patients with mental illness. Families assume the role of primary caregivers because of the Indian tradition of interdependence and concern for near and dear ones in adversities. They are meaningfully involved in all aspects of care of their sick relatives despite it being time consuming and lot of expenditure.18

Health is a state subject and government must provide basic minimum care to all mentally sick subjects. From the very beginning after independence of India, community psychiatry was practiced. Dr. Vidya Sagar had as early as 1950s involved family members of patients admitting into Amritsar Mental hospital.19 As far as treatment in general hospital is concerned the first Psychiatric Unit was set up at R.G. Kar Medical College Kolkatta in 1933. Many community-based mental health delivery projects were launched during 1970s and 1980s leading the government mental health program. The famous Raipur Rani experiment in Haryana20 and Sakalwara in Karnataka21 established that mental health delivery is possible through primary health centers.22 During this period primary care psychiatry replaced the term Community psychiatry in India. After Alma Ata Declaration of World Health Assembly in 1977 that emphasized Primary health care approach to achieve “Health for Jean Luc Roelandt et al: Community Services in France 173 All” by the year 2000. Since then training of PHC doctors, nurses and community level workers started to handle mental health and replacing psychiatrists which were available in meager number.23-26 In spite of such development, community psychiatry does not take concrete shape in India. Training of general doctors and other health professionals has been envisaged in National program.

The Government of India has launched the National Mental Health Program (NMHP) in 1982, keeping in view the heavy burden of mental illnesses in the community, and the absolute inadequacy of mental health care infrastructure in the country to deal with it. The Program envisages a primary health care community based approach in the rural areas supported by professional psychiatric supervision from the district level and referral services by the mental hospitals and mental health units of the general hospitals.27 Mental health is still not a priority at the national and local level although mental disorders contribute significant amount of disease burden. Stigma of mental disorders is more than that found in France and there are number of false beliefs and myths existing amongst the health professionals and the community.28-30 Training programs should include the socio-cultural, political and occupational aspects of mental health. This can be better imparted in trainees citing examples of community psychiatry practice in France and other areas in the world.

Number of psychiatrists in India is very less as compared to Western countries. However, India has huge health infrastructure in rural and urban areas and large number of Accredited Social Health Activists (ASHAs), Auxiliary Nurse Midwives (AMNs), Male Health Workers and others such as workers, link workers, and volunteers. Health workers are visiting the families but their focus is on family planning, maternal and child health, and communicable diseases. It is already known that providing mental health services improves the quality of overall health care delivery system.29 In presence of strong family system and existing peripheral health institutions such as primary health centers, subcenters, angawadis, India can definitely provide better mental health services. Indian health workers are capable to handle mental disorders at the primary level if minimum skills are provided. House to house visits by the health workers can also include screening, referral and follow-up for mental disorder supported by medical officer of PHC.30 Under the present National Mental Health Program number of PHC doctors is trained in handling psychiatric patients. Training should include other health professionals such as nurses, pharmacists, doctors of traditional system of Indian medicine, health workers male and females, ANMs, and ASHAs. These are forefront health force dealing with various stages of mental illnesses. Empowering them with appropriate training would be a significant improve in mental health care delivery in presence of paucity of trained 174 Psychiatry in India : Training & training centres psychiatrist in the country. Unlike Western world, families are already taking maximum burden of mental disorders in India. There is a need to take strong steps towards full integration of families in the care of mentally ill patients. At the same time through multi-prong approach family system should be protected from disintegration due to urbanization and industrialization. Mental health delivery system of Lille Metropole France is an excellent example of fully integrated mental health services with social system. India can learn from the Lille Metropole experiment for better generation of community participation, integration and rehabilitation.

References

1. Roelandt J-L, Desmons P. Manuel de psychiatrie citoyenne – L'avenir d'une désillusion. Editions In Press, 2002. 2. Pelletier JF; Davidson L, Roelandt, JL; Daumerie N. Citizenship and Recovery for Everyone: A Global Model of Public Mental Health. The International Journal of Mental Health Promotion 2009; 11:45-53. 3. Thornicroft G. Discrimination against People with Mental Illness Oxford University Press 2006. 4. World Health Organization: Atlas. Mental Health resources in the world 2001. Geneva, World Health Organization, 2001. 5. World Health Organization: Mental Health: facing challenges, finding solutions. Ministerial European Report. Helsinki Finlande, 2005. 6. Basaglia F. L'istituzione negata, Einaudi, Torino, 1968. 7. Basaglia F. Crimini di pace, (with Foucault, Goffman, Laing, Chomsky), Einaudi, Torino 1976. 8. Basaglia F. La chiusura dell'ospedale psichiatrico, Einaudi, Torino 1976. 9. Basaglia F. L'utopia della realtà (raccolta di saggi scritti tra il 1963 e il 1979), Einaudi, Torino, 1979. 10. Rotelli F. et al. Deinstitutionalization, another way: The Italian mental health reform. Health Promotion International 1986; 1:151-165. 11. Roelandt JL, Daumerie N. Contribution à l'ouvrage “Better Mental Health Care”. In. Thornicroft G., Tansella M. The Experience Base for Mental Health Care, England: Cambridge University Press 2007. 12. Roelandt J-L. Santé Mentale : relever des défis, trouver des solutions. Et en France ? L'Information psychiatrique 2006 ; 82 : 343-347 13. Roelandt J-L. Où va la psychiatrie ? Je ne sais pas … en tout cas elle y va ! Santé Mentale au Québec 2005 ;15: 97- 114. 14. Roelandt JL , De la psychiatrie vers la santé mentale, suite : bilan actuel et pistes d'évolution. L'Information psychiatrique 2010; 86, N° 9 – Novembre. 15. Rotelli, F. et al. 'Desinstitucionalização, uma outra via'. Em Nicácio, F. (org.), Desinstitucionalização. São Paulo: Hucitec, 1990:17-59. 16. Topor A. Désinstitutionalisation et destigmatisation. Changements dans un secteur psychiatrique à Stockholm (Suède). L'Information Psychiatrique, Décembre 2007 ; 83 : pp 844-5. 17. Roelandt JL, Daumerie N, Caria A, Eynaud M, Lazarus A. Changer la psychiatrie pour déstigmatiser… - Revue Santé Mentale 2007; 115. 18. Avasthi A. Preserve and Strengthen family to promote mental health. Ind J Psychiatry Jean Luc Roelandt et al: Community Services in France 175 2010; 52 (2): 113-2126 19. Kapur RL. Priority in mental health workshop on priorities in developing countries. Ind J Psychiatry 1971 ; 13 : 157-82. 20. Wig NN, Murthy SR, Harding TW. A model for rural psychiatry service-Raipur Rani experience. Ind J Psychiatry 1981; 23: 275-90. 21. Chandrashekhar CR, Issac MK, Kapur RL, Parthasarathy R. Management of priority mental disorder in the community. Ind J Psychiatry 1981 ; 23 : 174-8. 22. Issac MK, Kapur RL, Chandrashekhar CR, Kapur M, Parasarathy R. Mental health delivery in rural primary health care-developing and evaluation of a pilot training program. Ind J Psychiatry 1982 ; 24 : 131-8. 23. Shamasundar C, Jacob J, Reddy PR, Chandramauli AV, Issac M, Kaliaperumal VG. Training general practitioners in psychiatry. An ICMR multi-center study. Ind J Psychiatry 1989;31: 271-9. 24. Gautam S. Developing and evaluation of training programs for primary mental health care. Ind J Psychiatry 1985 ; 27 : 51-62. 25. Devi S. Short-term training of medical officers in mental health. Ind J Psychiatry 1993 ; 35 : 107-10. 26. Nagarajiah RK, Chandrashekhar CR, Issac MK, Murthy SR. Evaluation of short term training in mental health for multi-purpose workers. Ind J Psychaitry 1994; 36: 12-7. 27. Kishore J. National Health Programs of India : National Policies and legislations related to health.9th Ed. New Delhi : Century Publications 2011. 28. Kishore J, Mukherjee R, Parashar M, Jiloha RC, Ingle GK. Beliefs and Attitudes towards mental health among medical professionals in Delhi. Indian Journal of Community Medicine 2007; 32 (3): 198-200. 29. Kishore J, RC Jiloha, GK Ingle, Patrick Bantman, D Nicolas, JL Raulandt. Myths beliefs and perception about mental disorders and health seeking behavior of mental ill and normal population of Delhi. Poster presented in 63rd Annual National Conference of Indian Psychiatric Association (ANCIPS) 2011 from 16-19th Jan 2011 held at New Delhi. 30. Kishore J, RC Jiloha, GK Ingle, Patrick Bantman, D Nicolas, JL Raulandt. Comparative Myths beliefs and perception about mental disorders and health seeking behavior in India and France. Oral Paper Presentation in 55th Annual National Conference of Indian Public Health Association 2011 from 28-30th Jan 2011 held at Belgaum, Karnataka. 31. Caria A. and Al. Quality in Mental Health, In Press, Paris, 2003. 32. Kishore J, Kapoor V. Mental Health Care Through Sub-centres: An Approach. Swasth Hind, Central Health Education Bureau, Min. of Health & Family Welfare, 1996: 9-11.

Jean Luc Roelandt Psychiatrist, Director of the WHO Collaborating Centre for research and training in Mental Health (Lille, France), Head of East Lille Services EPSM Lille Métropole 176 Psychiatry in India : Training & training centres Nicolas Daumerie Clinical Psychologist, Project Manager WHO Collaborating Centre for research and training in Mental Health (Lille, France) www.ccomssantementalelillefrance.org

Laurent Defromont Psychiatrist, Consultant WHO Collaborating Centre for research and training in Mental Health (Lille, France), Head Medical Information and Research Department, EPSM Lille Métropole

Aude Caria Psychologist Project Manager WHO Collaborating Centre for research and training in Mental Health (Lille, France) Paula Bastow Paula Bastow, DH CSIP Eastern, UK

Corresponding address: Jugal Kishore Professor Department of Community Medicine Maulana Azad Medical College, New Delhi 110002, India; [email protected] Specialty Section 20 Psychiatric Training in the Indian Armed Forces

V.S. Subbarao Ryali, P. Shivram Bhat, K. Srivastava & K.J. Divina Kumar.

ABSTRACT

History & evolution: Armed Forces set the trend for psychiatric training and practice in the pre-independence period. Most of the initial training establishments in India were established for both soldiers and civilians and invariably headed by European psychiatrists of the Royal Indian Army. Undergraduate training: The undergraduate training in psychiatry in the Armed Forces is much beyond the minimum standards laid down by the Medical Council of India. Paramedical training: The psychiatric training of the Nurses and Nursing assistants is systematic and subject to periodic up gradation through repeated courses. Specialist grading system: The grading of psychiatrists in the Armed Forces, initially introduced to bring about a standard of care among specialists trained in varied training institutes still continues as a means of re-certification and up gradation of clinical and research skills. Post graduate and super specialist training: The post graduate training is pan Indian and international with the best practices from across the country and the world being adopted. Research & Conferences: Research is integral to the psychiatric training in the armed forces and areas of research selected are contemporary and appropriate to the varied environment in which the Indian troops operate. Pursuit of excellence: AFMC has consistently been rated among the best five medical colleges in the country over the last decade. This involved consistent improvement in training practices and interaction with centres of excellence in this country and abroad.

History and evolution of Psychiatric training in Indian Armed Forces: Training and Principles of Practice of Medicine & Psychiatry in the Indian Armed Forces set trends for training and practice of Psychiatry in civil in India. The first Mental Asylum for Indian soldiers of the East India Company was set up at Munghyr in Bihar in 1795 AD, which shifted to Patna in November 1821 178 Psychiatry in India : Training & training centres and to the present location at Kanke, Ranchi in April 1925. On 30th August 1958 the name was changed to Ranchi Mansik Arogyashala (RMA) and on 10th January 1998 to Ranchi Institute of Neuro-Psychiatry & Allied Sciences (RINPAS). The first MD in Psychiatry was awarded to Dr LP Verma from this institute in 1942 [1]. In 1918 AD, Col Owen Berkeley-Hill established the European Mental Hospital at Ranchi, Bihar for both European Army and civilian personal. The institute was affiliated to the University of London for Diploma in Psychological Medicine in 1922 and thus became the first postgraduate training institute in Psychiatry in India. The European Mental Hospital after Independence became the Central Institute of Psychiatry (CIP), Ranchi [2]. The initial heads of these pioneering Mental Health training establishments have all been Serving British psychiatrists of the Royal Indian Army Medical Corps. This system of integration between Armed forces and civilian psychiatrists and sharing of Armed Forces Mental Health facilities with civilian patients continues in Great Britain [3]. In contrast, in the US Armed Forces the integration to form a National Capital Military Psychiatric Residency Program was between the Uniformed Services University of Health Sciences (USUHS), Walter Reed Army Medical Centre (WRAMC), National Naval Medical Centre (NNMC) and the Malcolm Grow US Air Force Medical Centre (MGMC) [4]. The Indian Armed Forces follow a similar model in which the Medical Services of the Army, Navy and Air Force integrate under the aegis of the Director General Armed Forces Medical Services (DGAFMS) and pool in their best psychiatric personal at the department of psychiatry of the Armed forces Medical College (AFMC), Pune. Unfortunately, in Independent India the contact between the training establishments in the Armed Forces and in civilian sphere has been weak. During the Second World War (WW II), the war hospitals were for the first time authorized two psychiatrists and thus perhaps, the General Hospital Psychiatric unit came into existence in the Armed Forces [5]. The AFMC was established on 01 May 1948 by combining a clutch of Military Medical Training Institutes located at Pune. AFMC initially trained soldiers in nursing specialities and doctors in medical specialities without any affiliation to established universities. The Graduate Wing of AFMC was inaugurated on 04 Aug 1962 by Shri V K Krishna Menon, the then Defence Minister of India [6]. During the 1950-60 decade, psychiatric units were established in major peace and war hospital establishments of the Indian Armed Forces. Most of the psychiatrists of the Indian Armed Forces for these hospitals acquired Diplomas in Psychiatry (DPM) from various Indian Universities or acquired Membership/Fellowship from the Royal College of Psychiatry on study leave abroad. To attain standard of specialized care among specialists trained from varied backgrounds, the Armed Forces introduced a grading system for all specializations in medicine at AFMC. A full-fledged department of psychiatry at AFMC came into existence in the year 1970 and started offering Diplomas in Psychiatry initially and Doctor of Subbarao et. al : Psychiatric Training 179 Medicine (MD) degrees in Psychiatry subsequently with affiliation from the University of Pune initially and now by the Maharashtra University of Health Sciences (MUHS), Nashik.

Undergraduate training in psychiatry at AFMC: The Armed Forces Medical College at Pune selects approximately 105 boys and 25 girls each year on the basis of a nation-wide entrance examination and a refined interview process [7]. The nine term / four and a half year MBBS course is a totally Government funded and fully residential program which contracts the medical cadets to serve for 5 years as short commissioned officers or till superannuation as permanent commissioned officers depending on a merit cum choice basis on the completion of their course. There is provision to take approximately 10 students on deputation from friendly foreign nations for their Armed Forces each year. The Medical Council of India (MCI) currently recommends for the medical undergraduates in India a syllabus in psychiatry [8] to be covered by 20 lectures and 2 weeks of clinics in psychiatry. The MCI currently does not prescribe a separate examination in Psychiatry during the MBBS course. The Armed Forces practice a form of medical and health care for its troops which involve preventive, promotive and curative aspects. Such medical care can only be delivered by a medical graduate with a reasonable knowledge in Psychiatry. It has also been noted that detailed and conceptual knowledge in psychiatry equips the medical graduate with the required soft skills for able general practice. The Dean of AFMC in his foreword to the Hand book of Undergraduate Psychiatry writes that the MCI does not lay emphasis on psychiatry at undergraduate level despite much prominence being given in the psychiatric syllabi of undergraduates in the United States and Europe [9]. He further states that AFMC believes in setting standards rather than following minimum standards set by regulatory bodies which is reflected in the Psychiatric curriculum at AFMC which consists of 44 lecture classes delivered during the eighth and ninth terms of the MBBS course, as well as two weeks of clinics in psychiatry by rotation. This helps the students crack the internal psychiatry test conducted at the end of the ninth term, the marks from which are credited towards internal assessment for the university examination.

Psychiatric training of Para Medical staff: Soldiers, sailors and Air men joining the Armed Forces medical branch receive their preliminary military and nursing training at large training establishments at Lucknow, Mumbai and Bangalore respectively. They serve for a few years as General duty Nursing Assistants before being sent for specialist training as Psychiatric Nursing Assistants (PNAs) at approximately 10 large psychiatric centres located across the country. The preliminary PNA course lasts approximately 9 months and after a few more years of service in psychiatric centres, the PNAs return for an advance PNA course lasting approximately 6 months. By 2012, the AFMC at 180 Psychiatry in India : Training & training centres Pune and the School of Medical Assistants at Mumbai propose to offer in lieu to above specialist cadre courses, a 3 year Bachelor in Para Medical Training (BPMT) in Psychiatric Nursing course and a 2 year Diploma in Psychiatric Nursing Course for soldiers and sailors, both recognized by the MUHS, Nashik. The College of Nursing (CON) at AFMC, Pune came into existence in 1964. The CON conducts a 4 year BSc Nursing program, which prepares approximately 40 female candidates each year for serving in the Armed Forces as Military Nursing Service (MNS) officers. The CON also conducts a 2 year Post Diploma BSc Nursing course and multiple MSc Nursing course. In addition the Armed Forces run approximately 6 Schools of Nursing that offer a 3 year Diploma in Nursing exclusively for female candidates. The Nursing Council of India (NCI) unlike the MCI insists on rigorous psychology and psychiatric training [10]. The CON BSc Nursing course at AFMC is subjected to 75 psychology lectures in the first year and 65 psychiatry lectures in the fourth year, besides 4 months attachment in the psychiatric ward by rotation. Similarly the Post BSc Nursing course receives 75 psychology lectures in the first year and 65 psychiatry lectures in the fourth year, besides 2 months attachment in the psychiatric ward by rotation.

The system of Grading for psychiatrists in the Armed Forces: All psychiatrists in the Armed Forces are invariably graded. This was initially intended to bring about standardization among specialists trained from varied backgrounds. The initial grading in a speciality involved a two year course at AFMC called the advanced course. Evaluation at the end of the course was done by a Board of Eminent Service and civilian specialists. All qualified candidates were graded to practice psychiatry in Armed forces Hospitals. Subsequently, when AFMC got affiliated to the University of Pune to offer DPM and MD Psychiatry courses, students selected for Advanced course in psychiatry also registered for the DPM/MD courses. Though the university diplomas/degrees were valued, the permission to practice psychiatry in the Armed Forces was determined exclusively by one's ability to qualify in the Advanced Course. In recent times Armed Forces have commissioned psychiatrists, who have obtained an MD in Psychiatry from an MCI recognized medical college elsewhere. Such psychiatrists are being graded and allowed to practice psychiatry in the Armed Forces after observation under a Senior Advisor in Psychiatry for a minimum period of 12 weeks. Specialist practice in the Armed Forces is subject to continued evaluation. All Graded Specialists at the end of 4 years of specialist practice and after obtaining an MD from an MCI recognized institute are offered an opportunity to Classify in the concerned speciality, which involved observation for four to twelve weeks under a Senior Advisor in Psychiatry. Those graded specialists who qualify are designated as Classified Specialists in Psychiatry at the end of five years tenure as Graded specialist. At the end of five years tenure as Classified Specialist in Psychiatry, subject to promotion to the rank of Colonel Subbarao et. al : Psychiatric Training 181 equivalent in the Army, the some of the classified specialists are upgraded as Senior Advisors in Psychiatry. This system ensures continued improvement due to repeated evaluation of clinical and research skills.

Post graduate training in Psychiatry at AFMC and other Command Hospitals: The Armed Forces Medical College at Pune is attached to three large multi- speciality hospitals located in the Pune- Kirkee cantonment area and holding 800-1000 beds each for clinical training. The faculty in Psychiatry at AFMC comprises of 3 hospital units with a professor, Associate professor and assistant professor each. The number of hospital beds available in psychiatry for training purposes are approximately 120 for all the three units combined. The MCI currently approves an intake of 5 MD students and 5 diploma students each year. The college is affiliated to the MUHS, Nashik. Entrance to the Post Graduate (PG) courses is based on an entrance examination conducted each year in January followed by an interview in March by the Office of the Director General Armed Forces Medical Services (DGAFMS). Preference in selection is for Armed Forces Serving medical officers, followed by retired short service commissioned officers and officers of the central and state police organizations and paramilitary services like the Border Security Force (BSF) and Assam Rifles. Vacancies remaining are thrown open to civilian candidates who are physically fit and who are willing to serve in the Armed Forces for 5 years on completion of the course. Seats are offered to Military Medical officers of friendly Armed Forces like those of Nepal, Bhutan and Srilanka . The Naval Hospital, INHS Asvini at Mumbai and the Command Hospital at Kolkata have been recognized by the MCI for 2 MD seats each, the selection process for which is similar to that followed by AFMC, Pune.

Super/Sub-speciality training in the Armed Forces: The Armed Forces encourage their psychiatrists to do super/sub specialization courses in India and abroad in such subjects like combat psychiatry, forensic psychiatry, child & adolescent psychiatry, geriatric psychiatry and addiction medicine. The selection for these courses is after working as a graded specialist for approximately 3 years and based on an entrance examination and interview conducted by the Office of the DGAFMS.

Research, conferencing and pursuit of excellence: Research at the undergraduate and post graduate level is integral to training in the Armed forces training establishments. Both medical and nursing undergraduates are encouraged to take up psychiatric research topics of relevance to the Armed Forces as part of Indian Council of Medical Research (ICMR) projects during their vacation. On an average the ICMR approves about 15-25 research projects from AFMC undergraduates including 1-2 psychiatric projects. Research projects are also taken up by the department of Psychiatry every 182 Psychiatry in India : Training & training centres year under the aegis of the Armed Forces Medical Research Committee (AFMRC). The projects include areas of interest to the Armed Forces Medical services. The life events questionnaire was originally constructed by Holmes and Rahe (1967), two US Navy psychiatrists which is used most commonly in the western world [11]. This scale is not standardized on the Indian population and definitely not on the Indian soldier, where it has the most application. To measure the life change units in Indian soldiers, Raju MSVK et al standardized a stress scale known as the AFMC life events scale which rightly commemorates the institution, where it was developed [12]. Combat stress manifests as acute stress reaction, Adjustment disorder and Post Traumatic Stress Disorder (PTSD). The consequences of chronic stress can be in the form of physical and psychological symptoms like headaches, body aches, tiredness, reduced sleep or appetite and lethargy. Chronic stress may also manifest as psychosomatic disorders or psychiatric illnesses. Saldanha et al (1996) evaluated 601 poly trauma patients at a Zonal Military Hospital, and reported an incidence 24.3% of PTSD [13]. Chaudhury et al (2002) studied 140 limb fracture patients at another large multi speciality Military hospital and reported significantly higher scores on General Health Questionnaire, Michigan Alcoholism Screening Test, Carroll Rating Scale for Depression, Impact of Events Scale and Fatigue Scale in their sample [14]. The limb fracture patients also had a high prevalence of alcohol dependence/ abuse and depressive disorders. These were hospital based cross-sectional studies done on in patients and hence cannot be generalized to soldiers in the field. In a second set of studies, Puri et al (1999) reported that troops deployed in Counter Insurgency Operations showed higher and significant signs of stress indicators such as use of alcohol, unfavourable response to tasks, diminished efficiency, frustration, maladjustment, tension, isolation and depression [15]. Asnani et al (2001) studied stress and job satisfaction of soldiers in Counter Insurgency Operations using the Taylor's manifest anxiety scale and security /insecurity inventory of Srivastava [16]. Chaudhury et al (2005) using standardized scales reported high psychiatric morbidity, depression and alcoholism in soldiers in Low Intensity Conflict [17]. A third set of studies reported on the effects of soldiering and terrorism on children of Armed Forces personal. Harjai MM et al (2005) studied 16 children injured in a terrorist attack on an Army camp and found that five suffered Acute Stress Reaction of which three recovered with crisis intervention while two suffered persistent scholastic backwardness on review after one year [18]. Prabhu et al (2011) studied behavioural problems of 150 children of service personal in a field area and compared them with equal number of children from a peace area [19]. Interesting findings in this study were that the soldiers from the field and peace areas did not differ significantly in Life events past year (LEP) and Life events life time (LELT) on the AFMC Life Events Scale. Though the authors reported scores above cut off in 23.3% children on the Child Behaviour Check Subbarao et. al : Psychiatric Training 183 List, they did not find any significant increase in the behavioural problems among children of personal posted in field areas. This can be attributed to the successful implementation of the rotation policy between field and peace, which the Indian Army adopts for its soldiers.

Well planned scientific conferences are excellent means of exchanging information and continuing medical education. The sub section of the Indian Psychiatric Society (IPS) conducts at least two conferences each year, one of which takes place along with the Annual National Conference of IPS (ANCIPS). The other is usually held in one of the Major Military hospitals or AFMC and themes selected are of relevance to military psychiatry.

AFMC has consistently been rated among the best five medical colleges in the country over the last decade. This involved consistent improvement in training practices and interaction with centres of excellence in the country and abroad. Professors of Psychiatry from leading Indian medical colleges have been invited every year to give guest lectures to the faculty and students at AFMC. Students and faculty have actively participated in civil and military psychiatric conferences like the Asia Pacific Conference on Military Medicine to present relevant papers.

Conclusion: Training and Principles of Practice of Medicine & Psychiatry in the Indian Armed Forces have earlier set trends for training and practice of Psychiatry in civil in India. However since Independence, there has been an estrangement between Armed forces medical services and their civilian colleagues and military medical colleagues in other countries. This was for functional reasons as most of the work done in military psychiatry was not much of interest to civilian psychiatrists. There also was the requirement of confidentiality to the work being done in the Armed Forces. Even through this estrangement, the Armed forces psychiatric services built up a formidable system of continued, diligent and peer reviewed military psychiatric training practices. The undergraduate and paramedical training in psychiatry has been exhaustive and above the requirements prescribed by regulatory bodies like the MCI and NCI. The postgraduate and super speciality training is rigorous and keenly peer reviewed. Research is inherent to both undergraduate and postgraduate training and the topics selected are both contemporary and relevant to the military milieu. The training at the Armed forces Medical College and other Armed forces Training establishments has been acknowledged as first rate by most rating agencies over the last decade. Improvements in training and research are continuous and a recent editorial written by the faculty of the department of psychiatry in a military medical journal discusses the scope of such improvements [20]. Within the constraints of military confidentiality, military psychiatrists have strived to improve 184 Psychiatry in India : Training & training centres liaisons with their civilian counterparts and military medical specialists in friendly armed forces.

REFERENCES: 1. History of Ranchi Institute of Neuro Psychiatry and Allied Sciences as available at http://www.rinpas.nic.in/aboutus.htm 2. History of Central Institute of Psychiatry as available at http://cipranchi. nic.in/History.html 3. Greenberg N, Temple M, Neal L, Palmer I. Military Psychiatry: A unique National Resource. Psychiatric Bulletin, 2002; 26: 227-9 4. The National Capital Military Psychiatry Residency Program as available at http://www.usuhs.mil/psy/national[handbook.htm] 5. Prabhu HRA. Military Psychiatry in India. Indian J Psychiatry, 2010; 52: S 314-6. 6. History of Armed Forces Medical College as available at http://www.afmc.nic.in 7. MBBS admissions at AFMC as available at http://www.afmc.nic.in 8. Medical Council of India. Salient features of graduate medical examination at http://www.mciindia.org/RulesandRegulations/GraduateMedicalEducationRegulations1 997.aspx 9. Ryali VSSR, Srivastava K, Bhat PS, Shashikumar R, Jyothi Prakash, Suprakash Chaudhury (Eds).Handbook of Undergraduate Psychiatry, 4th Edition (2011): ISBN-978-81-8465- 731-9. 10. Competences expected from Nurses as elaborated at http://www.indiannursing council.org/guidelines-nursing-school-college.asp#B.Sc. 11. Holmes TH, Rahe RH. The social readjustment rating scale. Journal of Psychosomatic Research 1967;11:213-218. 12. Raju MSVK, Srivastava Kalpana, Chaudhury S, Saluja SK. Quantification of Stressful Life Events in Service Personal; Indian Journal of Psychiatry 2001; 43(3):213-218. 13. Saldanha D, Goel DS, Kapoor S, Garg A, Kochhar HK. Post-traumatic stress disorder in poly trauma cases. Medical Journal Armed Forces India 1996;49: 7-10. 14. Chaudhury S, John TR, Kumar A, Singh H. Psychiatric evaluation of limb fracture patients. Medical Journal Armed Forces India 2002;58:107-110. 15. Puri SK, Sharma PC, Naik CRK, Banerjee A. Ecology of combat fatigue among troops engaged in counterinsurgency operations. Medical Journal Armed Forces India 1999;55:315-8. 16. Asnani V, Pandey UD, Chaudhary PN, Singhal SNP, Tripathi RK, Boro SR. Stress and Job satisfaction among soldiers operating in counter-insurgency areas. DIPR Note No. 562 2001:3-33. 17. Chaudhury S, Chakraborty PK, Pande V, John TR, Saini R, Rathee SP. Impact Of Low Intensity Conflict Operations On Service Personnel. Industrial Psychiatry Journal 2005;14:69-75. 18. Harjai MM, Chandrashekhar N, Raju Uma, Arora P. Terrorism, Trauma and Children. Medical Journal Armed Forces India 2005;61:330-332. 19. Prabhu HRA, Prakash J, Bhat PS, Gambhir J. Study of Life Events in serving personal and its association with psychopathology in their children. Medical Journal Armed Forces India 2011;67(3):225-229. 20. Ryali VSSR, Bhat PS, Kalpana Srivastava. Stress in the Indian Armed Forces: How true and what to do? Medical Journal Armed Forces India 2011;67(3):209-211. Subbarao et. al : Psychiatric Training 185 Surgeon Commodore V.S. Subbarao Ryali Professor & Head, Department of Psychiatry, Armed Forces Medical College, Pune 411040. [email protected]

Col P.Shivram Bhat Associate Professor, Department of Psychiatry, Armed Forces Medical College, Pune 411040.

K. Srivastava Scientist 'F' & Clinical Psychologist, Department of Psychiatry, Armed Forces Medical College, Pune 411040.

Lt Col K.J. Divina Kumar Associate Professor, Department of Psychiatry, Armed Forces Medical College, Pune 411040.

21 Psychiatry In Armed Forces: Special Issues In Management

P.Shivaram Bhat, V.S.Subbarao Ryali , R. Shashikumar, Jyoti Prakash, S. Nath

ABSTRACT

Practice of Psychiatry in armed forces calls for special orientation, skills and training due to certain unique organsiational characteristics and clientele facing myriad kinds of stressors. Military psychiatry of Indian armed forces has evolved over time and presently has one of the best models of mental health care delivery system. Significant advances have been made in the fields of combat psychiatry, training of psychological counselors and community outreach activities. With an excellent networking and documentation procedures, it is providing a healing touch to the stressed out minds in the million strong armed forces.

Key words: Military Psychiatry, Combat

INTRODUCTION

Indian Armed Forces with more than a million strength in its cadres is a mammoth organization with some unique characteristics. It is a voluntary force with stringent criteria for commissioning of Officers and enrolment of Junior Commissioned Officers (JCO's) and Other Ranks (ORs). After induction they undergo rigorous physical and professional training at various stages of their service. With the rapid changes in the sociopolitical system, advances in military technology with volatile and hostile neighborhood, there has been a constant need to enhance the competency of the forces to deal with varied kind of needs that arise. Armed Forces are not only required to be combat worthy, they are required to deal more often with insurgency, natural disasters, communal violence, law and order issues and participate in international humanitarian assistance. They are required to work in most diverse climatic situations ranging from deserts of Rajasthan, rain forests of Nagaland, high altitudes of Himalayas to most inhospitable areas like Siachen Glacier. Quite often they are required to operate away from the motherland in 188 Psychiatry in India : Training & training centres various countries as part of United Nations Organization contingent to ensure peace. Though the organization has a time tested, well oiled health care delivery system in the form of large static hospitals, well equipped mobile filled hospitals and unit level medical establishments, there is a continuous need to be flexible to meet the ever changing demands. Psychiatric services of Armed Forces have evolved over a period of time to meet these challenges that are unique to the services. The challenges are special and different from the civil society, and the solutions are also innovative. These special issues of management are implemented with the objective of maintaining a sound mind in a sound body.

Historical Perspective

Though the life in the Armed Forces is quite stressful, the well knit nature of the service community ensures that any minor deviation of behaviour also is picked up early and brought to the attention to take care of. The origin of Indian military psychiatry services can be traced back to 19th century. The first hospital for the mentally ill Indian sepoys was established in 1975 in Monghyr, Bihar1. In 1918 Col Owen Berkeley Hill established European Mental Hospital at Ranchi and in 1922 Lt Col Lodge Patch at Lahore. With the advent of World War II, a rapid expansion of psychiatric services took place. From a strength of four psychiatrists for the whole of troops in India at the beginning of the war, the strength increased to 86 by 1945. Psychiatrists were posted up to forward Divisional level and they established “Exhaustion Centres” to treat cases of battle exhaustion. In the independent India, the psychiatric centres were established in major military hospitals located in big garrisons. General Nursing Assistants were given specialised training in these centres and posted as Psychiatric Nursing Assistants (PNAs). Members of Military Nursing Service were sent to premier institutions like NIMHANS for training in psychiatric nursing and then posted to these psychiatric centres. The major psychiatric centres of Command Hospitals were further augmented with the posting of Civilian Clinical Psychologists and Psychiatric Social Workers.

Soldier – A unique client

Though the Officers and soldiers of Armed Forces come from civil society of the country, due to the nature of rigorous training, posting of pan India nature, specialised role functioning, disturbed family life, need for continuous flexibility and adaptability, assignment of various new roles, use of sophisticated new equipments for communication and war puts them under significant stress and makes them a client with unique characteristics. Over the last few decades a significant amount of welfare measures have been instituted to tackle these issues, but the rapid changes in society with emphasis on materialism has put additional strain on them. Disintegrating Shivaram et al: Psychiatry In Armed Forces 189 joint family system with resultant strain on the emotional resources has had its deleterious effect on the marital sphere of the soldier. Small family norm has made every child a precious one, and a soldier parent also wishes to provide stability and a good education to his wards. But the long separation from the family, frequent shifting to new places of duty, financial constraints, lack of good schools at some places and inability to get admissions in time in good schools put tremendous pressure on him. The stress on the family is also equally insurmountable some times. In spite of all these, he is required to perform well in his duties amidst strict discipline and steep hierarchical system of the forces. However it is commendable that soldiers are still coping well with these stressors2, and their children are also able to manage them comfortably even when located in Field areas3.

Military Psychology

Military Psychology is the application of psychological principles and theories to the military context determined by the requirements of the armed forces4.It explores the domains of basic as well as applied research at the same time. Ensuring psychological well being of the troops and providing clinical intervention in times of crisis is its basic function. With the drastic changes in warfare, the role of military psychologists has seen sea change. Preparing for multiple role relationships as an embedded member with a military unit, managing the ethical considerations by maintaining a balance between professional commitment and organizational requirements while dealing with the mental health issues, and providing services to a multi-ethnic, multicultural force that has to function effectively in varied environments are some of the challenges faced by military psychologists.

Military psychology in India is a relatively recent development with its beginning around the time of Second World War, mainly concerned with the selection of personnel for military. Presently Defense Institute of Psychological Research (DIPR), New Delhi is the nodal agency and technical headquarters for the selection of Officers for armed forces. In addition to the basic research, it provides technical training to assessors of the Service selection Boards (SSB), monitors and evaluates the selection system and performance of selected candidates during service career. Recently a selection battery has been developed for the selection of Other Ranks in the Indian Army5. In addition to the above, senior clinical psychologists at Command Hospitals have been providing yeoman service to the troops by psychometric evaluation and psychological counselling. A senior scientist from Defense Research and Development Organization (DRDO) is posted to Dept of Psychiatry of Armed Forces Medical College (AFMC) Pune for the last two decades and the Department is on the verge of establishing a full-fledged Psychological Lab for the screening of candidates aspiring to join AFMC. 190 Psychiatry in India : Training & training centres Organization of Military Psychiatric Services

The psychiatric services in Armed Forces are delivered through psychiatric centres in military hospitals that function as General Hospital Psychiatric Units (GHPU). Presently there are seventeen psychiatric centres in Army, three in Air Force and three in Navy. They are of different sizes based on authorized beds ranging from 15 to 65. Few additional beds have been allotted to Psychiatric centre of Command Hospital (SC) Pune, the affiliated hospital of AFMC Pune, to facilitate better training of Medical Undergraduates and Post graduates. Generally they are situated as an independent subunit of the hospital in a large area covered with greenery. There is adequate space for conduction group therapy, yoga sessions and rehabilitation training. Adequate number of escorts/attendant are made available to the psychiatrists for the care and safety of patients. Based on the workload, these centres are posted with one to four psychiatrists. There is a liberal authorisation of two PNAs for every five beds of these psychiatric centres, probably the highest in any Government sector hospital. In addition, one to two psychiatric Nursing Officers are also posted to each centre.

Training of Manpower

During the MD (Psychiatry) training of future military psychiatrists at AFMC Pune, special emphasis is given on the nuances of military psychiatry. There is a continuous education and evaluation program in service for them even after MD as they progress to the level of Graded specialists, Classified specialists and Senior Advisers. Military Psychiatry has emerged as a subspecialty of Indian Psychiatric society (IPS), and conduct of regular military Psychiatry CMEs helps to horn their skills in dealing with the unique mental health issues of Armed Forces. The military trains the selected Nursing Officers in Psychiatric Nursing by sending them to premier institutions like NIMHANS. Psychiatric Nursing Assistants also undergo regular up gradation courses during the various stages of their service.

Referral System

The referral of Armed Forces personnel for psychiatric evaluation is done as per the laid down policies, which are in agreement with the provisions of Indian Mental Health Act. He can be referred when he reports to the Authorized Medical Attendant (AMA) with symptoms which the latter consider might be due to a psychiatric illness, when the relatives/friends bring him to AMA with history suggestive of psychiatric illness, when a military police/civil police/registered medical practitioner/a responsible government servant/member of public brings to AMA with features suggestive of psychiatric illness or when a patient already under treatment of AMA shows signs and symptoms suggestive of a psychiatric illness. The Commanding Shivaram et al: Psychiatry In Armed Forces 191 Officer (CO) of a unit also can send the person under his command for psychiatric evaluation through AMA. But it should be accompanied by a confidential written report (AFMSF-10) outlining briefly the nature of abnormal changes noted by him. Also, a serving person placed on charge for an offence and it is suspected that he might have suffered or is suffering from a psychiatric illness, the competent authorities may seek psychiatric consultation through the AMA. In an emergency, the services of a local government psychiatrist or a private psychiatrist may also be requisitioned. In all the above circumstances the CO and AMA are required to provide maximum possible information about the individual, as the family members are unlikely to be available to give input to the psychiatrist in most of the cases. Adequate measures are required to be taken to prevent harm to self or others by the individual by providing additional escorts during the transfer and hospitalization of the individual. Serving female patients are to be admitted to family wards and adequate female attendants are to be provided. The social stigma associated with a label of psychiatric diagnosis exists in the armed forces also as in civil and hence utmost care to be taken at all levels to avoid unnecessary referrals.

Diagnosis and Management

After detailed evaluation, the psychiatrist will make the diagnosis as per International Classification of Diseases (ICD) as amended from time to time. Meticulous care is taken in diagnosis of major psychiatric disorders, as they may adversely affect the career prospects and social status or even lead to litigation. Since the admitted patients are under continuous close observation, the inputs from the ward observation report by PNAs and Psychiatric Nursing Officers are also taken cognizance. Whenever feasible, detailed psychometric evaluation by clinical psychologist is also done to help arrive at a definitive diagnosis.

All the psychiatric centres are situated in military hospitals having other speciality services, and function as General Hospital Psychiatry Units (GHPU). Most of the centres have the latest laboratory services and neuro imaging facilities. All the cases are thoroughly investigated with appropriate investigations before the final diagnosis. All cases of major psychiatric disorders are also seen by a senior psychiatrist independently, and this acts as an excellent peer review. Management is by following appropriate clinical guidelines, and unscientific polypharmacy is strictly avoided. On good response to treatment, generally the patients are sent on four to six weeks of convalescence leave and reviewed thereafter before disposal. Depending on the nature of illness, they are placed in a lower medical classification with appropriate maintenance medication. This ensures sheltered appointment, compliance to treatment and regular follow up. 192 Psychiatry in India : Training & training centres Psychiatric Documentation

Armed Forces have got an excellent documentation system of health care delivery to all serving personnel. Everything related to the patient is documented from the time of first referral to till his retirement in various designated forms/ case sheets and are preserved even after retirement till his death. Since the patients and doctors are moving to various places every few years on posting, proper documentation and its availability are of paramount importance. This is ensured by sending the hospital documents, on discharge of the patient from the hospital, to the respective Regimental Records (in case of JCOs & ORs), and Service Headquarters (in case of Officers). A detailed opinion of the case with recommendations and employment restrictions imposed will be available in the unit of the individual. During follow up when the psychiatric patient comes to the psychiatric centre for monthly review, a follow up case note is endorsed on it. When he becomes due for six monthly review, he will be admitted to psychiatric centre and if need be all his old medical documents are asked for from the Regimental records/Service HQs. Since the patient visits different psychiatric centres for his review due to postings, he will get the advantage of independent review by many psychiatrists. This also imposes an excellent peer review, thereby help improve the professional skills of psychiatrists in handling the unique mental health problems of Armed Forces.

Legal issues in Military Psychiatry

A good knowledge of Forensic Psychiatry is an inescapable requirement for psychiatrists working in an organizational set up, and it is felt more so in Armed Forces. Frequently, various issues related to fitness to continue in service, fitness to plead the case, fitness to stand trial in a court martial and fitness to post to a particular place or appointment come up. More commonly, the appeals related to attributality /aggravation of the psychiatric illness to service conditions having financial implications on pensionary benefits are required to be assessed by military psychiatrists. Sometimes appeals are also filed against the removal from service on medical grounds, asking for reinstatement through court orders. Psychiatrists are required to be conversant with the various legal aspects related to psychiatric practice.

Armed Forces being a close knit family, any minor aberrant behaviour of an individual also is picked up very early and he will be referred for psychiatric evaluation. After a detailed evaluation if no psychopathology is noticed by the psychiatrist he will be discharged as Psychiatric Investigation – No abnormally Detected (NAD). Sometimes, in some centres this can be a significant number of psychiatric admissions6.

In Armed Forces all serving personnel diagnosed of psychotic disorders are Shivaram et al: Psychiatry In Armed Forces 193 independently reviewed by a senior psychiatrist before disposal. All cases are followed up for long duration to prevent relapses and ensure combat worthiness. Invalidment from service is done only as a last report when there is poor response to multimodal treatment or there are frequent relapses due to poor compliance. Substance use disorders are also treated for adequate duration as per relevant orders. Medical certificates are generally not issued, except in few cases of illness in the family, for posting of the serving personnel to places where psychiatric centres are located nearby. Existing checks and balances in the system ensures to minimise avoidable litigations.

Dilemma of Military Psychiatrist

As a part of the military organisation, psychiatrist has a natural allegiance to the service and is obliged to ensure good mental health of his clients. Since the combat worthiness of the military is of paramount importance for the nation, he is required to take certain decisions about his patients, sometimes including his removal from service. Ethical dilemmas arise sometimes when there is a conflict between his duties towards the patient versus his obligation to the organisation. This needs to be handled with an unbiased mind taking a path most beneficial to the patient and the organization.

Psychiatric referral and diagnosis still carries some stigma in military as in civil society. Psychiatric referral as punitive measures may occur sometime, and psychiatrist has to be extremely vigilant on this. At the same time, some personnel may try to get a psychiatric diagnostic label with the malafide intention of seeking sheltered appointment to avoid a difficult posting. Both the above issues need to be handled firmly.

Psychiatric services for families and veterans

Families of serving personnel are entitled for outpatient psychiatric services, and are provided with evaluation, counselling, investigations and all modalities of therapies. However in an emergency they can be hospitalised for short duration. However the problem of provision of female attendants arises sometimes. For the benefit of differently abled children of serving personnel suffering from mental retardation, autism, learning disability etc, special schools named ASHA are being run in many cantonments. These children are taught by special educators, and psychiatric services are provided by the military psychiatrists from nearby military hospitals. All out efforts are also made to post serving personnel with such children to places having ASHA Schools. Veterans (ex-servicemen) are also entitled for outpatient psychiatric services only, but with the introduction of Ex Servicemen Contributory Health Scheme (ECHS), their needs are fully catered for. They can be referred to civil psychiatric centres of empanelled hospitals and provided with free psychiatric services. 194 Psychiatry in India : Training & training centres Combat Psychiatry

Combat Psychiatry branch is unique to Armed Forces and deals with the mental health issues of soldiers deployed in forward locations. Indian Armed Forces have not only faced wars from some neighboring countries since Independence, but also been activity engaged in dealing with insurgents in the east for many decades and in the north for the last two decades. A large number of troops are actively engaged in these duties and exposed to varying kind of stressors7-8. Prolonged spells of stressful duty in such low intensity conflict (LIC) operations with inadequate opportunity for rest & relaxation imposes immense and often unbearable demands on even otherwise robust subjects. This can result in psychological distress, combat stress disorder or post traumatic stress disorders. In addition overstaying of leave, desertion, substance abuse, suicide and shooting at superiors may occur9-12. The psychiatric management of combat stress related disorders is based on the principles of Proximity, Immediacy, Expectancy and Simplicity (PIES).

In spite of the above there is no evidence to suggest an increasing trend of stress related disorders in Armed Forces2. This seems to be due to a series of welfare measures undertaken in the last few years. Military psychiatrists are actively involved in conducting various community outreach activities, stress management capsules, training of trainers and training of Religious Teachers of Armed Forces to become effective psychological counselors.

CONCLUSION

Psychiatric practice in armed forces calls for special skills and different approaches compared to civil due to unique kinds of stressors on the client, organizational requirements and regular movements of psychiatrists and client. But with an excellent system of referral, management, disposal and documentation procedures, a well oiled and time tested psychiatric service delivery system is in place. It goes beyond the curative realms of medicine, and is actively involved in community outreach activities to provide preventive and promotive services. All the psychiatric centres of armed forces are working in tandem to achieve the complete health of the soldier encompassing physical, mental, social and spiritual realms.

REFERENCES

1. HRA Prabhu. Military Psychiatry in India. Indian Journal of Psychiatry 52, supplement, January 2010. 2. Surg Cmde VSSR Ryali, Col PS Bhat, Kalpana Srivastava. Stress in the Indian Armed Forces: how true and what to do? Medical Journal Armed Forces of India, 2011;67:;209-211. 3. Brig HRA Prabu, Lt Col Jyoti Prakash, Col PS Bhat, Lt Col J Gambhir. Study of events in serving personnel and its association with psychopathology in their children: a multi centric study ? Medical Journal Armed Forces of India, 2011: 67: 225-229 Shivaram et al: Psychiatry In Armed Forces 195 4. Swati Mukherjee, Updesh Kumar, Manas Mandal. Status of Military Psychology in India. A review. Journal of Indian Academy of Applied Psychology. Jul 2009, Vol 35, No.2, 181-194. 5. DIPR : Development of new psychological test battery for the selection and trade allocation of other ranks in the Indian Army (DIPR Technical Report). 2008 : Delhi: DIPR. 6. Major Mamta Sood, Col D Saldanha: Socio demographic and service profile of cases diagnosed as Psychiatric Investigation NAD in Armed Forces. Indian Journal of Psychiatry, 2004, 46(4) 349-353. 7. Goel DS: Psychological aspects of counter insurgency operations. Combat 1998:27:43-8 8. Ray A: Kashmir Diary. Psychology of militancy. Delhi: Manas publications, 1997. 9. Badrinath P. Psychological impact of protracted service in low intensity conflict operations (LICO) on Armed Forces personnel: causes and remedies. Journal of United Service Institutions of India. 2003:83; 38-58. 10. Puri SK, Sharma PC, Naik CRK etal. Ecology of combat fatigue among troops engaged in counter insurgency operations. Armed Forces Medical Journal India. 1999:55: 315-318. 11. Chaudhury S, Chakaraborty PK, Pande V etal. Impact of low intensity conflict operations on service personnel. Industrial Psychiatry Journal. 2005:14: 69-75. 12. Chaudhury S, Goel D S, Hariharan Singh. Psychological effects of low intensity conflict (LIC) operations.Indian Journal of Psychiatry 2006:48; 223-221.

Col P. Shivaram Bhat Associate Professor, Department of Psychiatry, Armed Forces Medical College, Pune 411040. [email protected] Mobile- 963776825

Surgeon Commodore V.S. Subbarao Ryali Professor & Head, Department of Psychiatry, Armed Forces Medical College, Pune 411040

Lt Col R. Shashikumar Associate Professor, Department of Psychiatry, Armed Forces Medical College, Pune 411040.

Lt Col Jyoti Prakash Reader, Department of Psychiatry, Armed Forces Medical College, Pune 411040.

Lt Col S. Nath Classified Specialist in Psychiatry Command Hospital(SC), Pune 411040

22 Training in Child Psychiatry in India- A Review of Current Status and Recommendations

Savita Malhotra

ABSTRACT

Child psychiatry is an academic super specialty all over the world, recognized for several decades now. In India, because of major shortfall of psychiatrist in general, development of psychiatry has not kept pace with the global trends. It is now clear that the subject of child psychiatry is complimentary to general psychiatry, and is, therefore, an essential medical discipline that requires to be established in the country. There is urgent need to start postdoctoral DM as a super specialty course in India which would pave the foundation for its development as an academic super specialty. It is also necessary to embark on shorter term certificate courses or fellowship programmes for general adult psychiatrists who are required to see and treat a large number of child psychiatric problems in the community. Child psychiatry training in MD general psychiatry and MD general pediatrics too needs to be strengthened for making it more comprehensive and complete.

Child (includes fetal, infant and adolescent stages) mental health is an important and essential component of child health and also of national mental health. If we talk about the psychiatric morbidity in children the mere numbers are staggering. In a report from the WHO Collaborative study on Strategies for Extending Mental health Care, 22% of children attending the primary health care facility in India had some mental disorder.

Epidemiological studies have shown the prevalence of child psychiatric disorders to vary between 15-22% worldwide, and about 12% [1] in India. Annual incidence is reported to be about 18/1000 in India[2] in general population studies. Prevalence in school children is reported to be about 6%.[3,4] Considering that nearly 50% of India's population comprises of children and adolescents, the total number of children in need of psychiatric 198 Psychiatry in India : Training & training centres treatment would be enormous.

Further, research has now amply shown that most of the major adult psychiatric disorders including schizophrenia, depression, OCD, personality disorder, substance abuse etc. have their onset in childhood or adolescence.

In India, national health policies have focused on child health in the form of specific programs for immunization, nutrition, maternal and child care, thus bringing down the indices of infant mortality to 54/1000 live births. However, a parallel development of mental health services for children has not occurred. It must be understood that child's physical health and mental health go hand in hand and any health policies that do not target mental health can not bring fruitful results.

The child differs from adults not merely in size (quantitatively) but also in physiological and developmental characteristics i.e. qualitatively. Principles of adult medicine cannot be applied to children by simple extrapolation. For example, children cannot be simply administered smaller doses of adult prescriptions as there are differences in pharmacodynamics, pharmacological effects and side effects of psychotropic medicines. Further, children are growing and evolving individuals, and constantly in a state of flux influenced by biological, psychological and social factors in a reciprocal interactive manner. Understanding of psycho-pathology, occurrence of psychiatric disorders and their treatment requires attention to these facets. Unfortunately, adult psychiatrists are not attuned to these intricacies in their child patients.

In recent years, there has been tremendous amount of research in child development and child psychiatry providing a huge body of credible knowledge in fundamentals of child development, psycho-pathology, and treatments and so on.

Historically, the discipline of Child Psychiatry began with the pioneering work of William Healy in 1909 in USA which gradually gained momentum and became a child guidance movement. The phenomenal growth in child guidance centers led to the citation of the obvious need for setting the standards of clinical practice, for creating adequate academic education and clinical training in child development. Later it was emphasized that Child Psychiatry should be recognized as a sub-specialty because the body of knowledge in Child Psychiatry increased enormously which had be acquired over and above the course in general Psychiatry. Nothing in the training of a general psychiatrist prepares him/her to diagnose and treat competently, school age or preschool child. The advocates of the medical specialty school paralleled the rightful recognition of the child psychiatrist versus the general psychiatrist as similar to the sensible differentiation of the paradiatrician vs Malhotra: Training in Child Psychiatry 199 specialist in internal medicine. In 1957, American Board of Psychiatry and Neurology recognized Child Psychiatry as a subspecialty of Psychiatry.

As far as training is concerned it has been recommended that Child Psychiatry should constitute an essential part of any programme for post-graduate education in general Psychiatry and professional training must include both academic and clinical aspects of the subject (Royal Commission on Medical Education 1965-68).

In USA and UK Psychiatry residency training programme involves a full time posting for 6 months in Child Psychiatry, during the second year of residency. For further specialization in Child Psychiatry, a two years fellowship after a three years training in general Psychiatry is available in America. In UK one desirous of specialization can undertake MRCPsy which has a special paper in Child Psychiatry, or go for higher psychiatric training in child psychiatry.

A national workshop on Postgraduate Education in Psychiatry held under the aegis of the Psychiatric Education Committee of IPS in Bombay, recommended starting of a certificate course of one year duration in child psychiatry after MD way back in 1988. Since then a lot of thinking and development has taken place.

Recommendations were brought out in a national workshop held later in NIMHANS Bangalore in Sept. 1979 on postgraduate training of psychiatrists, which are:

i) Urgent attempts should be made for starting post M.D., DM course in specialties e.g. Child Psychiatry, running for a minimum of 2 years after MD Psychiatry. ii) During their general psychiatry training in the 2nd year the students should be posted in specialty units like Child Psychiatry for at least 3 months as a full time posting.

For this purpose it is necessary that all psychiatry teaching departments should aim towards developing service and training programmes in Child Psychiatry.

IPS body approved the need for starting post MD, doctoral course in the form of DM in child psychiatry in 1995. IPS has already started a specialty section of child psychiatry that holds CME's and other academic activities annually for several years now.

ICMR recognized child psychiatry as one of its thrust areas in 1980 and approved it again in its subsequent five year plans. Standing committee on CME's of the NAMS recognized child psychiatry as a specialty and 200 Psychiatry in India : Training & training centres recommended that nationwide CME's in the subject should be held.

The Specialty Board of the National Academy of Medical Sciences, in its meeting on 15.4.2002 in Delhi, recommended that Fellowship in Child and Adolescent Psychiatry should start in India as soon as possible. Members of this Specialty Board did prepare a detailed curriculum.

Most recently the Medical Council of India initiated the preparation of a curriculum for DM in Child Psychiatry which was successfully started at NIMHANS, Bangalore from 2011.

Despite all the above mentioned initiatives, the situation in India is not at all satisfactory. There are very few (

In contrast, there are approximately 133 centers in India imparting MD psychiatry training. It is clear that in 90% of cases, there is no child psychiatry training for adult psychiatrist in India which is a glaring deficiency in general psychiatry training. Since 50% of our population comprises of children and adolescents, psychiatric professionals are answerable for neglecting half of the population with no plausible defense to their rescue.

There is an urgent need to make a beginning in the development of child psychiatry as a separate discipline that is also complimentary to general psychiatry. We must start specialized training in child psychiatry to develop the manpower required to start and lead the academic service units in child mental health across the country. It has not acquired a status of service sub- specialty even whereas it is recommended to be an academic sub-specialty.

General psychiatry training must include 3-6 months full time posting in child psychiatry. Similarly general pediatrician must also have a 6 months posting in child psychiatry.

DM in child psychiatry should be a two year course after MD in psychiatry. It is a matter of debate if MD Pediatrics should also qualify for DM in child psychiatry. Considering all the pros and cons, it will be advisable to open the course for pediatricians after spending about a year in general psychiatry. DM in child psychiatry can qualify for appointments to academic posts where child psychiatry training is imparted. Initially, these child psychiatrists may have to occupy general psychiatry posts till new cadres of positions in child Malhotra: Training in Child Psychiatry 201 psychiatry are created in the country.

Model of training, curriculum and course content should be such which is commensurate with the requirements of Indian population and conditions.

Now, several other academic centers in India are in an advanced stage of preparedness to start post doctoral DM in child psychiatry but for some administrative hurdles. For example CSM University Lucknow, Niloufer Hospital Hyderabad, CMC Vellore, SMS College Jaipur, Vishakhapatnam, Institute of Psychiatry Chennai have well established child psychiatry Units. However, not all centers may have dedicated and fully qualified faculty. PGI Chandigarh has been very active and productive in child psychiatry teaching, service, research and advocacy through the years serving as a resource centre at the national and international level. There is sufficient infrastructure and staff to start DM programme.

Further, apart from DM, it is possible to envisage fellowship programme in child psychiatry at designated centers which can be proposed under the aegis of the National Academy of Medical Sciences or the National Board of Examinations (NBE). NBE has started postdoctoral fellowships in many medical and surgical super specialties. On the same pattern, fellowship in child psychiatry can be started. Centers can be recognized for NBE fellowships on the basis of available infrastructure. Pooling of faculty resource at the national level can be done as the starting point.

IPS Body has consistently shown its concern and commitment for development of child psychiatry in India. Now it should make a concerted effort to bring child psychiatry training in India to reality. Many young psychiatrists are opting for child psychiatry training overseas and there are many more who remain in India and are waiting for an opportunity. Child psychiatry is a preferred specialty among younger generations.

IPS should:

i) Lobby with the national and state governments to support the development of this super specialty and propose starting of the DM in child psychiatry. ii) Lobby with the National Board of Examinations for starting Fellowship in child psychiatry in India. iii) Conduct series of teaching/educational programmes for general psychiatrists in child psychiatry as a special thrust area in its effort to compensate for the deficiency in their training. iv) Consider developing courses such as fellowship programmes in 202 Psychiatry in India : Training & training centres Child Psychiatry for 6-12 months for general psychiatrists to fill the gap in service need. v) Propose distance education programme in child psychiatry for general psychiatrists.

REFERENCES

1 Srinath S, Girimaji SC, Gururaj G et al (2005) Epidemiological study of child and adolescent psychiatric disorders in urban and rural areas of Bangalore in India. Indian Journal of Medical Research 122, 67-79.

2. Savita Malhotra, Adarsh Kohli, Mehak Kapur, Basant Pradhan ( 2009) Incidence of Child and Adolescent psychiatric Disorders In India. Indian Journal of Psychiatry. 51, 101-107.

3. Malhotra S, Kohli A, Arun P (2002) Prevalence of psychiatric disorders in school children in India. Indian Journal Medical Research 116, 21-28.

4. Giel R, De Arango MV, Climent GE et al (1981). Childhood mental disorders in primary health care: results of observations in four developing countries. Pediatrics 68; 677-83.

Savita Malhotra Professor of Psychiatry Post Graduate Institute of Medical Education and Research, Chandigarh [email protected] 23 School Mental Health Program- Role of the Mental Health Professional

Srikala Bharath, K.V. Kishore Kumar

ABSTRACT

School Mental Program is the need of the day in India. The pivotal role of the Mental Health Professionals in organizing and setting up such a program is outlined.

Key Words: School mental health program, life skills education, mental health promotion, psychosocial competence, life skills educators

Introduction Globally, comprehensive school mental health program (SMH) has become an integral part of the school health program in most countries [1, 2]. There are two types of approaches in school based mental health promotion program – environment-based and child-centered. Often both approaches overlap and follow each other. Environment based programs focus on the system (administration, teachers, support staff), and processes (parent-teachers association). Child Centered approaches focus on work with children/adolescents* – either as screening, consultations or general sessions with the students themselves on coping, self-image. Documented successful projects and programs are available using either approach [3, 4, 5]. Most of the program available worldwide are child centered program addressing specific issues with the students – drug abuse [6], bullying [7] improving relationships with peers and improving academic performance [3]

School Mental Health Program in India

Awareness regarding the psychological issues of children has been meager and school mental health program was not present till the seventies. Subsequently there have been initiatives by mental health professionals *term ‘child’ will be used in the article to indicate child / adolescent students from the age of 6 to 18 / 19 years 204 Psychiatry in India : Training & training centres towards a School Mental Health Program in the major metropolitan cities like Mumbai, Delhi and Bangalore [8]. Table 1 summarizes the various known school mental health program in the country till date [9]. Srikala & Kishore: School Mental Health Program and MH professional 205

The above review reveals that SMH Programs in India vary in their 1. Aims / Focus – General, Specific like Sexuality, Drug Abuse 2. Structure - single sessions to continuous program over the year 3. Content – types of developmental needs 4. Methodology - Information only, Orientation, Participative 5. Target Population - Children/Adolescents/ Teachers/Parents. 6. Location - Private/Public Schools/Primary/Secondary/Junior Colleges 7. Evaluation – Implementation, Process, Impact

Most initiatives have focused on increasing the awareness of the teachers and/or parents about child mental health issues/disorders.

There is a need for a common/comprehensive framework in SMH program across the country. A comprehensive and inclusive SMH Program would address the developmental and psychosocial needs of all children in the school system (Figure 1).

Fig 1 206 Psychiatry in India : Training & training centres Hence it needs to be a Two Pronged Program at all levels of the educational system – Primary, Secondary, Higher Secondary levels (Figure -2).

The two prongs would be

1. A Universal Program – an inclusive promotional program for all students to develop psychosocial competence and self esteem. 2. A Targeted Program for ‘at risk’ and ‘vulnerable’ children/ adolescents. Children are at ‘risk’ due to bio-socio-economic- psychological reasons - those with chronic disabling physical conditions, affected by disasters and conflicts, parental divorce, death, alcoholism etc. ‘Vulnerable’ children are those with mental retardation, autism, attention deficit disorder, specific learning disabilities, psychiatric conditions including emotional/conduct disorders, severe mental illnesses. They need specific inputs by specially trained teachers and child mental health specialists.

Life Skills Education (LSE) is an ideal methodology to empower students and could be run as a Universal Promotional Program to enhance competence and self esteem. Department of Women and Child Welfare, Department of Public Instruction, Department of Health and Family Welfare, Department of Youth Affairs and Sports, Department of Human Resource Development would be the stake holders. Youth, teachers, MH and health professionals, parents, health workers, NGOs would be partners in the initiative. Children would be the beneficiaries.

Mental Health Orientation would focus on mental health disorders in children and counseling skills development in teachers. Inputs for identification, intervention if possible at the school level along with the liaison of the MH professional, pediatrician/physician, referral to MH professional if intervention is not possible at the school level and regular follow ups for identified children/adolescents with be the process that needs to be in place towards this. This would be suitable for population at risk. Stakeholders would be same as above. Teachers, schools nurses, MH professionals, health workers, PHC doctors, pediatricians would be partners in this part of the SMH program. Srikala & Kishore: School Mental Health Program and MH professional 207 MH Professionals & SMH program - Accessibility, Training & Capacity Building.

Mental Health Professionals have a key role in the development of SMH program in the community. Towards this they need to

1. Liaise with local community/schools, serve on school health advisory councils, and promote school-based mental health services. 2. As a mentor, recommend advocate and assist schools to develop holistic SMH programs with a strong preventive component that focuses on building strengths and resilience. Provide an ecological view of mental health and promote support structures to be built for families and the whole community. 3. Identify strategies and community resources that will augment school-based mental health programs – This would mean involving local non governmental organizations (NGOs) actively for promoting SMH program at all level – promoting awareness, training, resource and IEP package development and evaluation. 4. Set up training and capacity building system of personnel in the schools. This would involve training teachers and other volunteers to become Mental Health Facilitators for LSE and specific early identification/intervention. It would also encompass continuous orientation and sensitization program for the community - mainly parents, leaders, administrators of the local education system. 5. Ensure/promote inclusion of mental health services in individualized educational programs (IEPs) for child clients in the school – manage medical maintenance and ensure special education program within the school with trained personnel. 6. Lead regular outcomes-based audit on the effectiveness of various school-based mental health models that are designed to improve psychosocial, academic, specific mental health outcomes.

Since most MH professionals are familiar with the Orientation to Mental Health Disorders approach, a universal SMH promotional program is shared briefly here.

Srikala Bharath and Kishore Kumar, Department of Psychiatry, NIMHANS Bangalore have developed a Cascade Model of LSE for Adolescents as a SMH program using teachers as LS educators. It was developed after extensive need assessments and focus group discussions with adolescents and teachers in secondary schools, NGOs, social scientists, bureaucrats and policy makers working with adolescents [10]. Resource materials were prepared for the teachers in secondary schools who would be trained as Life Skills Facilitators 208 Psychiatry in India : Training & training centres [11]. The model has been implemented as a program in more than 261 Karnataka government schools and its effectiveness established [12]. It has been used by other boards of education (Navodaya Model Schools) in the country and other countries. Found to be relevant for training volunteers working with ‘out of school children’.

Highlights of NIMHANS Model of Life Skills Education – SMH Program

1. The model is an integrated, well structured one using already available resources of schools, teachers as Life Skills (LS) Facilitators. Training of teachers as Master Trainers (MTs) and LS educators and orientation of other stakeholders is part of the model. MH professionals provide training and support for the program.

2. It is promoted as a co-curricular activity for secondary school children in a continuous manner over 3 academic years by trained LS teachers on a weekly basis. Generic life skills are promoted.

3. The classes with increasing complexity are mainly through activities among students facilitated by the LS Teacher. Hence it is a participative program focusing on experiential and peer learning.

4. The activities are based on all developmental themes relevant in adolescents - Nutrition, Hygiene, Academics, Interpersonal Relationships, Substance Use, Gender Issues, Career, Social Responsibility. Cultural sensitivity is maintained in the activities.

5. Feedback and Evaluation are built into the model both at the training and implementation stages.

6. Structure of the training and resource materials are available (Appendix I, II). The latter in 2 vernacular languages – Kannada, Gujarathi.

As a specific goal this model of comprehensive SMH program has been able to

Ø Provides Class Teachers with Facilitative Skills to Promote Life Skills to deal with challenges of living among their students. Ø Provides Class Teachers with Knowledge and Skills to identify early symptoms of Developmental/ Mental Health Problems/disorders in their students Ø Provides Class Teachers the awareness of the need for a system of referral for students with psychological problems to the MH Team for inputs and treatment. Srikala & Kishore: School Mental Health Program and MH professional 209 Conclusion:

Mental Health Program gaining more and more relevance and place in the Health Program and budget of the country. The opportune is prime towards initiating a well integrated, comprehensive School Mental Health Program across the country. Mental Health Professionals need to lead the movement. This would be a suitable investment in the future of India.

..every school should enable children at all levels to learn critical health education and life skills .....Such education includes : ....comprehensive, integrated life skills education that can enable young people to make healthy choices and adopt healthy behavior throughout their lives - (WHO 1997). 210 Psychiatry in India : Training & training centres

REFERENCES

1. Mubbasher MH, Saraf TY, Afghan S, Wig MN . Promotion of mental health through school health program. EMR Health Serv. J (1996); 6:14-19. 2. World Health Organization. Programme on Mental Health : Life Skills in Schools. WHO/MNH/PSF/93.7A Rev.2, Geneva, WHO, Division of Mental Health and Prevention of Substance Abuse (1997). 3. Greenberg MT, Weissberg R, O’ Brien MU, Zins JE, Fredicks L, Resnik H, Elias MJ . Enhancing School –Based Prevention and Youth Development through coordinated Social, Emotional and Academic Learning. Am Psychologist 2003 ;June/July: 466-474. Srikala & Kishore: School Mental Health Program and MH professional 211 4. Nation M, Crusto C, Wandersman A, Kumpfer KL, Seybolt D, Kane EM, Davino K. What works in Prevention: Principles of Effective Prevention Programs. Am Psychologist 2003; June/July: 449-456. 5. Weissberg RP & Bell . A meta analytic review of primary prevention programs for children and adolescents : contributions and caveats Amer. J. Comm. Psychology 2003; 25 (2): 207- 214. 6. Botvin GJ, Baker E, Botvin EM, Filazzola AD & Millman RB. Alcohol abuse prevention through the development of personal and social competence: A pilot study. J. Studies on Alcohol 2003;45: 550-552. 7. Olweus D.Victimization among school children: intervention and prevention. In: Albee GW, Bond LA, Monsey TVC (Eds).Improving Children’s Lives: Global Perspectives on Prevention. Newbury Park, Sage Publications 1992:275-295. 8. Kapur M. Mental Health in Indian Schools. Sage Publications New Delhi 1997. 9. Bharath S., Kumar KVK., Mukesh YP (2007) School Mental Health Program – Clinical Guidelines in Avasthi A., Shiv Gautam (eds) Task Force on Clinical Practice Guidelines for Psychiatrists in India (Child and Geriatric Psychiatry) Chandigarh, IPS publication 10. Bharath S., Kumar KVK, Vrunda MN . Activity Manuals for Teachers on Health Promotion using Life Skills Approach (3 modules – 8th, 9th 10th) NIMHANS- WHO (SEARO) Collaboration 2002, 2005. 11. Bharath S, Kishore Kumar KV. Health Promotion using Life Skills Approach for Adolescents in Schools – Development of a Model. J Indian Assoc Child Adolesc Ment. Health 2008;4 (1): 5-11. 12. Bharath S, Kishore Kumar KV. Empowering adolescents with life skills education – School mental health program. Does it work? Indian J Psychiatry 2010;52 (4) 344 -349.

Srikala Bharath Professor of Psychiatry NIMHANS , Bangalore [email protected]

K.V. Kishore Kumar Senior Psychiatrist NIMHANS, Bangalore

24 Practicing Sexual Medicine - A primer for trainees

T.S. Sathyanarayana Rao

ABSTRACT

The Practice of sexual medicine has undergone tremendous changes in the last two decades. Even though there are attempts to remove myths and misconceptions in the society, socially problems exist because of many cultural aspects related to our country. The branch of sexual medicine is one of the most neglected area both by the profession and the society and for the same reason many unscientific practices prevail which are exploited by quacks. The need for training in psychiatry and more specifically sexual medicine at undergraduate and postgraduate level is well recognized and attempts are made to rectify the same. This article makes an attempt to sensitize both the students and the professionals to the emerging field of sexual medicine.

Keywords: Training in sexual medicine, Emerging field of sexuality, Sexual medicine, quacks.

INTRODUCTION

It is well accepted that the sexuality is an important component of physical, intellectual, psychological and social wellbeing of all the individuals. The “sex” is very commonly used to refer to the genital organs and the activities concerned which are primarily physical. In our country, still more commonly, it concerns the production of offspring. However, we must understand that it involves much more than procreation or reproduction. It is only one of the aspects of sex. The term “sexuality” is used in much broader sense and involves an individual's entire personality. It involves identification of a person with a gender-being male or female, identification - being masculine or feminine, of feelings, attitudes and behaviors that are appropriate for that sex. It is also about relationships, of how he/she will influence or be influenced by everyone with whom he/she comes into contact socially. In 214 Psychiatry in India : Training & training centres brief, sexuality refers to the entire person1. The biology - anatomy and physiology of reproduction and the psychology of sexual behavior have made us realize that individual's sexuality results from many factors and conditions that act at different times in one’s life time and these factors involve both the genetics and the environment. Constitutional factors and early upbringing are very important even in understanding the current situation. In brief, sexuality is a bio-psycho - social (multi-factorial) phenomenon.

Now it is clear that sexuality is a vast subject covering many feels of study and the genitality with which it is confused is only a small part of it. However there is a lack of agreement on what constitutes “normal”, “healthy”, “adequate” or “functional” sexual behavior. To overcome this difficulty in definition, clinicians have tried to adopt a patient - centered approach. Accordingly, a sexual problem exists when an individual presents a complaint about one or more behavioral, affective or cognitive problem in sexual relationship or functioning. Unless specified otherwise, sexual inadequacy refers to sexual dysfunction by which Masters and Johnson in 1970 implied some specific disruption of the “Sexual Response Cycle”. In both men and women it encompasses desire/appetite - excitement or arousal - plateau - orgasm and resolution phases. Sexual inadequacies need to be differentiated from gender identity disorders and paraphilias2.

The Practice of Sexual Medicine:

The Practice of sexual medicine has undergone tremendous changes in the last two decides or so with educators, counselors, therapists and scientists contributing significantly in removing illiteracy regarding human sexuality and by providing knowledge about the sexual behavior and biology of men and women from the womb to tomb3. With this progress it is possible to help both the individuals and distressed couples and make it possible to prevent sexual deficiencies and deviations.

Sexual expression is culturally determined and learned on the basis of innate individual drives. A proper relationship can be attained with commitment, effort, compromise, trust and faith. The conceptualization of human sexuality as a simple phenomenon is impossible and too simplistic a thought to be practical. Many theories abound and they are wrapped with myths, misconceptions and misdirection compounding the problem.

Helping patients who have sexual difficulties or dysfunctions does not demand more time or knowledge than an average physician or counselor can provide. However, it is commonly seen that some physicians are embarrassed in taking the sexual history with a view that it might cause embarrassment – actually it is the embarrassment of the physician! Workshops and brief clinical trainings are enough to provide the opportunity to learn what is left Rao: Practicing Sexual Medicine - A primer for trainees 215 out in the medical college. Spending enough time with the patients and partners is absolutely essential. A detailed medical history relevant to the sexual problems must be obtained from the patient and his or her partner. It is just not sufficient that a courtesy questioning will solve the problem, which infact is the case in the medical history proformas. It is necessary to remember that many mysterious symptoms may be related to individual / couple's sexual problems. Indian Psychiatry society has deliberated on this issue and a new speciality section has come into being. Indian Journal of Psychiatry (IJP) carried a stock taking article as an editorial titled 'Road Map for sexual medicine: Agenda for Indian Psychiatric Society' in its 2008 issue4. The pertinent parts emphasizing sexuality training for trainees is an eye opener and is reproduced here for its importance:

“To further the science of sexual medicine, it is most crucial that the trainee psychiatrists are amply exposed to clinical experience in the field. Supervised training in thorough case work up and management of patients attending psychosexual clinics should be mandatory. Manuals as the one mentioned before would come as an aid to the trainee doctors. Basic training in sexual medicine at the undergraduate level which is completely lacking needs to be introduced. Regular Continuing Medical Education programmes, seminars and discussions in the fraternity would provide the required momentum. In the long run, as steps to further the science of sexual medicine shall be taken, involving the community through sex education and such other programmes would be inevitable”.

In this direction, IPS has brought out the clinical practice guidelines on “Sexual Dysfunctions” for the use of all the members and practitioners. The spirit behind sexuality and sexuality practice are enunciated in very clear terms in the Valencia declaration on sexual rights by the World Association of Sexology in 1999 (Appendix I).

HOW TO ACHIEVE TRAINING & CONTINUED CAREER DEVELOPMENT

As trainees, there are many ways to acquire and further your knowledge in sexual medicine both in health and dysfunctions. Honing your clinical skills involves first and foremost your interest, initiative and willingness to excel.

The suggested methodologies for students – in – training are5: 1. Finding a mentor: The first advice that can be provided is to identify a senior level professional in your discipline with an interest in human sexuality. Please ask him to serve as your mentor. He can help you develop efficiently and effectively by providing ongoing research and clinical 216 Psychiatry in India : Training & training centres supervision. He can help you with the recent developments in theory and practice. He would be your role model in the long run to learn. 2. Take didactic courses Regardless of whether or not you will get a mentor, you should proceed by taking up didactic courses related to human sexuality. To have a holistic and comprehensive coverage it is ideal not to restrict your courses to your academic discipline alone. For a psychiatry trainee departments of clinical psychology, social work, nursing etc. are going to be of use. In the medical college, branches like psychiatry, endocrinology, urology, gynaecology can be synergistically combined to study. The basic sciences like Anatomy, Physiology, Biochemistry, endocrinology are important and can be good foundations for scientific understanding. 3. Get Clinical training & experience Internship, extended postings in the speciality sections, clerkship, residency programmes are all helpful. CMEs, symposias and workshops are coming up regularly even in India, and one must make use of them. 4. Getting involved in research The Job becomes easy if you are part of a major research centre, university or an academic centre. You need to search out opportunities to get involved in research. It is also possible that well known and internationally recognized scientists and institutes welcome volunteers and junior colleagues. Being involved in research helps you present your findings in various forum - both at national and international levels.

Suggested Methodology for the professional

Once qualified, you have much more chance to get involved with the sexuality practice, either privately or in an academic / research institution. Wincze & Carey5 suggest certain ideas which are helpful. 1. Read the classics This is the least restrictive approach for self initiated development. They provide both the overview and specialty aspects. 2. Reading professional journals To update on the developments in theory and practice. Rao: Practicing Sexual Medicine - A primer for trainees 217 3. Join professional organizations devoted to sexuality In the Indian context one which is active and very professional is “Council on Sex Education and Parenthood International” head quartered at Mumbai. Family Planning Association, India has SECRT (Sex education, counseling, research and training) centers all over India meeting client and professional needs. Internationally many organizations are doing the yeomen service in this field:

1. American Association of Sex Educators Counselors & Therapists (AASECT) 2. Society for Scientific Study of Sexuality (SSSS) 3. International Academy of Sex Researchers (IASR) 4. Society for Sex Therapy & Research (STAR) 5. One can have membership of World Association of Sexology and Asia – Oceania Federation of Sexology among others.

4. Seek postdoctoral training

Though many western, specifically USA, offer many such programmes. In India it is still at a nascent stage and evolving.

STARTING SEX THERAPY PRACTICE A. Certification: To the best of our knowledge, it is still non-existent in India. Kuvempu University, Amity University etc. provide varied nature of programmes but the selection of candidates, only part time in - house training and not so formal evaluations are the draw backs. As it stands today those who call themselves “Sex therapists” and who claim to be certified are those who are qualified in a core discipline such as psychology, social work, medicine, specifically psychiatry, nursing etc. As a result of absence of proper state licensing or certification, it is possible for any one to claim himself or herself as sex therapist without any credentials, expertise or training. Many quacks are thriving in our country who are not even remotely related to medicine or allied branches for this very simple reason. It is our responsibility to bestow attention to learn and practice sexual medicine scientifically to help people in distress with sexual concerns and problems. 218 Psychiatry in India : Training & training centres B. Recruitment of clients for practice Many strategies like seeking referrals, telephone listing etc have been suggested. But there is no alternative, like any practice, the best bet for 'advertising' is the satisfied client, who will enhance and enrich your practice. Networking with other professional organizations, working as a team in a multi-disciplinary setup, getting involved in teaching, training and research programmes are all very helpful. C. Insurance It is a nightmare situation in our country as even today 'mental illnesses' are not gives benefit of insurance. Similar story applies to sexual problems in general. Even reimbursement from many corporations or organizations will not be forthcoming. D. Ethics of sex therapy Sex therapy caries negative connotation in the mind of public and other professionals for the esoteric, unscientific, bizarre and unethical practices published in the media like nude marathon sessions with clients, touching, hugging, kissing, sexual intercourse etc. It is for this reason that those who practice sex therapy should have an impeccable professionalism. As suggested by Wincze & Carey5 'not only should we abide by the ethical standards of our professions, but we must also avoid even the appearance of impropriety'. It is advised to avoid sexual intimacies with clients and observe professional boundaries at work. A power differential exists as clients are in a vulnerable position and have a psychological dependence. Hence a possibility of sexual victimization exists. There are innumerable possibilities of transference and counter transference to occur. Since many may have the history of sexual abuse, possibility of revictimization has been emphasized.

CONCLUSION:

Rao and Avasthi4 in their editorial conclude and to quote them:

“Sexual health has twin facets- physical and mental. But the individual patient is torn between the various specialties, i.e. urology, neurology and psychiatry. It is time that with the development of sexual medicine, the psychiatrist acts as the coordinator. He should take up the responsibility of integrating the various fields and offer comprehensive services in the field of sexual health and medicine. One way of achieving this goal would be to establish multispeciality sexual clinics, affiliated to teaching institutions with Rao: Practicing Sexual Medicine - A primer for trainees 219 comprehensive liaison activities”.

Appendix I

DECLARTION OF SEXUAL RIGHTS

Sexuality is an integral part of the personality of every human being. Its full development depends upon the satisfaction of basic human needs such as the desire for contact, intimacy, emotional expression, pleasure, tenderness and love. Sexuality is constructed through the interaction between the individual and social structures. Full development of sexuality is essential for individual, interpersonal and societal well-being. Sexual rights are universal human rights based on the inherent freedom, dignity and the equality of all human beings. Since health is a fundamental human right, so must sexual health be a basic human right. In order to assure that human beings and societies develop healthy sexuality, the following sexual rights must be recognized, prompted, respected, and defended by all societies through all means. Sexual health is the result of an environment that recognizes, respects and exercises these sexual rights:

1. The right to sexual freedom. Sexual freedom encompasses the possibility for individuals to express their full sexual potential. However, this excludes all forms of sexual coercion, exploitation, and abuse at any time and situations in life. 2. The right to sexual autonomy, sexual integrity and safety of the sexual body. This right involves the ability to make autonomous decisions about one's sexual life within a context of one's own personal and social ethics. It also encompasses control and enjoyment of our own bodies free from torture, mutilation and violence of any sort. 3. The right to sexual privacy. This involves the right for individual decisions and behaviors about intimacy as long as they do not intrude on the sexual rights of others. 4. The right to sexual equity. This refers to freedom from all forms of discrimination regardless of sex, gender, sexual orientation, age, race, social class, religion, or physical and emotional disability. 5. The right to sexual pleasure. Sexual pleasure, including autoeroticism, is a source of physical, psychological, intellectual and spiritual well being. 6. The right to emotional sexual expression. Sexual expression is more than erotic pleasure or sexual acts. Individuals have a right to express their sexuality through communication, touch, emotional expression 220 Psychiatry in India : Training & training centres and love. 7. The right to sexually associate freely. This means the possibility to marry or not. To divorce, and to establish other types of responsible sexual associations. 8. The right to make free and responsible reproductive choices. This encompasses the right to decide whether or not to have children, the number and spacing of children, and the right to full access to the means of fertility regulation. 9. The right to sexual information based upon scientific inquiry. This right implies that sexual information should be generated through the process of unencumbered and yet scientifically ethical inquiry, and disseminated appropriate ways at all societal levels. 10. The right to comprehensive sexuality education. This is a lifelong process from birth through out the life cycle and should involve all social institutions. 11. The right to sexual health care. Sexual health care should be available for prevention and treatment of all sexual concerns, problems and disorders.

SEXUAL RIGHTS ARE FUNDAMENTAL AND UNIVERSAL HUMAN RIGHTS World Association for Sexology, Valencia 1999.

REFERENCES:

1. Steen, E.B & Price J.H (1998) Human Sex & Sexuality. Dover Publication Inc. New York. 2. TSS Rao (2004) Emerging Frontiers of Psychiatry. Sexuality Practice in the Indian context ANCIPS 2004 Souvenir, Mysore, India 3. Prakash Kothari (2000) A conceptual model for Human sexuality. Souvenir, KANCIPS 2000, Mysore, India 4. Sathyanarayana Rao TS, Avasthi A 'Road Map for sexual medicine: Agenda for Indian Psychiatric Society. Indian Journal of Psychiatry 2008: 50: 153 – 4. 5. John P Wincze & Michael P Carey (1991) Sexual Dysfunction. A guide to assessment & treatment. The Guilford press. New York.

T.S. Sathyanarayana Rao Prof. & Formerly Head, Department of Psychiatry, JSS University, JSS Medical College Hospital M.G. Road, Mysuru - 570004. [email protected], 25 Sexuality training in the West and its relevance to India

Gurvinder Kalra

ABSTRACT

The Kamasutra discussed a variety of topics such as the types of sexual congress, varieties of aphrodisiacs and even courtesans. It was used in the ancient times to teach people about sexuality; even today people refer to it as an important work on sexuality. Sexuality education is a fundamental topic but hardly finds adequate representation in any undergraduate and postgraduate teaching programs, at least in India. The present article focuses on sexuality training in the West and how it relates to India and outlines the implications for translating sexuality research into training. It is important that we as part of the faculty take initiatives at our own individual levels with the aim of encouraging the development of positive responsible attitudes to human sexuality.

Keywords: sexuality training, sex education, postgraduate, undergraduate, West

INTRODUCTION Vatsyayana’s Kamasutram, generally known to the Western world as Kama- Sutra, is an ancient Indian text consisting of teachings about sex and sexuality. With thirty-six chapters in sixty-four sections, the Kamasutra has been argued to be a work of dramatic fiction and a play about sex,1 featuring the Nayak (male character) and the Nayika (female character) in seven different acts. It has been translated into many other languages the world over and has been used to train and teach people the different aspects of sexuality. It is one of the most explicit works that is revered and admired deeply till date the world over. However this age-old treatise which may have served as an important reference work and training material in those times does not seem to be of much use for the latter purposes today in its own country of origin. Most trainees especially in India currently receive inadequate, non-standardized, informal and insufficiently organized training in sexuality. In this article, the 222 Psychiatry in India : Training & training centres author takes a look at training in sexualities in the West and compares it with that of India pointing the areas that we need to work upon and the need to come up with training modules in sexuality training suited to the Indian culture. Sexuality training: The Need Sex is an integral part of human life. In health, it has the potential to foster intimacy and promote bonding between the individuals involved, and also to create new life in case of heterosexual relationships. In un-health, it can lead to many negative consequences having life time implications on the individuals involved. A well known fact that all are aware of is ,that the physical and mental health affect each other to a large extent.2 One cannot ignore the role of sexual health in this binary notation, giving rise to a tripartite relationship between the three (figure 1). One can argue that sexual health is a part of both mental and physical health; however, this can be looked at from another perspective. Sexual health can be considered as having physical and mental components and being distinct enough to influence either physical or mental health on its own. The definition of these individual terminologies is a tough nut to crack.

Figure 1: Interrelationship of physical, mental and sexual health. For instance, sexual health has been repeatedly defined by the World Health Organization (WHO) almost four times from 1975 to 2002, still leaving space for criticisms from various groups. A simplistic and concise yet complete definition of sexual health given by Greenhouse is: sexual health is the enjoyment of sexual activity of one’s choice, without causing or suffering physical or mental harm.3,4 This definition provides the widest possible interpretation of the term ‘enjoyment’, without specifying the type of sexual relationship- heterosexual, homosexual or even, monogamous or polygamous to that extent? Kalra: Sexuality training in the West and India 223 In a country like India which has a pluralistic medical system, it goes without saying that even today most of the patients with sexual dysfunction that a clinician sees in clinical practice do not come directly. A large number of them seem to climb a ladder of ‘sexperts’ before consulting a formal expert (figure 2), making the help-seeking process long and more complicated. This pathway to help-seeking in sexual dysfunction may be true in cases from rural background and not necessarily in those from an urban setup, who in addition to these sources may resort to dailies, magazines, television or the internet for seeking help. A majority of individuals with sexual problem either remain silent about it or usually talk to their peers in order to seek help.

Figure 2: Pathway to help-seeking in a case of sexual dysfunction in the Indian setup

The patient’s peer group, although at a grass root level, appears to be the most significant link in this pathway shaping the patient’s cognitions of sexual functioning to an extent that it may be difficult to change these earlier cognitions once the patient comes higher up in the help-seeking process. In an unpublished study by Kalra and Kamath (2009),5 the main source of sex knowledge for 69% of their subjects was the peer group, who may be as ignorant as the patient himself. The next in help seeking could either be a local general practitioner or practitioners in Ayurveda, homeopathy, or Unani, the local pharmacist and in most cases, the local roadside hakeems who have been getting the art of treating sexual dysfunctions from their grand-families, the so called quacks specializing in age-old and traditional modalities of 224 Psychiatry in India : Training & training centres treatment. On reaching the professionals higher up in this hierarchy, many patients may have already spent huge amount of their earnings on the so called hakeems and suffer from some or the other psychiatric morbidity. It is thus clear how sexual function and hence sexual health can get affected by a lack of sexual knowledge and ignorance, doing more psychological harm. In this scenario, Greenhouse’ definition of sexual health3,4 cannot hold true leaving us with sexual ‘un’health. If one wants to achieve sexual health for people, it is important that this sexual ignorance is dealt with at every step in the pathway to help-seeking. Intervention at the grass-root level i.e. the peer group may involve sex-education in schools and other places; however targeting at the attic level i.e. the sexologists and psychiatrists may involve formally training them to deal with various aspects of sexual health. These groups of professionals can then help in educating the various intermediaries down in the help-seeking pathway. An important point that needs to be highlighted at this stage is how the patients may feel about their treating physicians being reluctant, disinterested, or unskilled in sexual problem discussion and management.6,7 Researchers have also demonstrated how many resident trainees feel uncomfortable and embarrassed discussing sexual issues with their patients.8,9 These and certain other factors work negatively in the sexuality- consultation dyad (figure 3). To make positive improvements in this dyad, one needs to work upon the consultant side of the relationship, improving their knowledge base, which can then influence the patient attitudes towards them positively.

Figure 3: The Sexuality-consultation dyad

After their training, the resident trainees are expected to practice in the community either in the public or private sector; one can then imagine the Kalra: Sexuality training in the West and India 225 plight of sexually dysfunctional patient who goes for consultation to such practitioners. It is also important to understand the effect that the advent of newer drugs like phosphodiesterase-5 inhibitors and dapoxetine has had on the sexual medicine practice. With the ever-increasing quest of patients for a solution at the click of a mouse, time constraints for comprehensive consultations, increasing reliability on psychopharmacology, the skills of important therapies like couple therapy seem to be slowly dwindling away. Hence the need for a formal sexuality training program arises. The umbrella term sexuality in this article refers to how people experience and express themselves as sexual beings, their sexual function, fantasy, orientation, behavior, activity, socio-cultural and moral-ethical, and spiritual aspects. It is not sufficient to train the resident trainees in the management of sexual dysfunction, when there is so much more to the sexual lives of patients that needs further exploration. The West Even as one may think the opposite, training in human sexuality in the International arena is still evolving across many clinical disciplines; however sadly the number of available courses is limited,10 keeping sexual health and sexuality a largely neglected discipline.6 Morreale and Balon (2010)11 provide a not-so-encouraging image of sexuality training programs in the U.S. medical schools; fewer than half of which have formal sexual health curriculum.12 A similar picture emerges in the U.K. undergraduate medical education where minimum hours are dedicated solely to sexual health education.10 In one survey of U.S. resident trainees from various specialties, 66% had no previous formal education in sexual health management, and only 48% were satisfied with the teaching they received on the subject.13 Sadly, less than 50% of US and Canadian medical schools spend more than 2 hours on sexual health,9,14 while only 43% of North American medical schools offer clinical exposure to the management of sexual dysfunction in detail.15 A multidisciplinary team was involved in sexuality training in almost 63.4% medical schools.15 Many a programs on human sexuality have been described consisting of seminars focused on human sexual response, sexual myths, sexual history taking; ongoing teaching consisting of case discussion, consultation, and joint interviews.16 Sansone and Wiederman (2000),17 in a national survey of around 69 training directors of psychiatry residency programs, found that a majority of them had expert faculty in sexual dysfunctions, sex therapy, and therapy with gay/lesbian patients, and HIV/AIDS patients; and that, for each of these sexuality topics, approximately 80% of programs reported curricula offerings through either didactics or clinical rotations. There have been a number of suggestions on how to integrate human sexuality education into psychiatric residency education, from Levine and Scott (2010)18 suggesting “vertical integration” (addressing sexual health in 226 Psychiatry in India : Training & training centres every year and every rotation of the residency program) to Green (2010)19 who suggests trans-inclusive sexuality education and provides strategies for implementing the same. India While India seems to have been the land of the Kamasutra, with time the importance of sexuality teachings have taken a backseat to the point that today one hardly finds a trace of formal training in any of the institutes across the country. One may come across many sexologists providing short term sexuality training modules; their credibility however remains questionable. Various researchers and academicians across the country have time and again talked about the need for research in sexuality;20,21,22,23,24 however, few have expressed their concerns over translating this research into training. Sexuality has been a highly neglected area of medical training in India,25 be it undergraduate or post-graduate. An average Indian student who opts for medicine as a career enters medical school by late adolescence or in early 20s. Barring a few, the sexual knowledge of these young students is questionable, especially when this knowledge comes from unreliable sources like the peer groups, internet, pornographic material, magazines etc. In medical school the subject of sexuality is dealt with in a more anatomical and physiological way, ignoring the sexual, sensual, and psychological aspects. As a result of this by the end of their training in medical schools, the students may be well equipped for dealing with different infectious diseases, but would hardly be able to answer a simple query raised by a curious neighbor on sexual issues. Evidence has been provided for the need to improve knowledge about different aspects of sex among a sample of Indian medical students.26,27 Even postgraduate medical students in a tertiary care teaching hospital were found deficient in their sex knowledge and harbored undesirable attitudes.28 In post-graduate courses, dermatology deals with the disease aspect of sexual health i.e. the sexually transmitted diseases; the only subject that remains then, is psychiatry. Nevertheless, psychiatry training too confines itself to teaching sexual dysfunction as per DSM IV TR and ICD 10 classificatory systems. The question that arises hence is where does normal sexuality go? Have we not westernized our own training systems as far as sexuality training is concerned, killing our own Sutras for the international classificatory systems! An online search of the word ‘sexuality’ on the Indian Psychiatry Journal website could fetch only 23 results with a majority of them being review articles and hardly any research paper on sexuality. This could mean two things: there is a dearth of sexuality based research in the country, or whatever meager amount of research is being done gets published in International journals. However modifying the word to ‘sexual’ revealed around 130 results, quite a good number of which were research studies done Kalra: Sexuality training in the West and India 227 on sexual behavior and dysfunction in diverse populations.29,30,31,32 Interestingly, the author also came across some research work on old-age sexuality in two non-mainstream psychiatric journals.33,34 Andrade (2005)35 argued that surveys of sexual dysfunction have not been done in India as much as in other countries and citing varied reasons from stress factors in urban India to the un-attractive dress of the average middle-class Indian woman leading to increased sexual dysfunction, he pointed out the need of systematically studying sexual dysfunction in the Indian context. However, with times fast changing, it is important that we also make efforts to translate research into teaching modules and start with whatever we have at hand. The Road Ahead Having seen what the scene in the West has to offer, the road ahead does not seem to be too difficult to travel. Along the lines of suggestions made by Levine and Scott (2010)18 curricular efforts do not require a sexuality expert. A small initiative taken by the existent faculty in developing their institution’s initial approach is good enough and will inevitably evolve towards greater comprehensiveness with time. The author successfully uses films to teach various aspects of sexuality to the psychiatry resident trainees in the department. Each module consists of an introduction to a topic and viewing of the film in the department, followed by a discussion and teaching of the sexuality specific issue portrayed in the film. Dunn and Abulu (2010)36 argue that psychiatrists with additional training in sexuality may be particularly adept in educating other specialty personnel about sexuality, due to various factors like being able to pick up subtle emotional cues and understanding the importance of interpersonal relationships giving rise to or resulting from sexual problems. However for that to happen, the psychiatrists themselves must be well aware of sexuality issues. The level of comfort and skill needed to discuss sexuality with patients trickles down from the senior to the junior through observation, which makes it important for the seniors to be comfortable in dealing with sexuality cases themselves. One need not limit oneself to studying dysfunctional sexuality. Knowledge about alternate (lesbian, gay, bisexual, transgender, intersex i.e. LGBTI) and abnormal sexuality, which may include various paraphilias is as important as knowing about normal sexualities and sexual dysfunction. With the sexual atmosphere of the nation changing rapidly due to changing laws, it is important that we look at the non-heteronormative stance at different sexualities and learn and teach about them. Kalra and Bhugra (2010)37 propose that with increasing globalization and migration the world over, sexualities may evolve and change leading to multi-sexualism in multi-cultural societies. It goes without saying that India as a nation is currently seeing national as well as international migration in search of better career or educational opportunities, a phenomenon that will in the long run surely give 228 Psychiatry in India : Training & training centres rise to more number of sexualities as it will also to sexual risks and problems. It is possible that clinicians including psychiatrists, sexologists, and general practitioners, will come across complex clinical situations and problems involving people’s sexualities. In the absence of an organized and structured curriculum to teach sexualities to these professionals, it would become increasingly difficult for them to help the distressed individuals.

Table 1: Sexuality training curriculum: a proposed content outline Introduction - to various terms, anatomy and physiology (an overview), some culturally used terms. Cross-cultural issues in sexuality - history taking. - interviewing techniques, cultural differences in approach to sexual topics in Indian patients. Heteronormative sexuality - may include geriatric sexuality issues. Alternate sexuality - may include homosexuality, transsexuality, bisexuality and other queer sexualities. - Should include coming out, relationships, ageing issues in this population. Child and adolescent sexuality - may include topics like talking to children or adolescents about sex, how to answer their questions on sex, peer pressure, parents teaching children about good touch-bad touch. Pathological sexuality - includes all the paraphilias. Sexual dysfunction - may include the diagnostic classificatory systems, etiology, presentation, systematic approach to a sexual dysfunction patient, management issues. Sensual sex - may include details of sexual positions, use of sex-toys and other means and accessories for sexual pleasure enhancement. Miscellany - sexual trauma and abuse. - sexual problems in various medical and surgical illnesses. The need for an integrated approach to sexuality training is not something that has emerged overnight, but one that has been obvious to a few clinicians Kalra: Sexuality training in the West and India 229 and educators.27 Developing systematic training modules covering normal, pathological and alternate sexuality is the need of the hour; a proposed outline of such training module being used by the author is presented in table 1. The author proposes that heteronormative and alternate sexuality should be covered separately in the training modules, as the dynamics in these relationships are totally different and should not be muddled up. However including non-heteronormative sexualities in the training program is a very sensitive and challenging issue; these sexualities being looked down upon as aberrations of normal human sexual response. At this point, we as psychiatrists are definitely in a position to contribute to positive social change by including these rapidly evolving sexual subcultures in the training programs. It is also important that we revive the details of Kamasutra back into these training modules including various sexual positions during intercourse, knowledge about aphrodisiacs mentioned in Ayurveda etc. The modules should also touch upon topics that may be of cultural significance like interviewing and questioning techniques, which may differ from the Western techniques. There has to be more clarity on dealing with children and adolescent questions related to sexuality and single males who come with sexual dysfunction; either they are unmarried or their spouses are not ready to come for therapy, a scenario which is quite common in the Indian settings. Efforts are on by various organizations like the Council for Sex Education and Parenthood International (C-SEPI) to include sexuality training into the mainstream medical courses and to start specialized training Fellowship programs within the country. It would provide a good opportunity to those interested in pursuing a career in sex medicine, who would have to otherwise go abroad for such courses. However such major change in the medical curricula takes its own time and needs major policy shift. The Indian Psychiatric Society should take an initiative in persuading the policy makers and other players in position to help start such courses in the country. The main goal of the sexuality training program would be to sensitize the medical professionals to sexuality issues and make them comfortable with such issues both professionally and personally, equipping them to take an initiative themselves in effectively dealing with sexual problems and issues with a level of comfort. REFERENCES 1. Vatsyayana M, Doniger W, Kakar S. Kamasutra. Oxford World’s Classics. Illustrated edition. Oxford University Press, 2003;xxv-xxvi. [ISBN: 0192839829]. 2. Kalra G, Natarajan P, Bhugra D. Migration and physical illnesses. In, Bhugra D, Gupta S (eds). Migration and mental health, 1st edition, New York, Cambridge University Press, 2011;299-312. [ISBN: 978-0-521-19077-0]. 3. Greenhouse P. A sexual health service under one roof. In, Pillaye J (ed). Sexual health promotion in genitourinary medicine clinics. London, Health Education Authority, 1994. 230 Psychiatry in India : Training & training centres

4. Greenhouse P. A definition of sexual health. BMJ 1995;310(6992):1468-9. [PMID: 7613294]. 5. Kalra G, Kamath R. Psychosocial profile of male patients presenting with sexual dysfunction. Unpublished MD dissertation 2009, Maharashtra University of Health Sciences, Nashik. 6. Parish SJ, Clayton AH. Sexual medicine education: review and commentary. J Sex Med 2007;4(2):259-67. [PMID: 17367420]. 7. Balon R, Morreale M. What has happened to teaching human sexuality in psychiatric training programs? Acad Psychiatry 2010;34:325-7. [PMID: 20833898]. 8. Sciolla A, Ziajko L, Salguero M. Sexual health competence of international medical graduate psychiatric residents in the United States. Acad Psychiatry 2010;34(5):361-8. [PMID: 20833907]. 9. Rosen R, Kountz D, Post-Zwicker T, Leiblum S, Wiegel M. Sexual communication skills in residency training: the Robert Wood Johnson model. J Sex Med 2006;3(1):37-46. [PMID: 16409216]. 10. Wylie K, Weerakoon P. International perspective on teaching human sexuality. Acad Psychiatry 2010;34:397-402. [PMID: 20833914]. 11. Morreale MK, Balon R. Lessons learned: what is happening to human sexuality education within psychiatry? Acad Psychiatry 2010;34(5):403-4. [PMID: 20833915]. 12. Malhotra S, Khurshid A, Hendriks KA, Mann JR. Medical school sexual health curriculum and training in the United States. J Natl Med Assoc 2008;100(9):1097-106. [PMID: 18807442]. 13. Morreale MK, Arfken CL, Balon R. Survey of sexual education among residents from different specialties. Acad Psychiatry 2010;34(5):346-8. [PMID: 20833903]. 14. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA 1999;281(6):537-44. [PMID: 10022110]. 15. Solursh DS, Ernst JL, Lewis RW, et al. The human sexuality education of physicians in North American medical schools. Int J Impotence Res 2003;15 Suppl 5:S41-5. [PMID: 14551576]. 16. Steinert Y, Levitt R. The teaching of human sexuality in a family medicine training program. J Fam Pract 1978;7(5):993-7. [PMID: 722272]. 17. Sansone RA, Wiederman MW. Sexuality training for psychiatry residents: a national survey of training directors. J Sex Marital Ther 2000;26(3):249-56. [PMID: 10929573]. 18. Levine SB, Scott DL. Sexual education for psychiatric residents. Acad Psychiatry 2010;34(5):349-52. [PMID: 20833904]. 19. Green ER. Shifting paradigms: moving beyond “Trans 101” in sexuality education. American Journal of Sexuality Education 2010;5:1-16. [doi: 10.1080/ 15546121003748798]. 20. Somasundaram O. Sexuality in Thirukural: the great Tamil book of Ethics. Indian J Psychiatry 1986;28(1):83-5. 21. Somasundaram O. Sexuality in the Kama Sutra of Vatsyayana. Indian J Psychiatry 1986;28(2):103-8. 22. Asha MR, Hithamani G, Rashmi R, Basavaraj KH, Rao KSJ, Rao TSS. History, mystery and chemistry of eroticism: emphasis on sexual health and dysfunction. Indian J Psychiatry 2009;51(2):141-9. [PMID: 19823636]. 23. Prakash O, Rao TSS. Sexuality research in India: an update. Indian J Psychiatry 2010;52(7):S260-3. [doi: 10.4103/0019-5545.69243]. 24. Kalra G, Gupta S, Bhugra D. Sexual variation in India: a view from the West. Indian J Psychiatry 2010;52(7):S264-8. [doi: 10.4103/0019-5545.69244]. 25. Rao TSS. Some thoughts on sexualities and research in India. Indian J Psychiatry Kalra: Sexuality training in the West and India 231 2004;46:3-4. 26. Aggarwal O, Sharma AK. Study in sexuality of medical college students in India. Chabra P J Adolesc Health 2000;26:226-9. 27. Sathyanarayana Rao TS, Avasthi A. Roadmap for sexual medicine: Agenda for Indian Psychiatric Society. Indian J Psychiatry 2008;50(3):153-4. [PMID: 19742236]. 28. Singh RA, Malhotra S, Avasthi A, et al. Sexual knowledge and attitude of medical and non-medical students. Indian Journal of Social Psychiatry 1987;3:126-36. 29. Bagadia VN, Dave KP, Pradhan PV, Shah LP. A study of 258 male patients with sexual problems. Indian J Psychiatry 1972;14(2):143-51. 30. Banerjee G, Dutta AK, Nandi DN, Banerjee G, Sen B. A study of psychiatric morbidity in married males with sexual dysfunction. Indian J Psychiatry 1987;29(2):139-141. 31. Agarwal AK, Kaur B, Kumar S. Sexual behavior in a group of urban females. Indian J Psychiatry 1992;34(3):236-4. 32. Gautam S, Batra L. Sexual behavior and dysfunction in divorce seeking couples. Indian J Psychiatry 1996;38(2):109-16. 33. Sanger KS, Singh PK, Prakash J, Singh A, Chaudhury S, Sharma DK, Chakraborty PK. Aging and sexuality- a study of sexual behavior of elderly males. Industrial Psychiatry Journal 2007;16(1):42-44. 34. Bammidi S. Understanding sexuality in the later years. Indian Journal of Gerontology 2009;23(1):88-99. 35. Andrade C. Sexual dysfunction in India. Indian J Psychiatry 2005;47(3):181. [PMID: 20814466]. 36. Dunn ME, Abulu J. Psychiatrists’ role in teaching human sexuality to other medical specialties. Acad Psychiatry 2010;34(5):381-5. [PMID: 20833911]. 37. Kalra G, Bhugra D. Migration and sexuality. Int J Cult Ment Health 2010;3(2):117-25. [doi: 10.1080/17542863.2010.498573].

Gurvinder Kalra Northern CCU, North-Western Mental Health Preston, Melbourne, Victoria 3072, Australia [email protected]

26 Forensic Psychiatry: Overview and Relevance in Post Graduate Training

S. Nambi

Forensic psychiatry is a clinical subspeciality within the medical speciality- psychiatry. The subject is concerned with area where psychiatry and the law meet. It overlaps interfaces and interacts with psychiatry and law in all aspects. Law is the sanctioning discipline and psychiatry is the therapeutic discipline.

Forensic psychiatry is firmly rooted in the medical science of psychiatry, but also requires some knowledge of criminology, the law, criminal justice, and public policy, Institutional Dynamics, Ethics and Organization of services for Mentally Disordered offenders. Due to various reasons, Forensic Psychiatry was reared as Cinderella, much neglected, ignored, misinterpreted and misunderstood.

BASIC KNOWLEDGE AND SKILLS IN FORENSIC PSYCHIATRY FOR POST GRADUATES

1. ASSESSMENT:

l Assessment of behavioural abnormalities.

l Assessment of risk and dangerousness.

l Writing reports for courts and mental health review tribunals.

2. KNOWLEDGE:

l Mental health legislation and relevant criminal and civil law.

l The range of services for mentally disordered offenders and, how to use them.

l Ability to give evidence in court. 234 Psychiatry in India : Training & training centres 3. THERAPEUTIC SKILLS:

l Understanding and using security as a means of control and treatment.

l The treatment of chronic disorders, especially where behavioural problems are exhibited, such as severe psychoses and personality disorders.

l Skills in psychological treatments for behavioural disorders (Particularly psychotherapy)

Syllabus in Forensic Psychiatry for MD psychiatry course.

The syllabus can be covered under the following six headings.

I. Psycho criminology. II. Laws relating to psychiatry in India. III. Civil and criminal responsibility. IV. Ethical issues in psychiatry-Confidentiality, Competence, Consent and certification in psychiatry. V. Forensic issues in special population. VI. Rights of the mentally ill.

I. PSYCHO CRIMINOLOGY:

This chapter deals with the following concepts :-

A) Psychiatric causes of aggression and violence.

B) Characteristic of murder by mentally ill person

Homicides by people with mental illness: myth and reality.

C) Crime and psychiatric disorders

l Crime and Schizophrenia.

l Crime and Epilepsy.

l Crime and Substances use disorders

l Crime and Affective disorders.

l Crime and Personality disorders. Nambi: Forensic Psychiatry 235

l Crime and mental retardation.

II. LAWS RELATING TO PSYCHIATRY IN INDIA.

1. The care and treatment legislation (Mental health legislations).

2. Criminal responsibility formulation. (Criminal laws).

3. Civil status provisions (Civil laws).

S. Nambi Prof and HOD, Dept of psychiatry, Chettinad Hospital & Research Institute, Kelambakkam, Chennai, Formerly Prof of Psychiatry, Madras Medical College, Chennai, Past President, Indian Psychiatric Society. [email protected]

27 Relevance of Forensic Psychiatry in Postgraduate Training

Abhinav Tandon, Anil Kumar Tandon, T.S. Sathyanarayana Rao, Dushad Ram

ABSTRACT

Forensic Psychiatry is a subspeciality of psychiatry in which scientific and clinical expertise is applied to legal issues and has a long history, modified with time and experience, into its current form. The Law concerning mental health came in the form of first Lunacy Act, which was introduced in India in 1858 and amended in 1912.The Mental Health Act (MHA) of 1987 took over the Lunacy Act based on the recommendations of Colonel Taylor and Bhore Committee and implemented in 1993.Recognizing major flaws in the 1987 MHA, the Ministry of Health & Family Welfare brought out a draft of the Mental Health Care Act 2013, based on the inputs from the 5 Regional consultations and those provided by the professional bodies and other stake holders, which was passed by the Cabinet in June 2013 and is pending approval by the Parliament. Recognizing the need for a new Law for Persons with Disabilities (PwD), Ministry of Social Justice and Empowerment constituted a Committee which submitted its report in the form of “The Rights of Persons with Disabilities Bill, 2014”.In formulation of this Bill the Committee has been guided by the basic principles mentioned in Article 3 of the UNCRPD(United Nations Convention on the Rights of Persons with Disabilities).

Forensic Mental Health Assessment (FMHA) holds a very important place in forensic psychiatry in ascertaining the Civil and Criminal Responsibility of persons with mental illness and their fitness to stand trial.In India, there are many instances in which fitness to stand trial has delayed the proceedings for decades. 238 Psychiatry in India : Training & training centres History, Concept and Definition of forensic psychiatry The word 'forensic' derives from the Latin word forensis (meaning of or before the forum or court). The scope of forensic psychiatry can be broadly defined as those areas where psychiatry interacts with the law.The American board of Forensic Psychiatry definition: “Forensic Psychiatry is a subspecialty of psychiatry in which scientific and clinical expertise is applied to legal issues in legal contexts embracing civil, criminal and correctional or legislative matters ;forensic psychiatry should be practiced in accordance with guidelines and ethical principles enunciated by the profession of psychiatry” (Adopted May 20, 1985). This may include admission of a mentally ill person in a mental hospital , crime committed by a mentally ill person , validity of marriage , being a witness , will , consent, right to vote and drug dependence. It may be impossible to find the earliest expert witness, but literature records that Antisius examined the corpse of Julius Caesar and opined that only the thoracic sword thrust was fatal; the other 22 stab wounds were not. The concept of Criminal Responsibility has its roots in the Babylonian legal system, known as the Code of Hammurabi, where the importance of intention in judging the actions of someone was evident. The Greek philosopher Plato and his student, Aristotle, described 'moral responsibility' for the crime. These approaches have endured to influence today's Psychiatric Expert Witness. In ancient India around 880 B.C., the laws gave special consideration to retarded persons and children younger than 15. The Corpus luris Civilis was compiled under Emperor Justinian in 5th century AD which mentioned an insane person as compos mentis non est (later known as non compos mentis ) with no control over his mind and cannot understand the consequences of his acts ,therefore not accountable in justice.[1] Paulus Zacchias [2], the personal physician of the pope in 17th Century is considered 'The father of Forensic Psychiatry'. Mental Health Laws The first Lunacy Act was introduced in India in 1858 with a view “to segregate those who by reasons of insanity were troublesome and dangerous to their neighbors.” The amendment to the Lunacy Act in 1912 brought the mental hospitals under the charge of Civil Surgeons instead of the Inspector General of Prison as in the earlier times. For the first time, psychiatrists were appointed and the control of such asylums handed over to the central government. Further, the names of all asylums were changed to mental hospitals in 1920. Although occupational therapy and family units were introduced, they remained primarily designed for custodial care and detention rather than treatment. The Mental Health Act (MHA) which took over the Lunacy Act [3] , was drafted Tandon et al: Forensic Psychiatry in PG Training 239 in 1987, based on the recommendations of Colonel Taylor and Bhore Committee and implemented in 1993. While there is much to commend in the new Act, merely changing the old terminology for new one, may serve as window dressing and be ineffective in making a difference. The Act fails to address the removal of social stigma , mandate medical opinion to licensing authorities of service organizations, more stress on institutionalization, lack of after discharge care and rehabilitation measures, providing for research possibilities as long as guardians' agree, lack of measures to restrict unnecessary detention by families or law agencies and adopting a different view of government and private hospitals are some of the serious limitations of the Act. [4] Furthermore, the MHA remains silent on and fails to correct the basic human rights violations of numerous earlier Acts and legislations. Some of these are; precluding the right of mentally ill individuals to marry and sanction divorce if the spouse is likely to remain mentally-ill under the Hindu and Parsi Personal Laws; Forbiddance of voting and standing for elections under the 1950 and 1951 Representation of the People Act, allowing for the subjective bias of the Property and Inheritance Rights under the Indian law to remain in force which increases the possibility that individuals recovered from mental illness will lose control of their own assets. Thus, inspite of the modern and scientific language used in the MHA, the law continues to severely curtail the civil, social and political rights of persons with Mental Illness. The Mental Health Act,1987 is divided into 10 chapters consisting of 98 sections.[4] Chapter I : Deals with the preliminaries of the act, definitions and changes made in the terminologies used in the Indian Lunacy Act, 1912. A mentally ill person here has been defined as “a person who is in need of treatment by reason of any mental disorder other than mental retardation.” Chapter II lists the procedures for establishing mental health authorities at central and state levels whereas chapter III highlights the guidelines for establishing and maintaining a psychiatric hospital or nursing home. Chapter IV briefs about the procedures for admission and detention of a mentally ill including involuntary admissions. Chapter V gives an overview with regards to inspection , discharge ,levels of absence and removal of mentally ill persons. Chapter VI gives the procedures in cases of judicial inquisition for management of property possessed by mentally ill persons. Chapter VII focuses on the maintenance of mentally ill persons in psychiatric hospitals or nursing homes . Chapter VIII protects the rights of mentally ill. Chapter IX deals with the penalties and procedures and chapter X with miscellaneous issues. Under the National Mental Health Programme ,1982, Primary Health Centres (PHCs) have been identified as the epicentre for psychiatric treatment. 240 Psychiatry in India : Training & training centres Mental Health Care Bill, 2013 : The Ministry of Health & Family Welfare has brought out the Mental Health Care bill based on the inputs from regional consultations and those provided by the professional bodies and other stake holders.[5] TITLE : MENTAL HEALTH CARE BILL (2013) Description : A bill to provide access to mental health care and services for persons with mental illness and to protect, promote and fulfill the rights of such persons during the delivery of mental health care and services and for matters connected therewith or incidental thereto. It is necessary to bring the current laws along the Convention on Rights of Persons with disabilities signed by India at United Nations head quarters, on 1st Oct. 2007. Statement of Objects and Reasons : The statement of objects and reasons are as follows:[5,6,7] Recognizing that : ü Persons with mental illness constitute a vulnerable section of society and are subject to discrimination ; the families bear disproportionate financial, emotional and social burden . ü Persons with mental illness should be treated like other persons with health problems and the environment around them should be made as conducive to facilitate recovery, and participation in society; ü The Mental Health Act, 1987 has failed to protect the rights of persons with mental illness and promote access to mental health care in the country. And in order to : ü Protect and promote the rights of persons with mental illness during the delivery of health care in institutions and in the community; ü Ensure health care, treatment and rehabilitation in the least restrictive environment possible while maintaining their rights and dignity. Community-based solutions are preferred to institutional solutions; ü Provide treatment, care and rehabilitation to develop his or her full potential and to facilitate his or her integration into community life; ü To fulfil obligations under Constitution of India and other International Conventions ratified by India; regulate the public and private mental health for greatest public health good; ü Improve accessibility to mental health care; provision of quality public mental health services and non-discrimination in health Tandon et al: Forensic Psychiatry in PG Training 241 insurance ; ü Establish a mental health care system integrated into all levels of general health care; promote active participation of all stakeholders in decision making; Mental Health Care Bill, 2013: [7] has been divided into XVI chapters and 133 clauses as follows. Arrangement of Chapters: Chapter I: Preliminary; Chapter II: Mental Illness and Capacity to make Mental Health Care and treatment decisions Chapter III: Advance Directives Chapter IV: Nominated Representative; Chapter V: Rights of Persons with Mental Illness; Chapter VI: Duties of Appropriate Government; Chapter VII: Central Mental Health Authority; Chapter VIII: State Mental Health Authority; Chapter IX: Finance, Accounts and Audit; Chapter X: Mental Health Establishments; Chapter XI: Mental Health Review Commission; Chapter XII: Admission, Treatment and Discharge; Chapter XIII: Responsibilities of Other Agencies; Chapter XIV: Restriction to Discharge Functions by Professionals not covered by profession; Chapter XV: Offences and Penalties; Chapter XVI: Miscellaneous The following are some of the important points put forward by the Mental Health Care Bill, 2013 (As introduced in Rajya Sabha). The term 'mentally ill' has been replaced with the term "person(s) with mental illness" across the entire Act. Chapter 1: Preliminary; Definitions (Sections 1 & 2): In this Act, unless the context otherwise requires : [7] “Care-giver”: a person who resides with a person with mental illness and holds responsibility for providing care; either a relative or any other person (either free or with remuneration) Family means a group of persons related by blood, adoption or marriage. Informed Consent means consent given to a specific intervention, without any force or undue influence, fraud, threat, mistake or misinterpretation and obtained after disclosing to the person adequate information including risks and benefits of, and alternatives to, the specific intervention in a language and manner understood by the person. Least Restrictive Alternative or Least Restrictive Environment or Less Restrictive Option means offering an option for treatment or a setting for treatment which meets a person's treatment needs and imposes the least restriction on a person's rights. Psychiatrist means a medical practitioner with a post-graduate degree or diploma in psychiatry awarded by any University recognized by University Grants Commission (UGC) / Medical Council of India / National Board of Examinations and includes, in relation to any State, any medical officer who, having regard to his knowledge and experience in psychiatry, has been 242 Psychiatry in India : Training & training centres declared by the Government of that State to be a psychiatrist for the purposes of this Act. Relative means any person related to the person with mental illness by blood, marriage or adoption. Prisoner with Mental Illness means a person with mental illness who is under trial or convicted of an offence and detained in a jail or prison. “Mental Health Establishment” means any health establishment (including Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy establishment) by whatever name called, either wholly or partly, meant for the care of persons with mental illness (established or maintained by the appropriate Government, trust, whether private or public, co-operative society, or any other entity or person) where persons with mental illness are admitted and reside at, or kept in, for care, treatment, convalescence and rehabilitation, either temporarily or otherwise; and includes any general hospital or general nursing home; but does not include a family residential place where a person with mental illness resides with his relatives or friends. Chapter 1 also mentions the definitions of Mental health professional, Medical Practitioner with few other definitions. “Mental health professional” means—(I) a psychiatrist as defined or(ii) a professional registered with the concerned State Authority (under section 55: registered clinical psychologists, mental health nurses and psychiatric social workers in the State as mental health professionals) (iii) a professional with Doctorate of Medicine (Ayurveda) in ‘Mano Vigyan Avum Manas Roga’ or Doctorate of Medicine (Homeopathy) in psychiatry. ü “Mental illness” means a substantial disorder of thinking, mood, perception, orientation or memory that grossly impairs judgment, behaviour, capacity to recognise reality or ability to meet the ordinary demands of life, mental conditions associated with the abuse of alcohol and drugs, but does not include mental retardation. Chapter II - Mental Illness and Capacity to make Mental Health Care and treatment decisions (Sections 3-4) Mental illness shall be determined in accordance with national/international accepted medical standards such as the latest edition of the International Classification of Disease of the World Health Organization. ü No person or authority shall state that a person has a mental illness, except for purposes directly related to the treatment or in other matters related to the Act or as required by law. ü A determination of mental illness shall in no way imply that the person lacks legal capacity or the capacity to make treatment decisions. Tandon et al: Forensic Psychiatry in PG Training 243 Section 3: Capacity to make Mental Health Care and/or Treatment Decisions : means a person has ability to understand the information relevant to the mental health care and/or treatment decision, is able to retain that information, weigh it as part of the process of decision making and communicate by any means, his or her decision.[7] Chapter III : Advance Directive (Sections 5-13) ü Every person who is not a minor has a right to make an 'Advance Directive' in writing, specifying a) the way the person wishes to be cared / treated for a mental illness and/or the way the person wishes not to be cared for; a Nominated Representative(s) may be appointed by the person. [7] ü An Advance Directive may be made by a person whether or not the person has had a mental illness, for which the person has received treatment or not. It may be invoked in case the person writing an advanced directive does not have the capacity to do so. A person in capacity, can make any changes to an earlier written advance directive. An Advance Directive shall be made in writing on a plain paper with the person's signature or thumb impression on it. The Advanced Directive shall be either registered with the State Panel of the Mental Health Review Commission in the district of residence of the person, or signed by a medical practitioner that he/she has the capacity to write the same and that it has been made of his/her own free will. There shall be no fees for registering an Advance Directive and the medical practitioner shall not charge any fees for countersigning an Advance Directive. ü If a person makes an Advance Directive which contains a refusal of all future medical treatment for mental illness, then it has to be first validated by the State Panel of the Mental Health Review Commission, following a hearing for the same. ü Medical officer in charge of a mental health establishment and/or the psychiatrist in charge of a person's treatment is duty bound to follow a valid Advance Directive. ü If a mental health professional or a relative / care-giver of the person desires to over-rule an Advance Directive during the process of treatment, they need to apply to the State Panel of the Mental Health Review Commission, which may take the appropriate decision. ü Notwithstanding any provision in this section, any Advance Directive shall not apply to emergency treatment. ü A medical practitioner or a mental health professional shall not be 244 Psychiatry in India : Training & training centres held liable for any unforeseen consequences on following a valid Advance Directive and shall not be held liable for not following it, if he or she has not been given a copy of the valid Advance Directive. Chapter IV: Nominated Representative (Sections 14-17) ü Any person who is not a minor has a right to appoint a Nominated Representative, to be made in writing on plain paper with the person's signature or thumb impression. If no such person has been nominated, a relative, care-giver or a person appointed by the State Panel of the Mental Health Review Commission shall act as a Nominated Representative. However if a person has been nominated in the advance directives he/she has priority over other nominated representatives. [7] ü A representative of registered organizations working with persons with mental illness, may temporarily undertake to perform the duties of a Nominated Representative pending appointment of a Nominated Representative by the State Panel of the Mental Health Review Commission. ü In case of minors, the legal gaurdian shall be the Nominated Representative, unless the State Panel of the Mental Health Review Commission orders otherwise. ü If no suitable individual is available for appointment as Nominated Representative, the Commission shall appoint the Director, Department of Social Welfare, or his designated representative, as the Nominated Representative for the person with mental illness. ü The person nominated to be representative must not be a minor, must be competent to fulfill the role as described in this Act, and must signify, in writing, his or her willingness to perform the role. ü The Nominated Representative has a duty to support the person, has a right to information on the diagnosis/treatment aspects, right to access family based rehabilitation services and right to be involved in discharge planning. ü The Nominated Representative has the right to apply to the State Panel of the Mental Health Review Commission on behalf of the person with mental illness for admission, discharge or violation of rights of the person with mental illness in mental health establishments. He may appoint a suitable attendant for the person with mental illness. Chapter V : Rights of Persons with Mental Illness (Sections 18-28) *Right to Access Mental Health Care Services run or funded by the Government.[8] Tandon et al: Forensic Psychiatry in PG Training 245 ü The Government shall make sufficient provision as may be necessary, for a range of services required by persons with mental illness. ü Mental health services shall be integrated into general health care services at all levels of health care including primary, secondary and tertiary care level . ü As a minimum provision, mental health services should be made available at all general hospitals which are run or funded by the Government in every district in the country and basic and emergency mental health care services shall be available at all Community Health Centers (CHC) run or funded by the Government so that no person would have to travel for long distances. ü Long term hospital based mental health treatment shall be used only in exceptional circumstances, as a last resort when appropriate community based treatment has failed. ü If minimum mental health services as outlined are not available in the district, any other mental health service in the district may be taken and the costs of treatment at such establishments in that district will be borne by the Government. ü Persons with mental illness living below the poverty line, in possession with or without the Below Poverty Line (BPL) card, or destitute or homeless are entitled to mental health services free of any charge. ü Mental health services shall be of equal quality to other general health services with no discrimination and the minimum quality standards shall be as prescribed by the State Mental Health Authorities. ü As a minimum, essential medicines used for the treatment of mental illness as enumerated in the World Health Organisation (WHO) Essential Drug List shall be available free of cost to all persons with mental illness at all times at health establishments starting from community health centres and above in the public health system. *Right to Community Living ü No person with mental illness shall continue to remain in a mental health establishment merely because he or she does not have a family or is not accepted by his or her family or is homeless or because of the absence of community based facilities. ü The Government shall therefore provide for and/or support the establishment of less restrictive community based establishments. *Right to Protection from Cruel, Inhuman and Degrading Treatment 246 Psychiatry in India : Training & training centres All persons with mental illness ü have a right to live with dignity, in safe / hygienic environment with facilities for recreation, education and religious practices. ü need to be protected from all forms of physical, verbal, emotional and sexual abuse. *Right to Equality and Non-discrimination ü There shall be no discrimination on any basis including gender, sex, sexual orientation, religion, culture, caste, social or political beliefs, class or disability. ü Public and private insurance providers shall make provisions for medical insurance for treatment of mental illness on the same basis as is available for treatment of physical illness. ü Emergency facilities and emergency services for mental illness shall be of the same quality and availability as those provided to persons with physical illness. ü Persons with mental health services are entitled to the use of ambulance services in the same manner, extent and quality as provided to persons with physical illness. The Insurance Regulatory Development Authority (established under the Insurance Regulatory Development Authority Act, 1999) shall ensure that all insurers make provisions for medical insurance for treatment of mental illness on the same basis as is available for treatment of physical illness. *Right to Information ü A person with mental illness and his or her nominated representative shall have the right to know the criteria for admission, rights to apply to the State Panel of Mental Health Review Commission, right to know the nature of the person's mental illness and the proposed treatment plan. *Right to Confidentiality ü A person with mental illness has a right to confidentiality in the context of his mental health, mental health care and physical health care. ü Information related to care and treatment of persons with mental illness may be disclosed: to a nominated representative, for discharge of his duties; to a health professional for care and treatment; to protect other person from harm; on the order of Supreme Court or Mental Health Commission; in the interest of public safety. *Access to Medical Records Tandon et al: Forensic Psychiatry in PG Training 247 All persons with mental illness shall have access to their medical records, except in cases where such disclosure may harm, the person with mental illness or others. *Right to Personal Contacts & Communication ü A person with mental illness admitted to a mental health establishment has the right to refuse or receive visitors, make telephone/mobile phone calls, send and receive emails. ü These activities may be prohibited by a medical officer , if it interferes with the treatment or puts the person in danger. The medical officer cannot prohibit communication from Court, Mental Health Commission, member of Parliament and nominated representative.

*Right to Legal Aid A person with mental illness shall be entitled to receive free legal services to exercise any of his or her rights given under this Act. *Right to make Complaints about Deficiencies in Provision of Services Chapter VI: DUTIES OF APPROPRIATE GOVERNMENT (Sections 29-- 32) *Promotion of Mental Health & Preventive Programmes The Government shall have a duty to plan, design and implement programs for the promotion of mental health and prevention of mental illness in the country. *Creating Awareness about Mental Health and Illness and Reducing Stigma associated with Mental Illness *Human Resources and Training Sufficient numbers of trained health professionals should be made available by the Government by planning and implementing educational and training programs in collaboration with institutions of higher education and training. Chapters VII : Central Mental Health Authorities (Sections 33-34) *The Central Authority shall: ü Compile, update, publish (also online) and maintain a register of all registered mental health establishments in the country. ü Develop quality and service provision norms for different types of mental health establishments under the Central Government; ü Supervise all mental health establishments under the Central Government and receive complaints . 248 Psychiatry in India : Training & training centres ü Maintain a national register of all registered mental health professionals . Chapters VIII : State Mental Health Authority (Sections 45--56) The State Government shall establish the State Mental Health Authority which will function under the Central Mental health Authority. Functions of the State Mental Health Authority ü The Authority shall register all mental health establishments in the State, develop quality and service provision norms, supervise and receive complaints against mental health establishments in the State. ü The authority shall train all relevant persons including judicial officers, law enforcement officials, health professionals, advise the State Government on all matters relating to mental health care and services, and submit an annual report. Chapter IX: FINANCE, ACCOUNTS AND AUDIT (Sections 57-64) *Includes grants by Central Government to Central Authority and grants by the State Government to the State Mental Health Authority. Chapter X: Mental Health Establishments (Sections 65-72) Registration and Standards for Mental Health Establishments. Procedure for Provisional and Permanent Registration: ü Registration of mental health establishment is mandatory. Until the State Mental Health Authority publishes the standards for mental health establishments a provisional registration shall be provided. ü Once the standards are published the mental health establishments shall provide an undertaking within a period of six months, to the State Mental Health Authority that the mental health establishment fulfills the minimum standards as prescribed. ü For registration and continuation of registration, every mental health establishment shall maintain minimum standards of facilities, qualified staff, maintenance of records. Section 66 & 67: Procedure for Registration, Inspection and/or Inquiry of Mental Health Establishments ü For the purpose of registration of the mental health establishment, an application in the prescribed proforma along with the prescribed fee shall be furnished to the State Mental Health Authority, in person, by post or online. For an already existent mental health establishment an application for its provisional registration shall be made within six months of constitution of the State Mental Health Authority. Tandon et al: Forensic Psychiatry in PG Training 249 ü The Authority shall within a period of ten days from the date of receipt of such application, issue to the mental health establishment a certificate of provisional registration without the need for prior enquiry. ü The Authority shall within a period of 45 days from the date of provisional registration, publish in print and in digital form online, all particulars of the mental health establishment. The provisional registration shall be valid for a period of 12 months and shall be renewable with an application 30 days prior to expiry / or renewable with enhanced fees in case of late application. ü In states where standards have been defined a permanent registration will have to be obtained within a period of 6 months from notification of these standards. ü The evidence provided by the mental health establishment shall be displayed publicly for 30 days (on the website) by the Authority for filing objections, if any, before processing for grant of permanent registration. ü If the Authority has not communicated any objections nor has passed an order within a period of 90 working days from the date of application for permanent registration it will be deemed that the Authority has allowed the application for permanent registration. ü The Authority may cancel the registration of a mental health establishment if norms laid are breached and not rectified even after sufficient time has been provided to the establishment to act. ü The Authority may act either suo moto or on a complaint received from any person order an inspection and/or inquiry of any mental health establishment. An establishment aggrieved by an order of the may appeal to the High Court in the State within a period of 30 days from the date of the order. ü The Authority shall conduct an audit of all registered mental health establishments every three years, to ensure the requirements of minimum standards for registration as a mental health establishment. Certificates, Fees and Register of Mental Health Establishments Every mental health establishment shall display the certificate of registration in a place visible to everyone . The registration is non-transferable but shall remain valid in case of change of ownership, in the mental health establishment.

Chapter XI : Mental Health Review Commission (Sections 73-- 93) 250 Psychiatry in India : Training & training centres Sections 73: Constitution of a Mental Health Review Commission ü The Central Government shall constitute the Mental Health Review Commission within 9 months from the date on which this Act receives the assent of the President, constitute the Mental Health Review Commission, which will have jurisdiction all over the Country with head office in Mumbai. ü The Commission shall consist of a President (qualified to be appointed as Chief Justice of a High Court and appointed by the President of India ), a Psychiatrist with at least 15 years experience, one member who is a person with mental illness or representative, one member who is a representative of families and care-givers to persons with mental ill ness or non-governmental organizations and one member with a background in public health administration Constitution of State Panels of the Mental Health Review Commission ü The functions, powers and authority of the Commission shall be exercised by the State Panels of the Commission. ü Each State Panel of the Commission shall consist of a District Judge, or an officer of the state judicial services who is qualified to be appointed as district judge or a retired District Judge who shall be Chairperson of the Panel; a representative of the District Collector/District Magistrate/Deputy Commissioner of the districts within the jurisdiction of the Panel; two members who are mental health professionals of whom one shall be a psychiatrist; two members who shall be persons with mental ill ness or care-givers or persons representing organizations of persons with mental ill ness or care-givers or nongovernmental organizations working in the field of mental health. Section 90: An Expert Committee (appointed by the Commission) will prepare a guidance document (for medical practitioners and mental health professionals), for assessing the capacity of persons to make mental health care or treatment decisions. Section 91: Functions of the Mental Health Review Commission and State Panel of the Mental Health Review Commission The Mental Health Review Commission shall appoint / remove members from the State panel, guide the State panel in discharge of duties, review use of Advance Directives, advice the Central Government on matters relating to persons with mental ill ness, to decide on applications / complaints regarding deficiencies in care and services, carry out inspection on receiving a complaint against a mental health establishment and take appropriate action. Chapter XII : Admission, Treatment and Discharge (Sections 94:108) Tandon et al: Forensic Psychiatry in PG Training 251 Sections 94 & 95: Independent (without Support) Admission and Treatment ü An “independent patient” or an “independent admission” refers to the admission of a person with mental illness to a mental health establishment, on request, who has the capacity to make treatment decisions or requires minimal support in making such decisions, and is not a minor. As far as possible, all such cases should be independent admissions except in cases where supported admission is unavoidable. ü However the medical officer or psychiatrist should be convinced that the person has a mental illness of a severity requiring admission to a mental health establishment and would benefit from admission. ü An independent patient shall not be given treatment without his or her informed consent. An independent patient may discharge himself/herself from the mental health establishment without the consent of the medical officer or psychiatrist in charge of the establishment, which should be communicated to the person at the time of admission. Section 96: Admission of a Minor ü A minor may be admitted to a mental health establishment only in exceptional circumstances, on application of a nominated representative, in which case a minor may be admitted if two psychiatrists, or one psychiatrist and one mental health professional or one psychiatrist and one medical practitioner, have independently examined the minor on the day of admission or in the preceding 7 days and concluded that admission is required. ü A minor so admitted shall be accommodated separately from adults, in an environment that takes into account the developmental needs, and should be accompanied by a nominated representative/ attendant for the entire duration of stay. ü The minor can be admitted with informed consent or discharged on request, from his/her nominated representative. ü Any admission of a minor, has to be reported to the Panel of the Mental Health Review Commission within a period of 72 hours; the State Panel shall have the right to visit and interview the minor or review the medical records if it desires to do so. Also any admission for a period of 30 days shall be immediately informed to the State Panel, which will carry out a mandatory review within 7 days of all admissions of minors, continuing beyond 30 days and every subsequent 30 days. Discharge of Independent Patients 252 Psychiatry in India : Training & training centres ü A mental health professional may prevent discharge of a person admitted independently for a period of twenty-four hours for assessment, if he/she feels that the patient requires substantial or very high support or has attempted/attempting to threaten self or others. Such a patient may be admitted either as a supported patient or discharged within 24 hours /after assessment whichever is earlier. Section 98: Admission and Treatment of Persons with Mental Illness, with High Support Needs, in a Mental Health Establishment, upto 30 days (Supported Admission) ü Upon application by the Nominated Representative of the person, he/she may be admitted only if he/she has been independently examined on the day of admission or in the preceding 7 days, by one psychiatrist and the other being a mental health professional or a medical practitioner, and both conclude that admission is required. ü If the person has to remain admitted after a period of 30 days, either conditions in the appropriate clause under Chapter XII has to be met and/or the person can remain admitted as an independent patient. ü If the level of support required is of such high degree that the Nominated Representative has temporarily consented to treatment, the medical officer or psychiatrist in charge of the mental health establishment shall record this in the notes and review this every 7 days. ü All admissions under this section shall be informed to the State Panel of the Mental Health Review Commission within 7 days (3 days in case of women) from date of admission which has the right to visit and interview the person and/or review the medical records. ü A person admitted under this section or his or her Nominated Representative or a representative of a registered non-governmental organization with the consent of the person, may apply to the State Panel of the Mental Health Review Commission for review of the decision to admit the person in which case a decision has to be made by the state Panel within 7 days. ü Following discharge under the clause mentioned above, a readmission under the same section shall not take place for a period of 7 days from the date of discharge. Any readmission within 7 days shall be considered as continuation of the admission, and provisions of Section 99 shall apply. Admission and Treatment of Persons with Mental Illness, with High Support Needs, in a Mental Health Establishment, beyond 30 days (Supported Admission beyond 30 days) Tandon et al: Forensic Psychiatry in PG Training 253 ü Upon application by the Nominated Representative of a person with mental illness, the medical officer or psychiatrist in charge of a mental health establishment shall continue admission of a person with mental illness in the establishment under this section if (I) The person is already admitted under the appropriate clause under Chapter XII and (ii) Two psychiatrists have independently examined the person on the day of admission or in the preceding 7 days and both conclude that admission is required. ü All admissions or renewals under this section shall be informed by the medical officer or psychiatrist in charge to the State Panel of the Mental Health Review Commission within 7 days of date of admission or renewal and has to be approved by the State Panel within 21 days. ü Admission of a person with mental illness to a mental health establishment under this section shall be limited to a period upto 90 days, and can be renewed upto a period of 120 days in the first instance and upto a period of 180 days thereafter, upon application by the Nominated Representative of the person, to the medical officer in charge of the mental health establishment and has to be approved by the State Panel. Section 100: Leave of Absence ü The medical officer or psychiatrist in charge of the mental health establishment may grant leave to any person admitted under other Sections, to be absent from the establishment subject to such conditions (if any) and for a duration as may be necessary, not exceeding beyond the period of the duration of admission permitted in the respective clause under the Bill. ü If an individual does not return to the establishment following the expiry or termination of his or her leave of absence, the medical officer or psychiatrist in charge of the mental health establishment shall contact the person/nominated representative and if they feel that admission need not be continued the person may be discharged. ü However, if the medical officer or psychiatrist in and the Nominated Representative agree that admission is required and the person with mental illness refuses to return to the hospital, the Police Officer in charge of the police station within the limits of whose station the mental health establishment is located, on request of medical officer/psychiatrist has to convey the person back to the mental health establishment. ü A person not returned by the Police Officer within one month of expiry or termination of his or her leave of absence, may not be returned and will be considered as discharged from the 254 Psychiatry in India : Training & training centres establishment. Section 101: Absence without Leave or Discharge If a person admitted to mental health establishment himself or herself without leave or without , he or she shall be taken into protection by any Police Officer at the request of the medical officer or psychiatrist and taken back to the mental health establishment immediately. Section 102: Transfer of Persons with Mental Illness from one Mental Health Establishment to another Mental Health Establishment A person with mental illness admitted to a mental health establishment under appropriate clause in Chapter XII may, subject to any general or special order of the State Panel be removed from such mental health establishment to another mental health establishment within the State or with the consent of the Mental Health Review Commission to any mental health establishment in any other State. Section 103: Emergency Treatment ü Notwithstanding anything contained in this Act, any medical treatment, including treatment for mental illness, may be provided by any registered medical practitioner to a person with mental illness, subject to the informed consent of the Nominated Representative, if available, and where it is immediately necessary to prevent death or irreversible harm to the health of the person or prevent serious damage to property. ü Nothing in this section shall permit medical treatment that is not directly related to the emergency identified; nothing contained in this section shall permit the use of Electro-convulsive therapy as a form of treatment. ü Emergency treatment shall be limited to 72 hours or till the person has been assessed at a mental health establishment whichever is earlier. However in disasters or emergencies declared by the Government, the period of emergency treatment may extend upto 7 days. Section 104: Prohibited Procedures Notwithstanding anything contained in this Act, the following treatments shall not be performed on any person with mental illness: (i) Electro-convulsive therapy without the use of muscle relaxants and anesthesia. (ii) Electro-convulsive therapy for minors. (iii) Sterilization of men or women, when such sterilization is intended as a Tandon et al: Forensic Psychiatry in PG Training 255 treatment for mental illness. (iv) Chained in any manner or form whatsoever. Section 105: Restriction on Psychosurgery for Persons with Mental Illness Notwithstanding anything contained in the Act, psychosurgery shall not be performed as a treatment for mental illness unless an informed consent of the person on whom the surgery is being performed is obtained and approval from the State Mental Health Authority to perform the surgery is given. Section 106: Restraints and Seclusion ü Physical restraint or seclusion may only be used after authorization from a psychiatrist, when it is the only means available to prevent imminent and immediate harm to person concerned or to others. ü The Nominated Representative of the person with mental illness shall be informed about every instance of seclusion or restraint within a period of 24 hours. ü All instances of restraint and seclusion at the mental health establishment shall be included in a report to be sent to the State Panel on monthly basis.

Section 107: Discharge Planning Whenever a person is to be discharged into the community or to a different mental health establishment or where a new psychiatrist is to take responsibility of the person's care and treatment, the psychiatrist in consultation with the person with mental illness, the Nominated Representative, the family member or care-giver shall ensure that a plan is developed as to how these services shall be provided, in future. Section 108: Research ü Free and informed consent shall be obtained by the professionals conducting the research, from all persons with mental illness for participation in all research involving interviewing the person or psychological, physical, chemical or medicinal interventions. ü In case research is to be conducted on persons who are unable to give free and informed consent but do not resist participation in such research, permission to conduct such research must be obtained from concerned State Mental Health Authority. Chapter XIII : Responsibilities of Other Agencies (Sections 109-114) Duties of Police Officers in respect of Persons with Mental Illness ü Every officer in charge of a police station has a duty to take into protection any person found wandering at large within the limits of 256 Psychiatry in India : Training & training centres the police station whom the officer has reason to believe: has mental illness and is incapable of taking care of himself or herself or; is at risk to self/others and taken to the nearest public health establishment within a period of 24 hours for assessment of the person's health care needs. Report to the Magistrate of a Person with Mental Illness in a Private Residence who is ill Treated or Neglected ü Every officer in charge of a police station, who has reason to believe that any person residing within the limits of the police station has a mental illness and is ill-treated or neglected shall forthwith report the fact to the concerned Magistrate. Any person who comes to know about such a person with mental illness, can give such information to the concerned police officer. ü The Magistrate may authorise admission of the person with mental illness in a mental health establishment for a period of ten days for enabling assessment of the person and to plan for necessary treatment, if any. Prisoners with Mental Illness ü An order under the Prisoners Act 1900 or the Air Force Act 11, 1950 or the Army Act ,1950 or under the Navy Act, 1957 or under the Code of Criminal Procedure 1973 ( 2 of 1974), directing the admission of a prisoner with mental illness into any suitable mental health establishment, shall be sufficient authority for the admission. ü The responsible medical officer of a prison or jail shall send quarterly reports to the State Panel that there are no prisoners with mental illness in the prison or jail. The State Panel may visit the prison or jail if it wishes to do so. ü The medical officer in charge of a mental health establishment wherein any person is detained, shall once in every six months, make a special report regarding the mental and physical condition of such person to the authority under whose order such person is detained. Question of Mental Illness in Judicial Process ü Notwithstanding anything contained in any other Act, proof of a person's current or past admission/treatment to a mental health establishment shall not by itself be ground for granting divorce. ü If during any judicial process before any competent court proof of mental illness is produced and is challenged by the other party, the court shall refer the same for further scrutiny to the State Panel of Mental Health Review Commission. Chapter XIV: Restriction to discharge functions by Professionals not covered Tandon et al: Forensic Psychiatry in PG Training 257 by Profession Section 115: No mental health professional or medical practitioner shall perform any function not authorised by this Act or recommend any treatment not authorised by the field of his/her profession. Chapter XV & XVI : Penalties and Miscellaneous (Sections 116-136) Penalties for Establishing or Maintaining a Mental Health Establishment in contravention of provisions of this Act ü Whoever carries on a mental health establishment without registration shall, be punishable by the State Mental Health Authority with a fine from fifty thousand rupees to five lakh rupees, for subsequent offences. ü Whoever knowingly serves in a mental health establishment which is not duly registered under this Act, shall be punishable with a fine upto twenty five thousand rupees. General Provision for Punishment of Offences ü Any person who contravenes any of the provisions of this Act, or of any rule or regulation made there under shall be punishable by a State Panel of the Mental Health Review Commission with imprisonment for a term which may extend from six months to two years or with a fine which may extend from ten thousand to five lakh rupees or both. ü Any person aggrieved by the decision of the State Panel of the Mental Health Review Commission may appeal to the High Court of the State within 60 days from the date of the decision. Special Relaxation in Requirements for States in North East and Hill States Attempt to Commit Suicide due to Mental Illness ü Any person who has attempted to commit suicide shall be examined by a psychiatrist before any criminal investigation in to the attempt to commit suicide. ü If there are reasonable clinical grounds to believe the suicide attempt was a result of the mental illness, no complaint, investigation or prosecution shall be entertained against the person who attempted to commit suicide, notwithstanding anything contained in the Indian Penal Code. Protection of Action taken in Good Faith - No prosecution or o legal proceeding shall lie against any person for an action taken in good faith in pursuance of this Act. The concept of mental disability in the Law 258 Psychiatry in India : Training & training centres The law does not regard any particular mental disorder as a proxy for incompetence. For good reasons ,legal standards are rarely framed in terms of diagnostic category e.g. some people with Schizophrenia may lack testamentary capacity and it may even change with time. Legal standards address functional capacity. Diagnosis by itself, is unhelpful in the determination. [7] The Union Cabinet cleared the Mental Health Care Bill, 2013 on 13th June 2013. In the World Report on Disability by W.H.O. the famous British theoretical physicist Stephen Hawking, who has amyotrophic lateral sclerosis (ALS) has stated in its Foreword - “We have a moral duty to remove the barriers to participation for people with disabilities, and to invest sufficient funding and expertise to unlock their vast potential. It is my hope this century will mark a turning point for inclusion of people with disabilities in the lives of their societies” The Persons with Disabilities (PwD) (Equal Opportunities, Protection of Rights and Full Participation) ) Act , 1995 received the assent of the President of India on 1st January, 1996.[9] The Rights of Persons with Disabilities Bill, 2014 “The PwD Act of 1995 has been there for nearly 15 years and has been the basis of a largely empowering jurisprudence on the Rights of Persons with Disabilities. Whilst the need to retain the empowering jurisprudence is unequivocally acknowledged, it is also recognized that the present Act, either does not incorporate a number of rights recognized in the UNCRPD (United Nations Convention on the Rights of Persons with Disabilities) or the recognized rights are not in total harmony with the principles of the Convention.”[10] The UN CRPD recognizes that disability is an evolving concept which results from the interaction between persons with impairments and attitudinal & environmental barriers that hinder their full and effective participation in society. The Persons with Disabilities Act, 1995 on the other hand has provided for an impairment based exhaustive definition of disability. Consequently, people with impairments not expressly mentioned in the Act have often been denied the rights and entitlements recognized in the Act.

A Bill to give effect to the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) and for matters connected with it : the United Nations General Assembly adopted its Convention on the Rights of Persons with Disabilities on the 13th day of December, 2006, to which India is a signatory and was ratified by it on 1-10-2007. Tandon et al: Forensic Psychiatry in PG Training 259

The principles guiding the UNCRPD are:(a) respect for inherent dignity, individual autonomy, freedom to make one's own choices, and independence; (b) non-discrimination and equality of opportunity; (c) full participation and inclusion in society; (d) respect and acceptance of PwD as part of human diversity and humanity;(e)equality between men and women;(f) respect for the evolving capacities of children with disabilities and respecting and preserving their identities. The Rights Of Persons With Disabilities Bill, 2014: Arrangement Of Clauses/Sections: Chapter I- Preliminary; Chapter II- Rights And Entitlements; Chapter III-Education;Chapter IV-Skill Development and Employment; Chapter V-Social Security, Health, Rehabilitation and Recreation;Chapter VI- Special provisions for persons with benchmark disabilities; Chapter VII- Special provisions for persons with disabilities with high support needs; Chapter VIII--Duties and responsibilities of appropriate governments; Chapter IX-Registration Of institutions for persons with disabilities and grants to such institutions; Chapter X-Certification of specified disabilities; Chapter XI- Central and state advisory boards on disability and district level committee; Chapter XII-National commission for persons with disability; Chapter XIII -State commission for persons with disabilities; Chapter XIV- Special Court; Chapter XV- National fund for persons with disabilities; Chapter XVI- Offences and penalties; Chapter XVII-Miscellaneous; THE SCHEDULE. Chapter I - Preliminary This Bill may be called the “The Rights of Persons with Disabilities Act, 2014” and extends to the whole of India except for the State of Jammu and Kashmir. The Act shall come into force after a notification from the central government. Definitions Obviously the definition includes persons with mental illness. Mental illness is included in the Schedule 1 as well and defined on the same line as in the Draft of Mental Health Care Act. [10] “Person with disability” means a person with long term physical, mental, intellectual or sensory impairment which hinder his full and effective participation in society equally with others. “Person with benchmark disability” means a person with not less than forty percent of a specified disability where specified disability has not been defined in measurable terms and includes a person with disability where specified disability has been defined in measurable terms, as certified by the certifying authority. “Person with disability having high support needs” means a person with 260 Psychiatry in India : Training & training centres benchmark disability certified as per Central Government guidelines who needs high support “Discrimination on the basis of disability means any distinction, exclusion or restriction on the basis of disability which has the purpose or effect of impairing or nullifying the recognition, enjoyment or exercise, on an equal basis with others, of all human rights and fundamental freedoms in the political, economic, social, cultural, civil or any other field. It includes all forms of discrimination, including denial of reasonable accommodation.” Chapter II: Rights and Entitlements (Sections 3-14) These include right to equality and nondiscrimination, protection from cruelty and inhuman treatment, protection from abuse, violence and exploitation. The persons with disabilities shall have equal protection and safety in situations of risk and humanitarian emergencies. Section 4 provides persons with disabilities with the right to live in community on equal basis with others. Governments shall launch suitable schemes and programs to achieve this objective. The living arrangements such established shall be non- coercive, non-restrictive and supportive. Sections 9 provides reproductive rights to PwD, particularly women and children with disabilities, the right to retain their fertility. The persons with disability have a right to have a home and family, voting rights (Section 10) and access to justice (Section 11). Section 12 of Bill provides that persons with disabilities enjoy legal capacity on an equal basis in all aspects of life and have the right to equal recognition everywhere as persons before the law. Any express or implied disqualification on the grounds of disability prescribed in any legislation, rule, notification, order, bye-law, regulation, custom or practice, which has the effect of depriving any person with disabilities (PwD) of legal capacity, shall not be enforceable. All PwD have right on equal basis with others in financial matters, own or inherit property. All PwD have the right to access all arrangements and support necessary for exercising the legal capacity according to their will and their legal capacity shall not be questioned irrespective of the degree and extent of support, by reason of accessing support to exercise legal capacity. Person providing support shall not exercise undue influence and shall withdraw from providing support in case of conflict of interest. A PWD may alter, modify or dismantle any support arrangement and substitute it with another. [10,11] Section 13:For mentally ill persons incapable of taking any legally binding decisions, any provision in any legislation, rule, regulation or practice which prescribes for the establishment of plenary guardianship shall be hereinafter deemed to be establishing a system of limited guardianship. Plenary Guardianship is a system whereby subsequent to a finding of incapacity a Tandon et al: Forensic Psychiatry in PG Training 261 guardian substitutes for the person with disability as the person before the law and takes all legally binding decisions for him or her. The guardian is under no legal obligation to consult with the person with disability or determine his or her will or preference whilst taking decisions for him or her. Subsequent to the enforcement of this Act all plenary guardians shall operate as limited guardians. A limited guardianship is a system of joint decision making which operates on mutual understanding and trust between the guardian and the person with disability. [10] Section 14 lays stress on the duty of governments to designate authorities to mobilize the community and create social networks to support persons with disabilities. Chapter III: Education Section 15: The Government funded educational institutions should provide inclusive education to the children with disabilities, admit them without discrimination, provide opportunities for sports activities equally with others, make a campus and various facilities accessible there with accommodation; provide necessary individualised support and an environment that maximises academic and social development; ensure education to persons who are blind or deaf; detect specific learning disabilities in children at the earliest and take suitable measures for there management; monitor participation and progress; and provide transportation facilities to the children with disabilities. Section 16: The Government should conduct school survey to identify children with disabilities, establish teacher training institutions, provide books and appropriate assistive devices to students, to provide scholarships in appropriate cases to students with benchmark disability, to make suitable modifications in the curriculum to meet the needs of students with disabilities, to promote participation of PwD in adult education and continuing education programmes equally with others. Chapter IV: Skill development and employment The Government should provide loans to PwD for vocational training and self- employment (Section 18) and nondiscrimination in employment(Section 19). Chapter V: Social security, Health, Rehabilitation and recreation The Government shall formulate necessary schemes and programmes (with due consideration to the diversity of disability, gender, age, and socio- economic status) for social security, provide free health care and rehabilitation services, insurance to employees with disability, and recreation facilities. Chapter VI: Special provisions for persons with benchmark disabilites Free education should be made available for children with benchmark 262 Psychiatry in India : Training & training centres disabilities and five percent reservation in higher educational institutions for persons with benchmark disabilities (shall be given an upper age relaxation of five years for admission in institutions of higher education). Appropriate Government shall reserve in every establishment under them, not less than five percent of the vacancies meant to be filled for persons with benchmark disability, out which 1% quota has been provided for persons with autism, intellectual disability and mental illness clubbed together. Chaper VII: Special provisions for persons with disabilities with high support needs Section 37- A person with benchmark disability may apply to the appropriate Government, requesting to provide high support. The appropriate Government, in consultation with the National Commission or the State Commission shall conduct and promote awareness campaigns and sensitisation programmes to ensure protection of rights of PwD. (Chapter VIII: Section 38) All public buildings shall be made accessible, as per the regulations formulated by National Commission within five years from the date of notification of such regulations.(Chapter VIII: Section 44) The State Government shall appoint a competent authority for the purpose of registration of institutions for PwD and grants to such institutions.(Chapter IX: Section 48) Any person aggrieved with decision of the certifying authority(for a disability certificate), may appeal against such decision.(Chapter X: Section 58) The Central Government shall, by notification, constitute a Central Advisory Board on Disability to exercise the powers and perform the functions assigned to it. (Chapter XI: Section 59). Similarly the State Government shall constitute a State Advisory Board on Disability. The Central Government shall constitute a National Commission for persons with disabilities (Chapter XII: Section 73) whereas the State Government shall constitute a State Commission for PwDs. Anyone who avails or attempts to avail any benefit meant for persons with benchmark disabilities, by fraud, shall be punishable with imprisonment for a term upto two years or with fine upto one lakh rupees or with both. (Chapter XVI: Section 104). Whoever intentionally insults or humiliates a PwD, or uses force with intent to dishonor him or harms the modesty of a woman with disability, denies food or fluids to him or her, sexually exploits a PwD or voluntarily injures, or interferes with the use of any limb or sense or any supporting device of PwD, performs any medical procedure on a woman with disability which leads to or Tandon et al: Forensic Psychiatry in PG Training 263 is likely to lead to termination of pregnancy without her consent (except in cases where it is done with consent of a guardian and medical practitioner) shall be punishable for not less than six months and upto five years and with fine. (Chapter XVI: Section 105). SCHEDULE 1 List of Disabilities (1) Autism Spectrum Conditions / Autism Spectrum (2) 'Blindness' with total absence of sight, visual acuity not exceeding 6/60 or 20/200 (Snellen) in the better eye with correcting lenses or limitation of the field of vision subtending an angle of 20 degree or worse.(3) 'Cerebral Palsy' (4) 'Chronic neurological conditions' (5) 'Deaf blindness' refers to a condition in which people may have a combination of hearing and visual impairments causing severe communication, developmental, and educational problems. (6) 'Haemophilia' (7) 'Hearing Impairment' refers to loss of 60 decibels or more in the better ear in the conversational range of frequencies; such impairment in hearing, whether permanent or fluctuating, that hinders the communication with others. (8) 'Intellectual Disability' refers to a disability characterized by significant limitations both in intellectual functioning (reasoning, learning, problem solving) and in adaptive behavior, which covers a range of everyday social and practical skills. (9) 'Leprosy cured' person (10) 'Locomotor Disability' refers to a person's inability to execute distinctive activities associated with movement of self and objects resulting from affliction of musculoskeletal and/or nervous system (11) 'Low-vision' i)Visual acuity not exceeding 6/18 or 20/60 and less than 6/60 or 20/200 (Snellen) in the better eye with correcting lenses; or ii) Limitation of the field of vision subtending an angle of more than 20 degree and up to 40 degree. (12) 'Mental illness': same as defined in Mental Health Care Bill 2013. (13) 'Muscular Dystrophy' (14) 'Multiple Sclerosis' (15) 'Specific Learning Disabilities' The term includes such conditions as perceptual disabilities, dyslexia, dysgraphia, dyscalculia, dyspraxia and developmental aphasia. (16) 'Speech and Language disability means a permanent disability (after laryngectomy) or aphasia affecting one or more components of speech and language due to organic or neurological causes. (17) 'Thalassemia' (18) 'Sickle Cell Disease'(19)'Multiple disability' mean two or more of the specified disabilities listed at from S.No.1 to 18 above,[10] occurring in a person at the same time. Note: For Discussion on Mental Health Care Bill(MHCB), 2013 & The Rights of Persons with Disability bill, 2014 see Schedule II at the end of the chapter Clinical Assessment in Forensic Psychiatry Moving forward and highlighting the basics - What are the essential themes here? First, the importance of careful assessment: "clearly ascertained." Then, the critical forensic question of possible malingering: "simulating insanity." 264 Psychiatry in India : Training & training centres Next, the importance of avoiding the "ultimate issue": "how he should be punished." Finally, the matter of clinical management: possible needs for restraint. Of utmost importance for a trainee is the assessment of a person's mental health, convicted for a crime and further writing a report to the concerned legal authority. Forensic Mental Health Assessment (FMHA) refers to psychological evaluations that are performed by mental health professionals to provide relevant clinical and scientific data to a legal decision maker, such as a judge or jury, or the litigants involved in civil or criminal proceedings. [12] The organization of the report into specific sections can facilitate the demonstration of many of these principles. The following sections have been suggested: [13] ü referral (with identifying information concerning the individual, his or her characteristics, the nature of the evaluation, and by whom it was requested or ordered), ü procedures (times and dates of the evaluation, tests or procedures used, different records reviewed, and third-party interviews conducted as well as documentation of the notification of purpose or informed consent and the degree to which the information was apparently understood), ü relevant history (containing information from multiple sources describing areas important to the evaluation), ü current clinical condition (broadly considered to include appearance, mood, behavior, sensorium, intellectual functioning, thought, and personality) ü forensic capacities (varying according to the nature of the legal questions), and ü conclusions and recommendations (addressed towards the relevant capacities rather than the ultimate legal questions). Criminal Responsibility of a mentally ill can be well understood in light of some famous cases, like the Hadfield case where James Hadfield was convicted for firing at King George III and the McNaughten case , which paved the way for McNaughten Rules , where Daniel McNaughten was convicted for killing Edward Drummond, secretary to the British Prime Minister Sir Robert Peel. [13] The Indian Law (Section 84 of Indian Penal Code),derived from McNaughten's rule, states that “nothing is an offence which is done by a person who ,at the time of doing it ,by reason of unsoundness of mind ,is incapable of knowing the nature of the act or that he is doing what is either wrong or contrary to Law.” That goes to say that if a person is not criminally responsible, he is mentally ill as per the Legal system. Contrastly a person Tandon et al: Forensic Psychiatry in PG Training 265 who is mentally ill on medical grounds may or may not be mentally ill on legal grounds. Civil Responsibility of a mentally ill comes into play in cases of marriage , contract, adoption, witness, right to vote or stand for election, civil proceedings and Testamentary capacity. Testamentary disposition is regulated by the Indian Succession Act (Act 39 of 1925) which states that “no person can make a will while he is in such a state of mind , whether arising from intoxication or from illnesses or from any other cause, that he does not know what he is doing” Also a psychiatrist may have to appear before a Court of Law as an expert witness and permitted to express opinions related to areas of professional expertise. A committee comprising of Prof. JS Neki , Prof. DN Nandi , Prof. A.K. Agarwal , Dr. VN Vahia and Dr. JK Trivedi were requested to prepare the recommendations for a code of ethics for psychiatrists in India . The committee prepared the draft recommendations , which were approved by the Indian Psychiatric Society at its Annual Conference at Cuttack (Orissa) in 1989. Psychiatric Disorders and the Legal framework Individuals with psychiatric problems may get involved with the law:[15-18] Substance Abuse : drugs and alcohol are major contributors to violence amongst both mentally disordered and non-mentally disordered offenders. Earlier research had linked violence with schizophrenic patients in particular but later studies have been more equivocal about this; however a recent meta-analyses suggests three-fold risk among those with psychosis; Current understanding is to give more relevance to psychiatric symptoms rather than diagnosis. Acute Psychiatric Symptoms: threatening and assaultive behaviour may be seen in mania but serious intentional violence is rare. In depressed patients, violence can be either self-directed (suicide) or directed towards others, close to the individual. examples: depressed mothers who kill their children; depressed men who kill family members and then themselves. Research indicates consistent links between violent behavior and delusions particularly paranoid delusions. Erotomania, pathological Love, pathological jealousy, paraphiliacs are more likely to be contributors to violence.Stalkers who Kill Strangers are more often mentally ill than otherwise. They believe themselves to be unique, collect newspaper clippings, etc. and research their target victims thoroughly. They may even purchase a weapon for the particular "mission" they are on. Command Hallucinations, Violent Fantasies: approximately 70% of males in general population have had violent fantasies or homicidal thoughts at one time or another. Antisocial Personality Disorders may begin in childhood as Oppositional 266 Psychiatry in India : Training & training centres defiant disorder or Conduct Disorder and is of higher prevalence in severely mentally ill population and in prison population (50-70%);has a strong association with substance abuse and is strong predictor of criminal recidivism, particularly violent recidivism, especially in women. Psychopathy often overlaps with Antisocial Personality Disorder and Narcissistic Personality Disorder with self-centredness, egocentricity, lack of empathy etc. Degree of psychopathy is measured effectively by Hare's Psychopathy Checklist-Revised (PCL-R) PCL-R score is a key feature in the Violence Risk Assessment Guide (VRAG) which assesses violence risk potential. Behavior of an individual with Dissociative Identity Disorder is necessarily “involuntary”. Violence can occur in various sleep disorders. In Automatisms crime should be sudden and with no obvious motive – no planning or premeditation. Presence of Organic Disorders and Learning Disorders increase the risk of violence; particularly elderly neurologically impaired are involved in violent incidents in health care facilities. Pre-Menstrual Syndrome is associated with violence by women against spouses (women who kill spouses are more often in the first five days of their cycle. Violence can be unintentional as a result of seizures and in inter-ictal period in temporal lobe epilepsy. Attention Deficit/Hyperactivity Disorder ( ADHD) is strongly associated with childhood aggression and later conduct disorder. Biological Aspects like frontal lobe deficits should also be considered. Early disruption in attachment of children with caregivers can lead to later psychopathology, mental disorders and criminality in some individuals. It may well be that prison environments tend to replicate or reflect lack of care that some offenders may have experienced as children. Peer Attachment and Social Functioning: maltreated children often begin early to relate inappropriately to people (eg. may respond with anger or aggression to friendly gesture from peers or signs of distress from them) Fitness to stand trial In India, there are many instances in which fitness to stand trial has delayed the proceedings for decades.[19-22] Case Vignette Mr. Machang Lalung, was arrested at his home village of Silsang near Guwahati in 1951 under section 326 of the Indian Penal Code for causing grievous harm. He was detained at the age of 23, he could secure his release only when he was 77 years old. Less than a year after he was taken into custody, Lalung was transferred to a psychiatric hospital in the Assamese town of Tezpur. Sixteen years later, in 1967, doctors confirmed that he was fully fit to be released, but instead he was transferred to Guwahati Central Jail, where he was imprisoned until 2005. He spent his valuable 54 years of life behind bars and could secure his release Tandon et al: Forensic Psychiatry in PG Training 267 only after the intervention from the Honourable Supreme Court of India in 2005. He was able to enjoy life outside the prison for only two years. He passed away on 26th Dec 2007 .[23] Case Vignette Mr. R, 55 years old, was accused of killing his neighbour over a property issue. He was arrested and charges framed against him. During his stay in prison, he started behaving abnormally, forgetting his barrack, passing urine in his clothes. He was unable to remember his family members names and had difficulty in remembering day-to-day events. He was referred for assessment to NIMHANS. He was diagnosed to be suffering Alzheimer's dementia (early onset), and certified as unfit to stand trial. Fitness to stand trial is different from Insanity defence In simple, words “insanity defence” is concerned with the state of mind during the commission of crime and is considered static. Whereas, fitness to stand trial is the assessment of the state of mind during the adjudicating process and it is considered dynamic since it changes over a period of time. Therefore, it needs to be assessed periodically in vulnerable populations such as people with mental illness. Insanity defense is the retrospective assessment of the state of mind during the crime but fitness to stand trial is a prospective assessment of the state of mind. Need for a screening instrument Various instruments and screening questionnaires have been devised to assist in the assessment of fitness to stand trial of mentally ill patients. [19] Some of the well-known instruments are MacArthur Competence Assessment Tool- Criminal Adjudication (MacCAT-CA) [20] , Evaluation of Competency to Stand Trial-Revised (ECST-R) [21] and Competence Assessment for Standing Trial for Defendants with Mental Retardation (CAST-MR). [22]

SCHEDULE II Discussion on Mental Health Care Bill(MHCB), 2013 & The Rights of Persons with Disability bill, 2014 The Mental Health Care Bill(MHCB), 2013 ignores the scientific advancements and evidence available for treatment of persons with mental illness (PwMi) and doesn't consider cultural differences in the treatment, care and rehabilitation of PwMi. It has neglected the expertise of mental health professionals in making treatment decisions; hence MHCB,2013 puts at stake the mental health needs of a very large number of persons with mental illness. The following points need to be noted: 24-27 1. Rights of persons with mental illness is being given at the cost of the Human Right, the right to receive treatment for mental illness. 268 Psychiatry in India : Training & training centres 2. Advance directive and nominated representative are western concepts, which are not suitable for India. Prediction of a psychiatric illness well in advance is rarely possible, and nobody is likely to accept the fact that they may suffer from a psychiatric illness in the future; so they are likely to deny treatment in an 'Advance Directive'. Legal guardian is the best nominated representative. 3. Decentralisation of clinical decisions to Mental Health Review Commissions and Board would deny emergency treatments to many patients. 4. The autonomy of mental health establishments is compromised in many ways. Compulsory information to be provided to the Board about admissions under certain sections would only increase the stigma. Some checks on Mental Health Establishments is acceptable, is most welcome. 5. Decisions regarding admission and discharge of PwMi, are important clinical decisions. Putting restrictions on the clinician with regards to the above will make the treatment process lengthy and more time is likely to be wasted on paper work. The Mental Health Review Commissions and Boards (final decision making authority) consists of just one expert (psychiatrist). 6. Restrictions on the use of ECT below 18 years and in unmodified form, is rather an emotional offshoot than based on scientific evidence. 7. The MHCB, 2013 is likely to alienate mental illness and mental health care, from physical illness and physical health care, increasing the stigma and going back in time when psychiatry was not a part of General Hospitals. 8. The redressal system for patients and their families should be at the level of hospital (hospital administration), so that a solution is provided then and there. Hence the Review Commission is unnecessary. 9. The definition of a mental health professional should be limited to only a qualified psychiatrist 10. The MHCB must distinguish between open wards vs closed wards inpatient settings.In Open wards patients voluntarily seek treatment accompanied by the family members. Consent of patients is obtained for all treatment decisions. On the other hand, the closed wards provide involuntarily admission, where there are chances of human rights violation and should be guided by legislation. 11. Psychiatry, as a medical speciality, is based on strong scientific evidence with treatment available for a wide range of disorders. Psychiatric disorders, besides major disorders, includes a large number of minor disorders precipitated by stress.General Hospital Psychiatry (GHP) has played a phenominal role in resulting in destigmatizing and deinstitutionalizing mental health care. 12. The private sector of mental health care should be encouraged considering scarce resources we have for mental health care. Making too many rules and laws at every step is contrary. The role of family, which remains with the patient in GHPU is important for recovery and rehabilitation. 13. Exemption from prosecution of those who attempt suicide was much needed and most welcome; provision of emergency treatment without any regulation is a progressive step. 14. There is an urgent need to bring mental illness under medical insurance claim , at Tandon et al: Forensic Psychiatry in PG Training 269 par with medical illness, since majority of mental illness are chronic in nature and require long term care and treatment. 15. The Rights of Persons with Disability Bill(RPwD Bill), 2014 provides for 5% reservation in higher educational institutions and for posts in all government establishments for persons with benchmark disability. Keeping in view of high prevalence rate of the disabilities due to mental illness in the society, the quota of 1% (for autism, intellectual disability and mental illness together) seems to be very less in comparison to 4% to persons with other disabilities. 16. In RPwD Bill, 2014, mandatory observance of accessibility norms is limited only to “establishments” vs that in UNCRPD where accessibility is extended to all services and places “open or provided to the public”. 17. The RPwD Bill,2014 mentions that “All existing public buildings” having to be made accessible. However the term “public building” has not been defined under the Bill. Similarly the term “Service providers” is not defined under the Bill. References 1. Lebigrs A. Quelques Aspects de la Responsibility Penale endroit Romain Classique Paris : Presses Universitaires de France 1967. 2. Zacchias P. Quaestiones Medico- legales Roma : Lib II,1625. 3. Ganju V. The Mental Health System in India: History, Current System, and Prospects. International Journal of Law and Psychiatry 2000;23(3–4):393–402. 4. Mental Health Act, 1987. Bare act with short comments ; Commercial Law Publishers , Delhi 2007. 5. Department of Health & Family Welfare. DRAFT MENTAL HEALTH CARE BILL (01.10.2012) Available at: http://mohfw.nic.in/WriteReadData/ l892s/MHC%20BILL%20SCAN%20 (Chapter%20I%20-%20II)-90558705.pdf (Last Accessed 19th July 2013) 6. Pathare S, Sagade J. AMENDMENTS TO THE MENTAL HEALTH ACT, 1987 DRAFT DATED 23rd May 2010. Centre for Mental Health Law and Policy Indian Law Society, Pune on behalf of The Ministry of Health& Family Welfare Government of India New Delhi. 7. The Mental Health Care Bill 2011. Ministry of Health & Family Welfare, Government of India New Delhi Available at: http://www.mohfw.nic.in/showfile.php?lid=946 [Last accessed on 2012, Jan 11] 8. The Hindu: Cabinet clears Mental Health Care Bill. June 14,2013. Available at: http://www.thehindu.com/news/national/cabinet-clears-mental-health-care- bill/article4812291.ece 9. PWD ACT, 1995. THE PERSONS WITH DISABILITIES(EQUAL OPPORTUNITIES, PROTECTION OF RIGHTS AND FULL PARTICIPATION) ACT, 1995 PUBLISHED IN PART II, SECTION 1 OF THE EXTRAORDINARY GAZETTE OF INDIA New Delhi, the 1st January, 1996/Pausa 11, 1917 (Saka). 10. THE DRAFT RIGHTS OF PERSONS WITH DISABILITIES BILL, 2012. Government of India, Ministry of Social Justice & Empowerment, Department of Disability Affairs , September, 2012. Available at: http://socialjustice.nic.in/pdf/draftpwd12.pdf (Last Accessed: 19th July 2013) 11. Narayan CL, Narayan M, Shikha D. The ongoing process of amendments in MHA-87 and PWD Act-95 and their implications on mental health care. Indian J Psychiatry 2011;53(4):In Press. 12. Grisso, T .Evaluating competencies: Forensic assessments and instruments , 2nd edition New York: Kluwer Academic/Plenum 2003. 13. Heilbrun K. Principles of forensic mental health assessment. New York: Kluwer Academic/Plenum 2001. 14. Allderidge P. Why was McNaughten sent to Bethlem. In: West DJ , Walk A (Eds) . Daniel McNaughten : His Trial and Aftermath . London : Gaskel 1977. 15. Release Decision-Making, 2nd Edition (2006), Webster, C.D. & Hucker, S.J.,Wiley: London. forthcoming: 2006. 16. Bloom H, Webster CD, Hucker SJ, DeFreitas K. "The Canadian Contribution to Violence Risk Assessment: History and Implications for Current Psychiatric Practice”. Canadian Journal of Psychiatry 2005;50(1):3-11. 17. Webster CD, Hucker SJ, Bloom H."Transcending the Actuarial versus Clinical Polemic in Assessing Risk for Violence.” Criminal Justice & Behaviour 2002;29/5: 659-665. 18. Serin R, Mailloux D, Hucker SJ. "The Utility of Clinical and Actuarial Assessments of Offenders in Pre-release Psychiatric Decision-Making.” Forum on Corrections Research 2001;13/2:36. 19. Pinals D, Tillbrook C, Mumley D. Practical application of the MacArthur Competence Assessment Tool-Criminal Adjudication (MacCAT-CA) in a public sector forensic setting. J Am Acad Psychiatry Law 2006;34:179-188. 20. Poythress NG, Nicholson R, Otto RK . Professional Manual for the MacArthur Competence Assessment Tool-Criminal Adjudication (MacCAT-CA). Odessa, FL: Psychological Assessment Resources 1999. 21. Rogers R, Tillbrook CE, Sewell KW. Evaluation of Competency to Stand Trial-Revised (ECST-R) and Professional Manual. Odessa, FL: Psychological Assessment Resources 2004. 22. Everington C, Luckasson R. Manual for Competence Assessment for Standing Trial for Defendants with Mental Retardation: CAST-MR. Worthington, OH: IDS Publishing 1992. 23. Supreme Court, Writ Petition [CRL] NO(s). 296 OF 2005.

Abhinav Tandon Hon. Asst. Editor, Indian Journal of Psychiatry Director & Consultant Psychiatrist Dr AKT Neuro-Psychiatric Centre Allahabad, UP & E.SR, MLN Medical College, Allahabad, KGMU, UP [email protected]

Anil Kumar Tandon Ex-President IPS-CZ Professor (Retd.) in Psychiatry MLN Medical College, Allahabad. T.S. Sathyanarayana Rao Professor and Formerly Head Department of Psychiatry JSS Medical College and Hospital, Mysuru Dushad Ram Asst. Prof. of Psychiatry JSS Medical College and Hospital, Mysuru 28 Training in Geriatric Mental Health: Needs, Ways and Contents

S.C. Tiwari, Anindya Das

Introduction: Geriatric psychiatry or psychogeriatrics is a branch of medicine which deals with the mental health issues of older adults (people aged 60 years or above) and is also popularly known as geriatric mental health (GMH). In rapidly ageing countries, health problems in older adults have attained the status of a challenge. The percentage of older persons in the world population is expected to increase rapidly from 9.5% in 1995 to 20.7% in 2050 and to 30.5% in 2150. The population of older adults in India is also growing at a very rapid pace (in 1951 it was 5.3%; in 1981; 6%; in 1991; 6.8%, in 2001; 7.4%; in 2006; 7.5%, and is projected to be 12.4% by 2025). In absolute numbers, India's elderly population aged 60 and above is expected to increase from 71 million in 2001 to 179 millions in 2031, and further 301 million in 2051 and is likely to become a challenge very soon in India as well [1,2]. The older adults are not merely extension of the adults, they are psychologically, biologically and socially distinct, and suffer from enormous mental health morbidities in comparison to adults (older adults: 43.3% Vs adults: 4.66% [3]). Similarly, high GMH morbidity has been reported by other studies as well [4,5,6,7,8]. Also the presentation and phenomenology of mental illnesses in elderly differ markedly from that of the adults. Due to higher prevalence of co morbid physical illnesses, the diagnosis and management are difficult and thus challenging; requiring special attention and advanced care with continuous monitoring. Health care of older adults has been a very low priority area in all sectors. There is neither any guiding policy nor any emphasis. However, the demographic transition has now made it mandatory to formulate and develop infrastructure, human resources, policies and programs for GMH Care in India. To develop human resources two pronged activities need to be started urgently. Theese are: (i) GMH manpower training which includes that at under-graduate level, at post-graduate level and at super speciality level, (ii) Geriatric paramental health manpower which includes specialized training for nurses, clinical psychologists and social workers, etc. Equally important is the development of infrastructure for teaching/training, clinical care, rehabilitation and research. 272 Psychiatry in India : Training & training centres 2. Human resource development: Training of geriatric mental and paramental health manpower is the need of the day. The training objectives, contents and schedule are discussed in the following sections. 2.a. Training to develop Geriatric Mental Health manpower [9,10,11] 2.a.1. At under graduate level: Objectives: To orient and sensitize undergraduate students to the importance of GMH care in present day medical practice, to correctly identify such problems in the elderly, develop competencies in emergency and psychosocial care and in appropriate referrals. Syllabus: 1. History of GMH in India 2. Scope of GMH 3. Aging and theories of aging 4. Epidemiology of GMH problems 5. Classification of GMH problems 6. Phenomenology and diagnosis of GMH problems 7. Common GMH and other specific problems of elderly 8. Management of GMH problems 9. National policies and programs for GMH care The program for teaching should include long clinics of three hours for two weeks for 4th and 5th semester MBBS students, short clinics of one hour for 8th and 9th semester students for two weeks and ten systemic lectures. 2.b.2. At post graduate level: Objectives: To orient postgraduate students of psychiatry to the importance of GMH care in the context of (mental) health needs of the community, familiarize them to the mental and other specific problems of the elderly; train them in the skills of diagnosis and evidence-based practices in GMH and sensitize them to the related research, legal and ethical issues. Syllabus: 1. The Myth, History, Science and Theories of Aging:

l The Prolongation of Youth and Life l Attitudes towards Aging l Definition of Aging l Biological theories of Aging: l Psychological Theories of aging l Social Theories of Aging l Length of Life: The Sex Differential l Stem cells and Aging Tiwari & Das: Training in Geriatric Mental Health 273 2. Neuropsychology in Late Life: l Functional specialization of Cerebral Hemisphere l Handedness and Cerebral Dominance l Plasticity and Restoration of Functions l Frontal Lobe Syndrome l Temporal Lobes Syndrome l Partial and Occipital Lobes Syndrome 3. Psychiatric Disorders in Late Life: l Cognitive Disorders l Movement Disorders l Mood Disorders l Schizophrenia and Paranoid Disorders l Anxiety and Panic Disorders l Somatoform Disorders l Sexual Disorders l Bereavement and Adjustment Disorders l Sleep and Circadian Rhythm l Alcohol and Drugs Problems l Personality Disorders l Agitation and Suspiciousness l Sub-syndromal Mental Health Problems 4. Treatment of Psychiatric Disorders in late life: Principles and practice of - l Psychopharmacology l Electroconvulsive Therapy l Diet, Nutrition and Exercise l Individual and Group Psychotherapy l Working with the Family of the Older Adult l Clinical Psychiatry in the Nursing Homes l The Continuum of care: Movement toward the Community l Acute Care inpatient and Day Hospital Treatment 5. Special topics: l Preventive measures of problems related with aging e.g., falls & fractures, bowel and bladder incontinence, and frailty. l Attitudes and supports of family members/society towards elderly l Benefits and Rights of elderly in our society l Legal, Ethical And Policy Issues l The Past and Future of Geriatric Psychiatry The training at the postgraduate level can be imparted in two ways, either 1. By postings in the Department of GMH for 12 weeks as rotatory 274 Psychiatry in India : Training & training centres postings of residents of MD psychiatry towards the later half of 2nd year or the early half of 3rd year of their residency training. 2. If Department of GMH do not exist in the institution, then through an inbuilt program in MD psychiatry curriculum over three years of residency. This should consist of at least l 10 important topics of GMH in seminars l 10 long case conferences related to GMH l 15 short case conferences related to GMH l 5 journal clubs related to GMH 2.c.3. At super specialty level: Objectives: To recognize the importance of the GMH in the context of the health needs of the community and the nation, identify social, economic, environmental, biological and psychological determinants of health in older adults in a given case, and take them into account while planning therapeutic, rehabilitative, preventive and promotive measure/strategies which are ethical and evidence-based. To develop competency in organizing and supervising health care services and demonstrating adequate managerial skills in the clinic/hospital or the field situation in GMH care. To develop competency in teaching, training and research skills to be able to develop trained GMH and paramental health human resources. Syllabus: 1. The Myth, History, Science and Theories of Aging:

l The Prolongation of Youth and Life l Attitudes towards Aging l Definition of Aging l Biological theories of Aging: l Psychological Theories of aging l Social Theories of Aging l Length of Life: The Sex Differential l Stem cells and Aging 2. Neuroanatomy, , Neuropathology and Neuropharmacology Of Aging and Behaviour:

l Neuroanatomy: l Brain Development l Neuroanatomy and Aging brain l Brain Stem l Prosencephalon l Cerebral cortex and its Connections l Association Cortex l Organisation of Sensori-motor systems Tiwari & Das: Training in Geriatric Mental Health 275

l Limbic System l Neurophysiology:

l Electrophysiological studies in the psychiatric evaluation of the elderly

l Electroencephalogram(EEG)

l EEG changes with normal Aging, Dementia, Delirium, Depression

l Magneto Encephalography (MEG) l Neuropathology: l Normal Aging l Alzheimer's Disease l Dementia with Lewy Bodies l Vascular Dementia l Frontotemporal Dementia l Neuropharmacology of Behaviour: l Neural transmission of Information l Principle of Chemical Neurotransmission l Receptors, Enzymes and Chemical Neurotransmission as the target of Drug Action l Special Properties of Receptors l Biogenic Amines and Behavioural Functions: l Nor epinephrine l Dopamine l Serotonin l Histamine l Acetyl-Choline and Behavioural Functions l Non-Neuropeptides and Behavioural Functions l Prostaglandins l Thromboxanes l Purines l Neuropeptides and Behavioural Functions: l Endogenous Opiods l GUT Peptides l Hypothalamic, Pituitary and Pineal Peptides 3. Genetics of Geriatric Psychopathology:

l Fundamentals of Genetics: l Molecular Genetics l Linkage Analysis l Candidate Gene 276 Psychiatry in India : Training & training centres

l Genetic factors in Normal and Accelerated Aging: l Cognitive impairment with Advancing Aging l Cellular Aging Research

l Methodology in : l Traditional Methods l Pedigree and family Studies l Twin Studies l Adaptation Studies

l Genetics of Psychiatric Disorders of Old Age:

l Cognitive Disorders: l Alzheimer's Disease l Multi-infarct Dementia l Parkinson's Disease l Huntington's Disease l Pick's Disease l Transmissible Dementias l Creutzfeldt-Jacob Disease l Gerstmann-Straussler-Scheinker Disease

l Non-Cognitive Disorders: l Schizophrenia and Related Psychosis l Mood Disorders l Schizo-affective Disorder l Anxiety Disorders l Alcohol and Substance Abuse 4. Physiological and Medical Considerations of Geriatric Patient Care: l Central Nervous System l Cardio-Vascular System l Respiratory System l Gastrointestinal System l Endocrine System l Musculo-Skeletal System l Haematological and Immune Systems l Renal System l Considerations in Geriatric Prescribing l Chronic Diseases in Elderly l Geriatric Syndromes l Geriatric Assessment 5. Psychological Aspects of Normal Aging: l Experimental and Cognitive Psychology l Neuroimaging and Neurosciences l Behavioural Medicine and Health and Behaviour Relationships Tiwari & Das: Training in Geriatric Mental Health 277

l Health and Disease Interaction with Intellectual and Cognitive Functioning l Health and Self-Related Health l Personality and Aging in the Social Context l Coping in later Life l Care-giving issues in the Normal Psychology of Aging l Longevity and the Extreme Aged 6. Social and Economic Factors Related to Psychiatric Disorders in Late Life: l Social risk Factors for Psychiatric Disorders l Age Changes and Cohort Differences in Social Risk Factors l Social Factors that affect Recovery from Psychiatric Disorders l Help seeking for Psychiatric Disorders l Public policies and Programs 7. Demography and Epidemiology of Psychiatric Disorders in Late Life: l Demography l Case Identification l Distribution of Psychiatric Disorders l Historical Studies l Etiological Studies l Health Service Utilization 8. Human Development through Life Cycle: l Infant Development l Childhood Development l Adolescent Development l Adult Development l Normal Aging – Psychological, Socio-cultural, Physiological Aspects l Self experience across the second half of the Life 9. Contribution of Intra-psychic and Phenomenological Theories in Psychopathology of Late Life: l Intrapsychic Theories l Freudian Approach l Jungian Approach l Adlerian Approach l Interpersonal and Social Approaches l Ego Theories

l Phenomenological Theories l Existential Movement l Humanistic Movement l Behavioural Theories 278 Psychiatry in India : Training & training centres

l Classical and Operant Conditioning Theories l Drive reduction and Reciprocal Inhibition Theories l Social learning and other Psychobiological Approaches 10. The History and Diagnostic Interview in Late Life: l The Psychiatric Interview of Older Adults: l History l Physical Examination l The Mental Status Examination l Family Assessment l Rating Scales and Standardized Interviews l Effective communication with the Older Adults

l Use of the Laboratory in the Diagnostic Workups: l Complete Blood Count l Serological Tests for Syphilis l HIV Testing l Thyroid Function Test l Vit-B12, Folate and Homocysteine l Toxicology l Urine analysis l ECG, EEG, Polysomnography l Imaging Studies: CT Scan, MRI l Genetic testing, Apo-E Testing l Ethical and Psychological concerns

l Neuropsychological Assessments:

l Neuropsychological Assessment in Geriatric Settings

l Neuropsychology of Normal Aging

l Differentiation of Alzheimer's Dementia From Normal Aging

l Neuropsychological profile of Cognitive Syndromes: l Mild Cognitive Impairment l Alzheimer's Disease l Frontotemporal Dementia l Lewy body Dementia l Vascular Dementia l Parkinson's Disease Dementia l Huntington's Disease l Progressive Supranuclear Palsy l Hydrocephalus l Creutzfeldt-Jakob Disease l Dementia of Geriatric Depression 11. Clinical Phenomenology and Psychopathology in Late Life: l Disorders in General Appearance and Behaviour Tiwari & Das: Training in Geriatric Mental Health 279

l Disorder of Consciousness and Orientation l Disorder of Attention and Concentration l Disorder of Affect l Disorder of Thinking l Disorder of Perception l Disorder of Memory l Disorder of Intelligence l Disorder of Insight and Judgment 12. Socio-cultural foundations of behaviour related to late life:

l Normality and Abnormality:

l Concept of Mental Health and Illness

l Attitudes towards Mental Illness, Stigma and Social Identity

l Epidemiological studies and Socio-Demographic correlates of Mental Illness in India.

l Family:

l Personality Formation in the Family: Parent child Dyad

l Early Development and Communication Pattern: T triadic relationship, Family Norm

l Self-Image and Self-Esteem

l Impact of Mental Illness on the Family: The attribute of Responsibility, Decision Taking, Role Performance, Power Orientation, Care Giver Burden

l Problems due to Family, Society, Community and Generation Gap in Old Age

l Disturbance in Interpersonal Processes:

l Personal relationships in different Mental Disorders of Old Age.

l Abnormal Self-Attitudes, Self Perceptions, Self-other Perceptions, Social Competence, Interpersonal Perceptions.

l Socio-psychological Methods:

l Clinical applications of Social Identity, Interdependence, Social skill and Interaction Models.

l Trans-cultural Aspects:

l Socio-cultural studies of socialization: Culture and Mental Illness, Social class and Mental Illness, Religion and Mental Illness, Social Change.

l Ancient Indian Concepts of Mind: Cognition, Emotion, Motivation, Stress, Personality and their relevance to Modern 280 Psychiatry in India : Training & training centres Health.

l Concepts of mental illnesses and its treatment in Ancient Indian Thought, and Promotive aspect of Mental Health

l Contemporary Indian Concepts, Theories and Models used in the field of GMH. 13. Neuropsychology in Late Life:

l Frontal Lobe Syndrome: l Basic Anatomy l Pre-frontal Cortex l Disturbance of Regulatory Functions l Disturbance of Attentional Processes l Disturbances in Emotions, Memory and Intellectual Activity l Premotor Cortex: Disturbances in Psychomotor Functions

l Temporal Lobes Syndrome: l Basic Anatomy l Special senses, Hearing, Vestibular Functions l Integrative Functions l Disturbances in Learning and Memory Functions l Disturbances in Speech l Disturbances in Emotions, Time Perception and Consciousness

l Partial and Occipital Lobes Syndrome: l Basic Anatomy l Disturbances in Sensory Functions and Body Scheme Perception l Agnosias and Apraxias l Disturbances in Visual Space Perception l Disturbances in Visual Memory l Disturbances in Emotions, Time Perception And Consciousness

l Functional specialization of Cerebral Hemisphere l Handedness and Cerebral Dominance l Split brain and reported studies on Cerebral Lateralization of Functions. l Plasticity and Restoration of Functions

l Psychophysiology l Methodology and Measurement l Psychophysiology of Cognition And Emotional States l Studies in Psychiatric Conditions 14. Psychiatric Disorders in Late Life: Tiwari & Das: Training in Geriatric Mental Health 281

l Cognitive Disorders l Movement Disorders l Mood Disorders l Schizophrenia and Paranoid Disorders l Anxiety and Panic Disorders l Somatoform Disorders l Sexual Disorders l Bereavement and Adjustment Disorders l Sleep and Circadian Rhythm l Alcohol and Drugs Problems l Personality Disorders l Agitation and Suspiciousness l Sub-syndromal Mental Health Problems 15. Treatment of Psychiatric Disorders in late life: Principles and practice of - l Psychopharmacology l Electroconvulsive Therapy l Diet, Nutrition and Exercise l Individual and Group Psychotherapy l Working with the Family of the Older Adult l Clinical Psychiatry in the Nursing Homes l The Continuum of care: Movement toward the Community l Acute Care inpatient and Day Hospital Treatment 16. Special Topics: l Legal, Ethical and Policy Issues l Integrated Community Services and Rehabilitation l Housing for Elderly l Yoga/meditation and its applications in Mental Health. l The Past and Future of Geriatric Psychiatry 17. Recent Advances:

l Basic Sciences: Neuroanatomy, Neurophysiology, Neuropathology, and Neuro-psychopharmacology l Applied Sciences: Phenomenology, Diagnosis, Management, Rehabilitation l Other Special Issues: Forensic GMH, Liaison GMH and Community GMH. 18. Methods of Clinical Research:

l Descriptive Statistics l Univariate: Central Tendency, Skewness and Kurtosis l Bivariate: Regression and correlation Coefficient 282 Psychiatry in India : Training & training centres

l Special measure of association: Rank Order Correlation Coefficient, Tetrachonic Correlation Coefficient and Phi- Coefficient.

l Probability

l Probability laws, Binominal, Poisson and Normal Distributions, Sampling from finite population, Sample Size, Sample Spare, Student t-statistics, Chi-square statistics, F- Variate, Statistical Inference.

l Estimation, point estimation, interval estimation, Test of hypothesis, Type I and Type II errors, Tests based on student- t, Chi-Square, V-Variate, proportion tests, tests of goodness of Fit: 2 x 2 contingency table, 2 x r contingency table, r x c contingency table.

l Analysis of Variance:

l Basic models, Assumptions, One way and Two-way classifications, Analysis of covariance Multiple variate analysis: Principle component analysis, Factor analysis, Cluster analysis, Discriminate function analysis, and Multiple Regression, Data processing and Computer analysis.

l Non-parametric Statistics:

l Central limit theorem, One sample and Two sample problems, Analysis of variance of rank order statistics.

l Scientific Methods:

l Various methods to ascertain knowledge, Scientific method and its features, Courses and effect: Mill's canons.

l Theory of Measurement:

l Measurement Nominal, Ordinal, Interval and Ratio Scales, Constructing Rating Scales and Attitude Scales, Reliability and Validity.

l Epidemiological Studies:

l Prospective and Retrospective Studies, Prevalence, Incidence, Age Specific Disease and Adjusted Rates, Life Table Technique.

l Survey Technique:

l Various Tools, Mail Questionnaire and Interview Schedule

l Sampling Methods: Complete Enumeration, Sample Survey, Tiwari & Das: Training in Geriatric Mental Health 283 Sampling and Non-Sampling Errors, Random and Non- Random Samples

l Sample Random, Systematic Random, Stratified Random and Cluster Random Sampling Design; Methods of minimizing Non-Sampling Errors.

l Experimental Design:

l Experiments versus Surveys, General Principles in Experimental Design, requirements for a good Design, Methods of Controlling Experimental Errors, Idea of Control, Matching, Local control, Concomitant variation, Randomization and Replication.

l Completely Randomized Design Randomized Block Design, Latin Square Design, Factorial Designs and Cross-Over Designs. Super-speciality training in GMH is a full time three years course after MD/DNB/Diploma in psychiatry leading to award of DM in GMH. The training course is going to start in Department of Geriatric Mental Health, CSMMU, Lucknow soon. 2.b. Training to develop Geriatric Paramental Health manpower: As a result of declining physical abilities, functions of sensory organs, cognitive functions, high prevalence of physical morbidities limiting locomotor activities, debilities, etc., older adults with mental health problems require special care by specially trained paramental health manpower. Thus, there is a need to develop this type of manpower simultaneously with mental health manpower. Objectives: To generate geriatric paramental health manpower to provide required special care to mentally ill older adults. To provide specially trained support manpower to accomplish total goal of GMH care. Geriatric paramental health manpower can be generated by formulating and starting speciality courses for clinical psychologists, social workers and psychiatric nurses either through departments/ units of GMH or through centers of excellence being developed by Ministry of Health, Government of India. The course curriculum for this training has been developed by the Department of Geriatric Mental Health and courses are going to start soon. 2.c. Infrastructure development: The state and central governments need to come forward, formulate specific policies for GMH care and rehabilitation, initiate establishing Departments of GMH at least one in each state headquarter's medical institution to start with and plan for such infrastructure development in other medical colleges of the 284 Psychiatry in India : Training & training centres state/center in future as well. Indian Council of Medical Research has taken the initiative of establishing “Institute for Research on Aging” in the country realizing the need and urgency. REFERENCE

1. Rajan SI, Sarma PS, Mishra US. Demography of Indian aging, 2001-2051. J Aging Soc Policy 2003;15(2-3):11-30. 2. Rajan SI. Population aging and health in India. 2006, Mumbai, CEHAT. Available from: http://www.cehat.org/humanrights/rajan.pdf, accessed 09.12.2010 3. Tiwari SC. Geriatric psychiatric morbidity in rural northern India: implications for the future. Int Psychogeriatr 2000;12:35–48. 4. Tiwari SC, Associates. An epidemiological study of prevalence of neuropsychiatric disorders with special reference to cognitive disorders, amongst (urban) elderly- Lucknow study. Preliminary report of an ICMR funded Project, 2009. 5. Tiwari SC, Associates. An epidemiological study of prevalence of neuropsychiatric disorders with special reference to cognitive disorders, amongst (rural) elderly- Lucknow study. Preliminary report of an ICMR funded Project, 2009. 6. Sood A, Singh P, Gargi PD. Psychiatric morbidity in non- psychiatric geriatric inpatients. Indian J Psychiatry 2006;48 (1):56- 61. 7. Reddy VM, Chandrashekar CR. Prevalence of mental and behavioural disorders in India: A meta-analysis. Indian J Psychiatry 1998;40(2):149-57. 8. Gururaj G, Girish N, Isaac MK. Mental, neurological and substance abuse disorders: Strategies towards a systems approach. NCMH Background Papers-Burden of Disease in India. 2005, New Delhi, Ministry of Health & Family Welfare, Government of India. 9. Medical Council of India. Syllabus of post graduate degree/diploma training programmes. New Delhi, MCI, 2006. 10. Medical Council of India. Post graduate medical education regulations 2000. New Delhi, MCI, 2000. 11. Competency based post graduate training programme for MD/MS, (Developed by MCI- Nominated group of experts).

S.C. Tiwari Professor and Head Department of Geriatric Mental Health Chhatrapati Shahuji Maharaj Medical University UP, India. Chairperson, Geriatric Psychiatry Specialty Section of Indian Psychiatric Society. [email protected]

Anindya Das Senior Resident, Department of Geriatric Mental Health Chhatrapati Shahuji Maharaj Medical University UP, India. 29 Psychiatric Rehabilitation: Training for psychiatrists

T.Murali and M.T. Sathyanarayana ABSTRACT

Psychiatric rehabilitation is a neglected area in the training program for psychiatrists. Varieties of reasons may be attributed to this situation. An ideal training program should contain aspects of psychiatric rehabilitation which enables a patient to function as normal as possible in the community. There is a need to incorporate psychiatric rehabilitation in the post graduate training program with adequate practical experience.

Psychiatric rehabilitation is an area which is often neglected during postgraduate training in psychiatry. Reasons for this state of affairs are many. It may be: (1) common belief that rehabilitation is the responsibility of non medical mental health professionals as most of the techniques used are non medical in nature (2) settings for psychiatric rehabilitation are situated outside hospital setting (3) Management of disability is more of a social welfare subject than health (4) general disinterest in the care of the chronic mentally ill (5) Lack of rehabilitation programs in teaching curriculum in medical colleges (6) absence of components of psychiatric rehabilitation in examinations (7) preeminence given for biological aspects of mental illness and medical management (8) improvement in patient's functioning perceived very slowly(9) The medical council of India does not insist for rehabilitation facility for awarding postgraduate courses. Psychiatric rehabilitation, also known as psychosocial rehabilitation, and usually simplified to psych rehab, is the process of restoration of community functioning and well-being of an individual who has a psychiatric disability (been diagnosed with a mental disorder). Rehabilitation work undertaken by psychiatrists, social workers and other mental health professionals (psychologists and social workers, for example) seeks to effect changes in a person's environment and in a person's ability to deal with his/her environment, so as to facilitate improvement in symptoms or personal distress. These services often "combine pharmacologic treatment, 286 Psychiatry in India : Training & training centres independent living and social skills training, psychological support to clients and their families, housing, vocational rehabilitation, social support and network enhancement, and access to leisure activities."[1] There is often a focus on challenging stigma and prejudice to enable social inclusion, on working collaboratively in order to empower clients, and sometimes on a goal of full psychosocial recovery. Psychiatric conditions rank among the first ten disabling diseases. Intervention in preventing or reducing disability is paramount in the management of mental illness. Further mental illness is one of the seven disabilities in the persons with disabilities act 1995, which needs certification and is done by a psychiatrist. As per the mental health act 1987 any facility which manages psychiatric patient requires licensing which needs a psychiatrist. Above all it is the responsibility of the psychiatrist to ensure that the patient functions adequately in the community as normal as possible. Rehabilitation is a team effort and psychiatrist should take the lead as all medico- legal issues are primarily the responsibility of the psychiatrist. Considering the above factors it is necessary for any student of psychiatry to have the knowledge and skills of psychiatric rehabilitation. Certification of disability in mental illness is another duty to be performed by the psychiatrist and needs adequate information about the disability in mental illness. In India very few post graduate training centres have rehabilitation facilities and these are mainly in institutes attached to large mental hospitals. Among these facilities training in rehabilitation with one month posting of residents is done only at NIMHANS. Majority of the medical colleges which are conducting postgraduate training in psychiatry do not have an exposure to rehabilitation. There are few formal training programs in rehabilitation in India for non medical students; one of these is conducted by the Richmond Fellowship Society India, Bangalore under the Rajiv Gandhi University of Health Sciences. This is a two year course leading to MSc degree in Psychosocial rehabilitation and Counseling. This course is a full time program with a course curriculum involving theory and practical management of patients in residential and non-residential rehabilitation facilities. The other course is in the Department of Psychiatry, Maharashtra Institute of Medical Sciences, Pune, which is of one year duration. This course offers training in psychiatric social work, clinical psychology, psychiatry and psychiatric rehabilitation with theory, practical and field visits. Formal short term training curriculum has been developed by the Rehabilitation Council of India. What should be the content/ course curriculum? It is essential to have a rehabilitation training for post graduates in psychiatry which clearly delineates the knowledge and skills for PSR. The course content should include both theory and practical. Murali & Sathyanarayana: Psychiatric Rehabilitation 287 Basic training should include Definitions, concepts, assessments, techniques, settings, legal and administrative issues, family involvement, community awareness, and community participation, networking and leadership skills for working in a team. Methods of training In NIMHANS the training consists of detailed workup of cases with a rehabilitation diagnostic formulation; this spells out a management plan with specific techniques, which includes medication management, type of intervention based on disability and goals to be achieved, up to the placement. Students are expected to monitor the patients and apply appropriate techniques like behavior modification, social skills training, token economy, family intervention, home visits and placement experiences. Identification and management of disabling side effects of medication and their management is as important as other aspects of disability. In a month there will be two seminars covering important contemporary issues and two journal clubs pertaining to psychiatric rehabilitation. The students will be taken for visits to other rehabilitation facilities outside NIMHANS. Working with a multidisciplinary team is one of the important components in rehabilitation training. The PG should know that the contribution of each and every staff member of the rehabilitation team is important and all team issues are to be dealt with in the team meetings. A practical guideline for PG training in rehabilitation Considering the ground realities in many of the teaching centres it may be prudent to have a two week training in rehabilitation. This includes theory and practicals with placement to a rehabilitation facility for at least one week. The rehabilitation facility may be outside the teaching hospital managed by independent agencies. Theory components should cover assessment of impairment and disability, specific intervention techniques (ABC analysis, behavior modification, social skills training, cognitive training, group and individual therapies, therapeutic community), different types of rehabilitation facilities, (day care, vocational training centres, sheltered workshops, halfway homes, quarter way homes, hostels, long stay facilities, community based rehabilitation, domiciliary care), family intervention (education, expectation, resource utilization, management of EE, coping strategies), community awareness and community participation ( techniques of awareness programs, types of community participation), legal and administrative issues (Metal health Act 1987 in relation to rehabilitation and rules thereof, PWD Act 1995 and rules, RCI ACT, UNCRPD , compliance to the local laws and requirements to start a rehabilitation centre, staff issues and conflict resolution), research and related issues in rehabilitation and innovations. 288 Psychiatry in India : Training & training centres Practical part of the training can be in two parts First part is on assessment and planning of rehabilitation program for different diagnostic categories which can be done in the teaching facility itself during the first week. Second week can be a placement in any rehabilitation facility preferably a residential facility including places where homeless mentally ill are managed. During this period the student is expected to take up at least one patient for day to day program where he or she will actually do the programs like taking care of personal hygiene, conducting groups, social skills training, cognitive training, community resource utilization, community awareness programs etc in association with the personnel of the NGO or any other agency. One Seminar or journal club on Psychosocial rehabilitation is essential during this two weeks along with information on professional associations in psychosocial rehabilitation and funding agencies. As the rehabilitation training is not mandatory in PG training in psychiatry, it is necessary to make it mandatory in all PG programs. By providing adequate training in the local realities we can develop a young psychiatrist who can handle psychiatric disability with confidence rather than communicating to the patient and family that nothing can be done (The author had personal experience of many psychiatrists communicating to the patient and family that nothing more can be done other than the medicines) We can also communicate to the PG that something can be done along with medicines which can improve a patients functioning. If a psychiatrist does not experience the joy of rehabilitating a person with mental illness he or she is missing a great reward in mental health care. Suggested reading list Liberman R.P., Recovery from disability Manual of Psychiatric Rehabilitation, American psychiatric publishing, inc. Washington, D.C., London,UK 2008.

Murali.T and Tally A.B Foundations and Techniques in psychiatric rehabilitation manual for CBR workers and caregivers, National Institute of mental health and Neurosciences Bangalore 2001

T. Murali Vice President, World Association for Psychosocial Rehabilitation. Professor of Psychiatry, Sree Sidhartha Medical College, Tumkur 233,2nd cross,12th Main, 4th Block, Koramangala, Bangalore 560034

M.T. Sathyanarayana ”Swarnashri” 2nd Cross, Ashoka Nagar, Tumkur – 572103. Karnataka [email protected] Specialised Training 30 Psychiatric Interview

Vihang N. Vahia, Ipsit V. Vahia, Amit Kulkarni

ABSTRACT

Mental status examination is of paramount importance in psychiatry. It defines the cluster of symptoms and signs that form the focus of therapeutic intervention and highlights the factors that determine outcome. Each patient has a unique set of symptoms that may not be revealed spontaneously. A standardized interview format helps to obtain relevant information. This article details the purpose, settings and the stages of a psychiatric interview. It highlights the significance of verbal and nonverbal communication and the importance of rapport. It describes a pattern for conducting and documenting mental state examination. The article concludes with brief mention of needs of specific population and reiterates that the article is a broad overview as it recommends suggested reading.

Key words: diagnosis, psychiatry, interview, symptoms, signs, stages, special population.

“The first important step towards optimal case management is to make a diagnosis. The second crucial step in the direction of optimal case management is to make a diagnosis. The third most important and decisive stride for optimal case management is to make a diagnosis. “ - Personal Communication (1973) to Dr. V.N. Vahia from Dr. D. R. Doongaji

INTRODUCTION

Every clinician endeavours to offer a treatment that has the highest prospect or probability of recovery and return to premorbid state of health. Formulating at least a provisional diagnosis soon after the first consultation is therefore imperative. The traditional approach is to obtain a reliable history of the factors causing and contributing to the illness, to elicit signs and to substantiate the diagnosis after authenticating its aetiology. As such, diagnosis in all branches of medicine is based on aetiology, which is 290 Psychiatry in India : Training & training centres established through clinical examination and laboratory or radiological investigations. Psychiatry, however, is unique since diagnosis is based on clusters of symptoms collaborated with signs elicited on mental status examination. Hence psychiatric diagnosis relies heavily on clinical information presented to the interviewer. The precise aetiology is often speculative and can rarely be confirmed clinically, biochemically or through radiological tests. This relative lack of empirical reliability and validity of psychiatric diagnosis impacts computerized data management. Several branches of medicine are starting to put into practice a system of computer-based data collection. Such computerized systems involve comparing clinical findings to electronic inventories of causative and contributing factors, lists signs that may be elicited along with coordinated lab values or radiological observations. Such inventory approach in psychiatry is not easy to design or implement. Psychiatry contributes to be a comparatively subjective branch of medicine. In this context mental status examination is of paramount importance in psychiatry. It defines the cluster of symptoms and signs that form the focus of therapeutic intervention and highlights the significant bio-psycho-social factors that determine or contribute to the outcome. Each patient has a unique set of symptoms, an exclusive cluster of signs and frequently, no lab tests or radiological tests can reliably confirm the diagnosis. Compounding the clinical conundrum are pervasive anxiety against revealing personal feelings, hidden fears or guilt for past indulgence, exposing personal prejudice, reluctance to accept psychiatric intervention or at times overt hostility towards authority in general and psychiatrists in particular, and widely prevalent stigma against psychiatry. Also, persons with mental illness may have poor insight and hence may inadvertently present misleading data. It is also important to note that subjective perception of self may be different from observation by the significant others. Hence a reliable objective data from caregivers is essential in formulating a diagnosis. The literature suggests that Adolf Meyer and his students were the first clinicians to highlight the significance of the psychiatric interview. Their research emphasized that 'nearly everything of clinical importance would be derived from the study of the patient as an individual and precise and detailed knowledge was therefore required of the way in which the patient's personality differed from that of other men, how it had grown and how it had been influenced by all life events of the person's life. The whole philosophy and theory of the causation of mental illness were implied in the method of examination 1 Several authors have proposed formats for mental status examinations. However all formats acknowledge that the quality of rapport facilitates Vahia et al: Psychiatric Interview 291 elicitation of significant information. With practice and experience, every clinician develops a distinctive pattern of psychiatric interview. However, anchoring the interview to a standardized format helps ensure that clinicians can identify consequential pathological factors that may otherwise be missed, or may not be reported by the patient. The authors have personally pursued and advocated the general format which is used by the Maudsley Hospital, London.2 This format facilitates eliciting psychopathology as incorporated in the current ICD and DSM.

Situational Indications for Psychiatric Interview:

Psychiatric interview may be conducted for the following broad purposes:

1. Diagnostic formulation and patient management at the intake. This could be the first consultation interview to establish the nature of the problem. 2. Liaison psychiatry or problem-referral interviews, usually to address a specific management or diagnostic query. 3. Psychiatric interview prior to procedures like HIV testing or preoperative orientation interviews to explain and allow understanding about the proposed procedures and expectations while participating in the procedure. 4. Termination and debriefing interviews eg. summaries of procedures, instructions for domiciliary care. 5. Crisis interview to provide support, assess data and assist in managing a crisis. 6. Observational interviews to scrutinize emotions and behaviours for legal or administrative purposes e.g. certification of fitness to be part of a legal process, specific psychiatric recommendation for a regulatory authority or aptness for employment 7. Clinical Research purposes.

Stages of the Interview Process:

Without prejudice to the primary purpose of the interview, the interview for the first six purposes listed above would focus on the current episode, an episode representative of the purpose of current intervention, habitual patterns of behaviour and emotional response to life events or the life style before the onset of mental illness. The process of conducting an interview could be divided into the following stages. 1) Non-directive stage. This is the phase of free association aimed at exploring and eliciting data. The interviewer avoids interrupting flow of information being revealed by patient, care givers or other 292 Psychiatry in India : Training & training centres relevant sources. This phase is important for development of rapport. 2) Semi-structured stage. The interviewer organizes the topics explored up to that point. It is important to exhibit flexibility and ask clarifying questions to explore information presented by the patient. Interpretation of verbal and nonverbal responses is an integral aspect of the entire interview. Questions should be simple, preferably in the habitual language of the person being interviewed and essentially open-ended. Attention must be paid to eliminating communication errors. 3) Expanding the interview. The interviewer focuses on specific aspects of the history that seem especially pertinent. This in an opportunity to understand fine points of significant events in the person's life, their emotional balance and the extent to which the events may have influenced the personality, interpersonal relationships and other factors that may have contributed to the current psychopathology. The interviewer should consider the interviewee's physical health, educational status, and personal beliefs. It is necessary to be sensitive about religious, political and gender related issues while formulating questions. An interviewer perceived as opinionated, biased, aggressive, incompetent or disinterested is likely to be at a loss by increasing the risk of not being provided with all the necessary clinical information. 4) Structured stage of the interview. The interviewer may choose to ask direct questions that may be either open or close ended. This is the stage of the interview where the interviewer attempts to ensure that all primary areas are covered. This phase helps to confirm a clinical diagnosis and rule out other differential diagnosis in a systematic manner. The goal is to elicit responses that would contribute to formulating diagnosis and determine choice of management options. Most interviewers form their own style to clarify vague responses.

Shift within the stages is determined by the content and significance of the information revealed during the process. It is important to ensure that the questions are properly understood and replied clearly. Appropriate recognition of non verbal communication like spells of silence, flushed face, tearful eyes, spells of sudden shuffling, feeling thirsty, hostile outbursts, refusal to reply or attempts to prematurely conclude the interview may give clues about the factors causing or contributing to the current illness.

Format for Recording Information from Interview:

In order to systematically record all clinical information obtained during the interview, the format below may be used a general guideline: Vahia et al: Psychiatric Interview 293 A. Demographic data to identify the patient. B. Details of current symptoms including nature, duration, mode of onset and list of contributing factors. C. Progress of the symptoms since onset. List of factors that indicate provisional diagnosis and dispense with differential diagnosis. D. Pre-morbid personality. Specific attention to social interactions, ability to obtain and retain employment, relations with colleagues at work, unusual beliefs or behaviours, outstanding achievements, gender preference and sexual practices. E. Personal history about early childhood development with specific attention to occurrence and nature of childhood trauma and its impact, school experiences, neurotic symptoms, substance abuse, occupational data F. Marriage and sexual history. Include relations with the spouse and family, children, marital discords and data about children. G. History of medical or surgical illness including head trauma and history of any medications that the patient may be regularly taking including psychoactive substance use or abuse. H. Mental or physical illness in the past and in the family. I. Mental state examination: This is the documentation of observations of the interviewer. To ensure an extensive record, the observations may be divided into following subheadings. a. General behaviour: Complete and accurate description incorporating data obtained from care givers, colleagues, acquaintances and when relevant, the ward staff. i. General reaction and posture ii. Facial expression- spontaneous and in response to specific inquiries iii. Eyes, open or closed, ability to establish and sustain eye to eye contact with the interviewer. iv. Reaction to questions, including emotional responsiveness v. Muscular reactions like tics, swaying, fidgety, restlessness, nail or lip biting, negativism, stiffness of posture. b. Speech and thought: Note the spontaneity, stream, content, presence of abnormalities like overvalued idea, superstitions, delusions, misinterpretations, concept formation (primary and proverbs). 294 Psychiatry in India : Training & training centres c. Repetitive behaviours and compulsive phenomenon d. Perceptions: Document illusions or hallucinations e. Mood and Affect of the patient. f. Brief Cognitive Examination, which should include a test of (I) Memory for immediate, recent and remote events. (ii) Orientation in time, place and person. (iii) Intelligence as tested by age-, education- and experience-appropriate general knowledge. g. Insight and Judgement: which include personal attitude towards the current mental state, accepting the symptoms as indicative of mental or nervous state that need to be treated and spontaneity of responses. Personal response towards financial, domestic and personal environmental events may also be recorded. h. Neurological and systemic examination. I. Blood tests to determine general health and metabolic profile. j. Brain imaging if indicated. J. Summary of mental state. K. Diagnostic formulations eliciting symptoms as obtained during the interview, duly collaborated with signs elicited on mental status examination that fulfill the diagnostic and exclusion clauses of the diagnostic categories of the classification system being followed at the respective centres.

Interviewing Special Populations:

It is important for clinicians to note that certain elements of the interview may be especially important in specific populations. For example, when interviewing children, it is important to incorporate developmental history, and to obtain a history or behaviour and performance in school. When interviewing geriatric patients, clinicians should obtained detailed medical history, a complete list of all medications including doses and perform a cognitive examination. When interviewing persons with a history of substance use, or criminal involvement maintaining a non-judgemental attitude is likely to build trust and rapport and improve the chances of patient revealing information that they may have been resistant to disclosure. Developing a good rapport and providing a trustworthy environment for disclosure of personal information is critical while interviewing any patient.

In conclusion, we wish to specify that this is intended only as a very broad Vahia et al: Psychiatric Interview 295 overview of history taking and not as a comprehensive treatise on the skills of history taking. Several specific issues that are relevant to history taking are beyond the scope of this article and for more comprehensive information; readers are advised to refer the text books of psychiatry.

REFERENCES 1. Muncie, W. 1948 Psychobiology and Psychiatry. 2nd Edn. London: Kimpton. 33,50. Cited by Slater E, Roth M. Clinical Psychiatry, 1969.Mayer-Gross, Slater and Roth Clinical Psychiatry.3rd Edn. Bailliere, Tindall & Casell, London. P 33 2. Slater E, Roth M. Clinical Psychiatry, 1969.Mayer-Gross, Slater and Roth Clinical Psychiatry.3rd Edn. Bailliere, Tindall & Casell, London. P 36

Suggested Readings 1. http://web.jjay.cuny.edu/~pzapf/classes/PY761/Week%202%20Notes.htm 2. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th Edition. 1994 3. Practice Guidelines. Psychiatric Evaluation of Adults. 1996. American Psychiatric Association. Washington DC 4. Merkel, L.G. http://www.healthsystem.virginia.edu/internet/psych-training/seminar/pgy-i- psychiatric-interview.pdf. Downloaded Dec 24, 2010 5. 'Stages of psychiatric interview: Techniques and Settings'. Copyrighted by psychiatry. healthse.com http://psychiatry.healthse.com/psy/more/stages_of_the_psychiatric_ interview. Downloaded Dec 12, 2010.

Vihang N. Vahia Professor Emeritus of Psychiatry Cooper Hospital 261, D.N.Road, Fort, Mumbai 400001 [email protected]

Ipsit V. Vahia Stein Institute for Research on Aging Department of Psychiatry University of California, San Diego 9500 Gilman Drive #0664 La Jolla, CA 92093

Amit Kulkarni Consultant Psychiatrist BCJ Hospital and Asha Parekh Research Centre Mumbai

31 How to make a case presentation

P.K. Dalal, Adarsh Tripathi, Anil Nischal

ABSTRACT

Learning to present a case to the teachers and in examinations is a necessity of psychiatric training and vital in mastering the assessment and understanding of patients in psychiatry. In order to present a case, one must have knowledge of psychiatric terminology and phenomenology, be able to detect or elicit necessary data during the interview, and know how to interpret and integrate these data in a clinically meaningful way. Students of psychiatry should learn to describe their findings in a predictable, concise, and unambiguous manner. The vocabulary and organization used in case presentation may vary slightly from one resident to another, but overall it is quite similar. Among several other aims, reaching to a correct diagnosis and making a thorough management plan to help the patient in best possible way is essential while discussions regarding case are done in the clinics or examination. The organization or outline of format of case presentation enables the psychiatrist to describe objectively what has been seen and heard during the interview. Although this text includes few details on eliciting information, it is not intended to instruct the reader in interviewing techniques. A basic system of organization which can be used during case presentation is described in the text below.

Key words: Case presentation, interview in psychiatry, mental status examination, history presentation

Clinical interviewing is central skill of a psychiatrist and development of interviewing skills is the main aim of basic psychiatric training. Interviewing skills are considered both the science and art thus it can't be solely learned from a textbook or reading elsewhere. A trainee psychiatrist should take the opportunity to observe experienced clinicians as they interview patients and most importantly, carry out many clinical interviews and present the results to their teachers. Skills in this area come with experience and practice. 298 Psychiatry in India : Training & training centres Aim of the clinical interview: The psychiatric interviews are performed with the following aims.

l Assessing history and performing mental status examination l Understanding personality, social circumstances, life story and possible causative, contributory, perpetuating and maintaining factors of the illness

l Assessing diagnosis and differential diagnosis l Deciding nature and setting (indoor, outdoor etc) of the treatment required

l Explaining the diagnosis and management plan to the patient l Discussing future investigations or referral if needed l Discussing course and prognostic factors of the illness l Establishing therapeutic alliance, instilling hope and encouraging self help if possible

l Assessing risk to self and others

Case Presentation:

During training, making a case presentation is very important to learn and develop interviewing skills. Below is the format for timely and thoroughly presenting a case during examinations to the examiners and in routine presentations to teachers:

How to present History:

Identifying data (Basic information): Provide a succinct demographic information including Name, age, sex, occupation, residence, domicile, marital status, religion, education, patient's and family income, and current medicolegal status. Also report whether patient came of his own, brought by someone else or referred form somewhere.

Informants detail and their reliability: Present name, age, sex and relationship with the patient of key informants.

Five parameters should be assessed. Consistency, Coherence, Chronological information, Closeness with patient, Concern for patient (5 Cs). Overall decision regarding reliability (reliable, partially reliable or unreliable) should be told.

If the informants are reliable only for particular part of the history, it should be clearly mentioned. Patient should also be an informant till he/she is completely unreliable or uncooperative. Dalal et al: How to make a case presentation 299 Presenting or chief complaints and summary: Presented in patients own words and in chronological order. One can present both the complaints given by patient even if they appear bizarre or irrelevant and complaints of the informants separately.

Summary is presented under headings of- Onset, course, duration, episode, precipitating factor, treatment taken, compliance and their response.

History of present illness: This part provides a comprehensive and chronological picture of the events leading upto current moments in the patients' life. Therefore, a detailed and well planned presentation is necessary in this part. For each individual complaint report its nature (in the patient's own words as far as possible); chronology; severity; associated symptoms and associated life events occurring at or about the same time. Note precipitating, aggravating, and relieving factors. Patient and family attribution of their symptoms should be described? Each information should be supplemented with adequate evidences and an example preferably in patient's/informant's verbatim.

Neurovegetative functions (Sleep, appetite, sexual interest) should be described in detail. Dysfunction (Social, occupational and personal) and its progressive evolution to current status need to be reported separately.

Details of treatment taken and response to the treatment, compliance, reasons for noncompliance, if so. Any attempts for faith/religious healings etc and their response.

Current medical conditions, their status and medications. Any possible correlation with psychiatric symptomatology.

Present relevant negative history to clarify possible differential diagnosis.

Past psychiatric and medical history

Previous psychiatric diagnoses. Chronological list of episodes of psychiatric inpatient and outpatient care. Chronological list of episodes of medical or surgical illness. Episodes of symptoms for which no treatment was sought. Any illnesses treated by doctors. Previous psychiatric drug treatments. History of adverse reactions or drug allergy. Any non-prescribed or alternative medications taken.

Family history

Family tree with details of names, ages and relationship needs to be drawn. Examiners might see the family tree or may ask the examinee to draw one. Are there any familial psychiatric or medical illnesses and their treatment details? 300 Psychiatry in India : Training & training centres The patient may be more likely to respond with few psychotropic medications (i.e. lithium, antidepressants etc) which were useful in their family members.

Living conditions, nature of relationships among family members, family members’ understanding and acceptance of illness, social support system. Details regarding history of origin are presented here. History of substance abuse, suicide, absconding or missing person in the family.

Personal/Developmental history:

Perinatal period (Antenatal, natal and postnatal), Developmental milestones. Childhood and adolescence history, education, occupation, sexual and menstrual history.

Marital and history of family by procreation: Details like duration of marriage, quality of relationships, relevant/important qualities of spouse and offspring. Other details like family history of origin needs to presented.

Medicolegal history : any medico-legal issues.

History of psychoactive substance abuse: Details regarding initiation, current pattern of use, withdrawal, tolerance, impairment in personal, social and occupational spheres are presented. Any implication on current illness may be described.

Premorbid personality (Adopted from Slater E. and Roth M. 1999):

Presented under headings of 1. Relationships with friends and family (social relations) 2. Predominant mood 3. Intellectual activities, Hobbies and interest 4. Character- a. Interpersonal relationship b. Attitude towards work and responsibility c. Energy levels and work initiatives d. Moral, religious and health related activities 5. Fantasy life

Assessment of personal and premorbid personality is likely to take significant time and it is often not possible to go in very much details during time bound interview of examinations. Descriptions don't satisfy with series of adjectives and epithets so illustrative anecdotes and statements from life of the patient should be quoted as evidences. Briefly the aim is to assess: Dalal et al: How to make a case presentation 301 I) Recurring patterns of behavior and experiences in relationship and jobs in life. ii) An evolving sense of personal identity across the nonvegetative spheres of human behavior- namely, relationships, work, and enjoyment.

Physical examination: Present assessment of overall general health, monitoring of vitals and systemic examination. If organic etiology is possible, detailed assessment of that particular system should be presented (i.e CNS examination in dementia, CVS examination in Panic disorder etc).

Mental Status Examination:

General appearance and behavior: Describe appearance, predominant physical characteristics, cleanliness, hair, clothes and style of dressing, any unusual dressing or ornaments, apparent age and general physical health, any involuntary movement.

Eye to eye contact, facial expression, use of posture and gestures.

Behavior and psychomotor activity, attitude towards examiner, cooperativeness and openness in conversation.

Speech (volume, rate, tone, prosody, fluency).

Rapport could be established or not. If not, the effort made by the examinee to establish rapport should be described.

Consciousness and orientation: Alertness and awareness of surrounding. Orientation to time, place and person .

Attention and concentration: Attention is described as easily arousable or arousable with difficulty.

Digit span test, 100-7 test or 40-3 test.

Months/weekdays names forward or backwards may be useful in illiterate or less educated patient.

Mood and Affect: Subjective and objective assessment (based on facial expressions, vocal tone modulations, gestures and posture).

Describe predominant mood (euthymic, depressed, elevation, elation, anxious, distressed etc). 302 Psychiatry in India : Training & training centres Describe stability, intensity or depth, range, reactivity, appropriateness to thought content and setting

Thinking:

Flow- Increased, Decreased or Normal

Form- Relevant, coherent, Degree of connectedness (loose associations, tangentiality, derailment etc.), Presence of peculiarities (clang associations, punning, neologisms, etc.)

Content- Predominant topic or issues, Overvalued ideas, Beliefs, Delusions, Preoccupations, Ruminations, Obsessions, Suicidal/homicidal ideation, Phobias

Describe frequency, intensity/severity and impairment due to each problem in thought content

Possession of thoughts- Thought broadcast, Thought block, Thought withdrawal, Thought insertion

Perception: Illusions, Hallucinations, Depersonalization, Déjà vu The sensory system involved (e.g., auditory, visual, taste, olfactory, or tactile) and the content of the illusion or the hallucinatory experience should be described. Circumstances of the occurrence of hallucinations like relation to sleep or stress should be described. Clearly differentiate between hallucinations, pseudohallucinations or imagery. Describe frequency, intensity/severity and impairment due to each of the above symptom in perception

Intelligence: Test of intelligence should be performed according to educational and sociocultural background of the patient. Examinee should describe

1) Abstract thinking- Similarities, proverb interpretation 2) Arithmetic calculation- Addition, subtraction, multiplication etc as per educational background 3) General fund of Knowledge- Useful tests for illiterate or less educated patients are naming of five major rivers, five big cities, vegetables and fruits Asking about current events, famous persons in country and politicians also helps to know and report general awareness of the patients

Memory: Immediate registration and recall (3 unrelated words like coin, cycle and tomato are given. Describe ability to register and recall after 5 minutes) Dalal et al: How to make a case presentation 303 Recent memory (describe food items ingested in the morning and yesterday night, recent visitors, route and ways of travel to hospital etc)- applies on the scales of minutes to days

Remote memory (dates of important life events, important events of national/international interest of the past)- encompasses months to years

Information asked in recent and remote memory should be cross checked with an informant of the patient

Judgement: Personal and social judgment (Reasoning regarding current important issues, Ideas about decisions or actions to be taken including a current illness, Evidence from past judgments as clues to current thinking, social behavior and evidences from direct observation)

Test judgment- Addressed and stamped letter test, Fire test

Insight: Grade I to VI

Diagnostic formulation: Often the examiners ask for a diagnostic formulation. It is brief outline of overall case where only relevant positive and negative aspects from history and MSE are presented to the examiner so that important clinical decisions like diagnosis and management can be planned.

Diagnosis and differential diagnosis: Discuss the points in favor and in against for each diagnosis being considered

Management: Consider following points Setting of the treatment- Place of the management (indoor, outdoor) should be discussed with the reasons for the same.

Investigations required- Relevant and necessary investigations for diagnosis and differential diagnosis required should be described

Biochemical- Blood and Urine investigations etc

Radiological- CT scan, MRI scanning, EEG etc

Psychological- Rorschach inkblot test, Thematic Apperception Test, Bender Gestalt Test etc

Treatment- Discussed in two broad headings

Pharmacological- Group of medications and name, dose of initiation and maintenance, precautions before starting medication 304 Psychiatry in India : Training & training centres Non pharmacological- Type of approaches required, psychoeducation, Cognitive behavior therapy etc and strategies for rehabilitation.

Personal suggestions: l Before starting interview, keep a format for history and MSE ready so that during interview the trainee should be able to record information as it comes. Most part of MSE can be completed during history taking itself with this strategy and a lot of time can be saved. l Appear unhurried: Despite time limitations appearing unhurried will help the patient and attendant to be at ease and time taken to complete interview is also not prolonged much. In hurry, people often make careless mistakes leading to ultimately more loss of time. l It may not be possible at times to take satisfactory details of personal or family history and premorbid personality in few cases with long history. In such cases it is prudent to report to the examiner about the same but also emphasizing at the same time areas which you like to enquire in details in future assessments. l Practice finishing history and MSE in 45 minutes. Rest of the time should be utilized to revise the information elicited, to gather the thoughts regarding case and writing diagnostic case formulation etc.

REFERENCES

1. McIntyre KM, Norton JR, McIntyre JS (2009). Psychiatric Interview, History, and Mental Status Examination. In Sadock BJ, Sadock VA, Ruiz P (eds): “Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 9th Edition”. Lippincot Williams & Wilkins 2. Goldbloom DS. Psychiatric clinical skills, Pheladelphia, 2006, Elsevier 3. Psychiatric assessment in Oxford Handbook of Psychiatry, 1st Edition. Eds: Semple, David; Smyth, Roger; Burns, Jonathan; Darjee, Rajan; McIntosh, Andrew. 2005 4. Slater E. and Roth M. (1999). Examinations of psychiatric patient. In Mayer-Gross, Slater and Roth (eds): “Clinical Psychiatry 3rd edition.” Delhi, A.I.T.B.S Publishers

P.K. Dalal Professor & Head of the department [email protected]

Adarsh Tripathi Lecturer

Anil Nischal Associate Professor Department of Psychiatry CSM Medical University (Erstwhile K.G. Medical University) Lucknow 32 Teaching Post-graduate Psychiatry Through Clinical Rounds

P.S.V.N. Sharma

The use of clinical rounds to examine and treat inpatients in hospitals has a hoary past in clinical medicine. With time this model came to be adopted in psychiatry also. As the setting of inpatient treatment for psychiatric patients changed from traditional mental hospitals to general hospitals and nursing homes, there followed a progressive identification of the discipline with clinical medicine, further fostering the use of clinical rounds as a major mode of interaction of the doctor with patients.

With the introduction of formal training in psychiatry, one of the important points of student-teacher interaction became the teaching clinical rounds. Often this is the most significant avenue for teaching and assessing clinical skills; be they in interviewing, diagnosis making, therapeutic interventions etc. This is especially so when outpatient departments are overstretched for time as well as space, there is a paucity of hands to complete routine clinical work and there exist no other treatment settings for the teacher and student to interact in the context of the patient, his family and the clinical problem to be addressed. However, it has been suggested by Grantcharov and Reznick[1] that the basic skills training should take place in a skills lab before starting work on patients. This is a suggestion worth considering especially in postgraduate training in psychiatry.

Clinical teaching in rounds is an educationally sound approach which is often undermined by problems of implementation. Spencer[2] writes that problems arise with clinical teaching because of lack of clear objectives; excessive focus on factual recall; teaching pitched at the wrong level; learning by passive observation; inadequate supervision and feedback; little opportunity for reflection and discussion; teaching by humiliation; lack of congruence or continuity with the rest of the curriculum, amongst others. Questions can be put to good use in teaching. One needs to avoid closed questions, allow time to the student to answer, be nonconfrontational and use counter questions to learners' questions. Similarly when giving explanations, information should 306 Psychiatry in India : Training & training centres be given in limited amounts, putting it in a broader perspective. The techniques of summarising and reiteration are also very useful in clinical teaching.

The issue of time shortage is perhaps universal. Irby and Wilkerson,[3] suggest that time can be saved in the teaching rounds by identifying the needs of each individual learner, teaching according to his specific needs and providing feedback on performance. The trick to save time is to ask questions, observe the learner's performance for brief periods of time to assess needs, teach rapidly (there are several theoretical models of rapid teaching) and use demonstration.

Every teaching clinical rounds has a leader – by seniority or speciality. This is inevitable and indeed necessary, even in a non-hierarchical multidisciplinary psychiatry team, to ensure the smooth functioning of the rounds and management of the patients' health problems.

As is the case with medicine, and perhaps even more so in psychiatry, the need for confidentiality, sometimes, makes the bedside clinical rounds an uncomfortable exercise. Despite allusions to our social systems, joint family, public decision making about private affairs etc., it would be very daunting for a patient to feel comfortable in a bedside rounds used for teaching and demonstrating. Understanding ethical concerns should also be a part of clinical rounds. Sokol[4] writes about 'the substantial difference between studying ethics in a class and doing ethics on the wards'. Furthermore, as Ker et al.[5] observe, teaching in the presence of patients may be an awkward task because the patient plays a central role and also is the most attentive member of the audience. Many training centres use the ward side-room or class room for psychiatric rounds. Even this is a less than satisfactory arrangement when there are a large number of persons attending the rounds. Perhaps one should consider options such as video-monitoring or the use of a one-way mirror for teaching in the rounds, provided the patient consents.

The clinical rounds revolve around two basic points of focus: providing patient care and at the same time serving the purpose of learning for the trainee (and very often the trainer as well). The duration, frequency, time spent per patient etc may vary according to the dictates of the situation.

A few points may be central to the effective use of teaching rounds. Firstly, the rounds are probably better conceptualised as treatment-providing efforts for the benefit of the patient as well as teaching exercises, rather than a purely 'professorial performance' where the latter is something of a prima donna, as is sometimes the case in the so called grand rounds in many disciplines including psychiatry. (The term 'grand rounds' is also used in some centres to Sharma: Teaching Post-graduate Psychiatry 307 denote a series of lectures or CMEs though this is not the meaning of the term in the present article). Secondly, the invidious tendency to discuss 'the case of depression', or 'the case of agoraphobia' rather than a person suffering from a particular illness needs to be discouraged by the teacher in his own mind before this precept can be compulsorily delivered to the trainee. Thirdly, the teacher must encourage the student to - present the examination finding, interrupt the discussion whenever in doubt, ask questions, raise queries and take contrary positions of opinion as he genuinely believes; without feeling intimidated by the teacher. It is the responsibility and duty of the teacher to ensure this. If the student is unable to do the above, especially in psychiatric training, then there may be something wrong in the procedure of training being followed; very often the issue may be one of covert discouragement of such interventions by the teacher. Fourthly, it would be helpful if the teacher co-opts the opinions of the students into decision making regarding management of clinical problems, even if this means that it takes up extra time of the teacher. Fifthly, it will always be clinically fruitful to invite a discussion from fellow faculty (of various disciplines) in the rounds, to enrich the inputs to the student, this is especially essential in a multidisciplinary subject such as mental health care. This last practice will prove beneficial in the training of the junior faculty to graduate to a senior level. In fact some parts of the teaching rounds or rounds on some days should be lead by the junior teachers, with the senior teacher in attendance, also as a means of training the junior teacher.

It is extremely important for the teacher to access all sources of information regarding the patient – from the patient, the relatives, the nurses, other team members, and if necessary other persons on the ward as and when necessary, in the rounds itself. This will provide more complete information which may benefit the patient ultimately. It also teaches the student the importance of wide-ranging information gathering as well as reinforces his use of the biopsychosocial multidisciplinary model by seeing it being done.

The teacher needs to plan a clinical round before it starts rather than making it an impromptu affair relying on his 'vast experience'. This planning is vital if students of different levels of proficiency are attending, and even more so, when students of different disciplines participate in the rounds. The planning should be 'micro' involving the particular round at issue and 'macro', involving a term or semester of clinical rounds. The planning includes setting of the goals that have to be reached in each round and by the end of the term. The targets may be very different for students of different levels of proficiency, different specialities and even in some cases, for different students of the same seniority. For example: if a patient suffering from Depression is being presented in a round, the focus for a first year student could be interview technique, knowledge and elicitation of symptoms, risk assessment etc; the 308 Psychiatry in India : Training & training centres second year student may be guided to think about types and methodologies of interventions, other clinical - aetiological correlates, investigations etc; the third year student would plan the acute and long term comprehensive management, prognosticate and dwell on larger theoretical issues pertaining to the illness; the faculty may then contribute in terms of hard literature, evidence based matters and so on – all this orchestrated by the senior teacher conducting the rounds. The same pattern needs to be followed in the liaison or referral setting also. As Ker et al.[5] noted, it is necessary to keep the following points in mind in a teaching ward round: what is the plan for teaching and learning; what do the learners know; what can be achieved in the time available; who should do the teaching; how can I help students to learn; how will I know what has been learned? Is there a need for such fine tuning, after all every one learns to swim when thrown into the water? Yes, but everyone does not become equally adept at swimming left to ones-self without exclusive inputs over and above generic ones.

An important lacuna in our clinical rounds is that as teachers, many find it difficult to reach the fine mix of clinic and theory that is so necessary for the student, in the clinical rounds. Some teachers treat clinical rounds as exercises which are totally divorced from theory (the 'men are from mars and women from venus' syndrome). A few teachers may even undermine the relevance of theory in clinical practice. This obviously is not only unsatisfactory but smacks of a form of inverse snobbery. Other teachers load their rounds with theoretical discourse (which often becomes an exercise in tangentiality), underplaying the clinical problem or phenomena, with no clinical rooting for the student to associate with. Coomarasamy and Khan[6] noted in a systematic review, that standalone teaching improves knowledge but not clinical skills, attitudes and behaviour. Clinically integrated teaching improves knowledge, skills and behaviour. In a study of imparting clinical instruction, Mascola[7] found a method of instruction using guided mentoring of EBM skills during actual patient promising. He notes that this is different from plain literature appraisal in a class room and involves actual bedside decision making. What we need to remember in medicine is that we learn in a unique system where 'the clinical' is linked to 'the theoretical' and vice versa. From clinical precepts are distilled theoretical constructs, which in their turn inform clinical practice. The clinical rounds hence must focus on both. After achieving this balance, space is created for discussing the shortfalls in our knowledge, be it theoretical or clinical-practical. This sets the tone for scientific inquiry and indeed healthy scientific skepticism. For example: in a discussion of a person suffering from substance use disorder, after examining 'the clinical', a discussion of - psychological assessments, case-work, the theory of childhood experiences, adverse social circumstances, enhanced genetic burden of disease or existing cultural determinants of illness; and linking these to the clinical problem at hand 'in a manner so as to bring the Sharma: Teaching Post-graduate Psychiatry 309 text-book alive' will inform clinical management as well as produce a lasting engram of memory in the student – and perhaps an interest to explore further.

Teaching also occurs in bits and pieces during routine management rounds. Irby and Wilkerson[3] write that the time saving rule of thumb is to 'target, then teach', thus saving time by not teaching what the learner already knows or is not ready for. This can be achieved by asking questions to identify what and how to teach, followed by two-minutes observation to gather information about the learner's needs for guidance, direction, feedback, or enrichment. The second step is 'teach rapidly' using specific techniques as required.

Feedback is the cornerstone of effective clinical teaching. Cantillon et al.[8] write that though teachers believe they give regular and sufficient feedback, often this is not how it is perceived by learners. They suggest that feedback should be an everyday component of clinical teaching; the criteria for assessment should be clear; feedback should be on specific observed behaviours and not generic; it should be non-judgemental and given soon after an event; it should be limited to one or two items at a time; and learners' own perception also should be sought during the feedback exercise. Feedback can be given in various ways to suit the occasion. It is suggested that clinical teachers should regard the art of giving feedback as a critical skill to be acquired through repeated practice and reflection on their own performance.

The ability to reflect on one's actions and decisions is an important skill that is necessary for learning from clinical experience. The teacher is expected to help the student to learn the reflective habit. Driessen et al.[9] suggest that students can be helped to learn reflective skills by stimulating them to assess and analyse their clinical actions and devise alternative actions; by providing them a challenging environment; by giving feedback and by asking them the right type of open ended questions.

The role of humour in the rounds is often under-recognised. It is a very important ingredient of successful teaching rounds. It is often a great reliever of monotony and a stress buster for an anxious student (or a bored teacher). Humour helps the teacher not to take himself too seriously and to communicate at a more equal level with the team – something very important in a multidisciplinary setting.

Some teachers, during their rounds, raise topics that are only remotely linked to the current clinical discussion. This is sometimes a good technique to retain the attention of the student. This, in psychiatry, when done with finesse, can succeed in making the student read materials which are of 310 Psychiatry in India : Training & training centres peripheral interest to the subject but very important for perspective. For example a brief digression from the subject of phenomenology into literature may interest the student to read Sartre or Kafka and gain in his perspectives of existentialism! However this should always be done judiciously, without losing sight of the teachers' primary suit.

Clinical rounds can be a forum for discussing other specialities of medicine as they impact on psychiatry. Other systems of treatment can also be a legitimate subject of discussion. All this will obviously be done keeping in mind the need to strike a balance in terms of time and relevance. What needs to be discouraged, is a discussion on other professionals, their practices and personal matters etc. Such practices border on slander and the student needs to be clearly shown the line of demarcation in such matters. Similarly, teaching clinical rounds cannot be a forum for political or religious pontification. However matters of politics, policies and religion of relevance to psychiatric practice or mental health at large are fine as long the plane of discussion is not colored by the teacher's personal emotional leanings.

Teachers are very often role models to students. This is especially so in the clinical rounds setting where the interactions between the clinician teacher and the students are intense and often prolonged. Teachers must be aware of the conscious and unconscious components of learning from role modeling. Cruess et al.[10] point out that effective role models have clinical competence, teaching skills, and positive personal qualities. They advise that the teacher should be aware of being a role model, keep time for dialogue with the learner and make a conscious effort to articulate what is being modelled, so that the net effect of the process is positive.

How do we deal with the 'recalcitrant resident'? Throw him out of the rounds, shout at him, be sarcastic, make him rewrite the case files or discharge summaries, repeat or cancel his posting, make him apply for leave, make fun of him in front of others, ask him not to appear for the examinations? Steinert[11] writes that the common problems identified in the challenging or difficult juniors were insufficient medical knowledge, poor clinical judgment, inefficient use of time and attitudinal problems. The teachers should attempt to find out where the problem lies, i.e. in the learner (knowledge, attitude or skills), in the teacher (assumptions and biases) or in the system (unclear standards and responsibilities, overwhelming workloads, inconsistency in teaching or supervision and a lack of feedback or appraisal). Customised inputs can then be devised to improve the situation instead of contemplating punitive measures.

The teacher also gains from the clinical rounds. They, due to multiple inputs, often help in arriving at a better understanding of the patient's problem and Sharma: Teaching Post-graduate Psychiatry 311 then its better solution. The process of imparting clinical skills to others (not as received wisdom, but as something to be evaluated in the open rounds and accepted, modified or rejected) is itself a gratifying matter. The teacher also gains technically as well as theoretically, in the preparation for and interactions in, the rounds. There are many questions that rise de novo or when asked by others, which then become a source of enquiry and rediscovery. Old notes are dusted out and re-read, memories that were warped with time are corrected, new knowledge is imbibed. Then, there is of course the thrill of the whole exercise of intellectual jousting with peers – what better kickback could there be, that too without a scam!

Mental health speciality training involves a high emphasis on the acquisition of clinical skills and knowledge. The teaching clinical rounds are a very important tool in achieving the goal of skill and knowledge acquisition. They are likely to be highly beneficial and intellectually satisfying to the student, the future teacher and the senior teacher alike, if care is taken to conduct them in a well planned and enlightened manner.

REFERENCES

1. Grantcharov TP, Reznick RK. Teaching procedural skills. BMJ 2008; 336: 1129-31. 2. Spencer J. Learning and teaching in the clinical environment. BMJ 2003; 326: 591-4. 3. Irby DM, Wilkerson L. Teaching when time is limited. BMJ 2008; 336: 384-7. 4. Sokol DK. Ethicist on the ward round. BMJ 2007; 335: 670. 5. Ker J, Cantillon P, Ambrose L. Teaching on a ward round. BMJ 2009; 338: 770-2. 6. Coomarasamy A, Khan KS. What is the evidence that postgraduate teaching in evidence based medicine changes anything? A systematic review. BMJ 2004; 329: 1017-21. 7. Mascola AJ. Guided mentorship in evidence-based medicine for psychiatry: a pilot cohort study supporting a promising method of real-time clinical instruction. Acad Psychiatry 2008; 32: 475-83. 8. Cantillon P, Sargeant J. Giving feedback in clinical settings. BMJ 2008; 337: 1292-4. 9. Driessen E, van Tartwijk J, Dornan T. The self critical doctor: helping students become more reflective. BMJ 2008; 336: 827-30. 10. Cruess SR, Cruess RL, Steinert Y. Role modelling--making the most of a powerful teaching strategy. BMJ 2008; 336: 718-21. 11. Steinert Y. The "problem" junior: whose problem is it? BMJ 2008; 336: 150-3.

P.S.V.N. Sharma Prof. and Head, Dept. of Psychiatry, KMC, Manipal [email protected]

33 About Professional Biomedical Journals

K. Nagaraja Rao

ABSTRACT

This article covers importance of reading professional journals, Types of professional publications, quality of a journal, contents of a journal, broad guidelines to analyse an article and limitations of journals.

Professional Journal is a periodic publication by a professional association or a body. It contains professional information and information about events concerning that profession. Journals are published in every field of subject including medicine. This article deals with Biomedical Journals.

Why read a journal? : The articles in a Journal usually contain recent information on a topic and often have very specialized content on a particular subject. Professionals benefit from reading journals as it helps them to know recent trends and progress in a specific subject area. Through journal reading it is possible to trace how trends have changed in a particular field of study. In addition if one is carrying out a study it helps to prevent duplicating the work already done, avoid errors of previous research, find ‘gaps’ in existing research, choose and design a research study. Journals are also good source for references for conducting a study. Journals are the best source for practicing evidence based medicine (1). An example of the stratification of evidence by quality for ranking evidence about the effectiveness of treatments or screening is given in the appendix.

Types of Professional publications: Based on content and size, professional publications are titled as; Journal, Bulletin, News letter, Report, Supplement, Updates, Practice Guidelines and monographs. Based on area of circulation the journals are classified as; International, National, Zonal, and State. Based on quality journals are classified as Peer reviewed and Indexed.

Supplements: These are collections of articles that deal with specific issues or topics, published as a separate issue of the journal or as a part of a regular issue. The abstracts of scientific papers presented at the scientific forums and 314 Psychiatry in India : Training & training centres conferences may also be published as Supplements. Supplements can serve useful purposes such as: enhancing knowledge, exchange of research information, easy access to focused content and improved co-operation between academic and corporate entities. These may be funded or sponsored by sources other than the publisher of journal.

Practice guidelines: These are amalgam of clinical experience, expert opinion, and research evidence. These are developed to; improve the process and outcomes of health care, optimize resource utilization and tackle issues such as prevention, diagnosis, and treatment.

Quality of a Journal: The quality of a journal is mainly based on three important factors. These are; whether the journal is peer reviewed or not, whether it is indexed or not and the impact factor of the journal. The journals which are peer reviewed, indexed and having high impact factor are considered as high quality journals.

PEER REVIEW: A peer–reviewed journal is one that submits most of its articles for review by experts in the field who are not part of the editorial staff. The number and kind of manuscripts sent for review, procedures, the use made of the procedures, and the use made of the reviewers’ opinions may vary from journal to journal. Therefore each journal is expected to publicly disclose its policies in its instructions to authors for the benefit of readers and potential authors.

INDEXATION: Indexes are compilation of articles published in journals. It provides title of the article, name of the publication, name of author(s), volume / issue number (or month), and page numbers. Abstracts provide similar details as an index, but in addition will have a brief summary of the article. Indexing and abstracting services provide sufficient information to find the full-text of articles. Important indexing publications relating to medicine are: Index Medicus & Cumulated index medicus, Current contents, Current contents (India), Excerpta Medica, Chemical abstracts, Biological abstracts, Excerpta medicinal and aromatic plant abstracts NC,. Details of some of the indexes and abstracts are given in the appendix.

THE IMPACT FACTOR: The impact factor is a measure of the frequency with which the “average article” in a journal has been cited in a particular year or period. The impact factor of a journal is calculated by dividing the number of current year citations to the source items published in that journal during the previous two to five years. Considerations in calculating impact factors include; types of material published in a journal, number of review, variations between disciplines, and item-by-item impact. The impact factor of various important journals can be accessed through internet (3) . For example impact factor for AJP is 10.55 (2008) and 12.552 (2010), BJP is 5.07 (2008) and Rao : Professional Biomedical Journals 315 5.777(2010), Archives of General Psychiatry is 14.27 (2008) and 12.257 (2010).

Contents of a Journal:

Volume of a journal indicates number of years of publishing.

Number of a journal indicates number of issues in the year. a. Editorial i. Regular ii. Guest or invited b. Review articles c. Research articles i. Original article ii. Drug trials iii. Brief research communication d. Case reports e. Letter to the editor/ Correspondence i. Professional information ii. Professional comment on article iii. Response to comments f. Quiz g. News or events of the professional body h. Advertisements – mainly drugs, jobs, hospitals. i. Instructions to the authors (once or twice a year) j. Index of authors and Subject (once or twice a year) k. Book review l. From the history page – photographs, events, anecdotes

Editorial:

Editorials usually focus on subject of current relevance or articles contained within the journal. It is the prerogative of the editor of the journal to choose the topic for the editorial. Sometimes the editor may invite a person in the specified field to write an editorial as a guest editor.

Review articles

A review article is one that summarizes different studies and draws conclusion. There are different types of reviews.

Qualitative (narrative) reviews: These types of reviews make general unsystematic selection of articles for a specific purpose. They are often broad in scope and may be potentially biased. These may include expert opinions and evidence, which may not have strict criterion based evaluations. 316 Psychiatry in India : Training & training centres Overviews: These are summaries from the prevalent medical literature concerning a subject matter. In a way these are current research summed up. There are many types of overviews

Journalistic reviews: These are overview of primary studies not analyzed in a systematic (standardized and objective) way. The commonest example of this type of review is the review done by post-graduate students for their dissertations.

Systematic (quantitative) reviews: These are overview of primary studies that uses explicit and reproducible methods. It includes both qualitative and quantitative studies. These have well defined objectives. These can be more effective in translating research evidence into practice. A Systematic review will reveal dissenting and assenting views about a subject matter. It helps to reveal duplicate publications. It uses explicit methods of searching, selecting, critically appraising, and summarizing the results of primary studies. Two useful sources of systematic reviews of health care interventions are the Cochrane Collaboration and NHS Center for Reviews and Dissemination.

Meta-analytic studies: These are mathematical or quantitative synthesis of the results of two or more primary studies that addresses the same hypothesis in the same way. These use statical criteria to validate the results of the selected articles. These are often carried out after systematic reviews.

Research articles

These are usually referred to as original articles. These are invariably experimental studies involving samples, controls and statistical analysis of the results. The authors choose a topic of their interest and conduct research study and report them. Drug trials are also included under this heading.

Case reports – These include description of clinical cases which have unusual signs and symptoms, treatment methods, course or complications. These could be single case reports or series of cases.

Letter to the editor/ Correspondence Column: All biomedical journals usually have a section carrying comments, questions, or criticisms about articles published in the journal. In this section the original authors respond to queries and comments raised about their articles. Usually, but not necessarily, this may take the form of a correspondence column. Sometimes brief academic and research articles are published under this heading or under the heading Brief Research Communication. Rao : Professional Biomedical Journals 317 Selection of articles for Journal club by Postgraduate students:

Postgraduates may select an article by themselves or on suggestion by a faculty member. The article should cover an important topic or of current relevance. It could be an original or a review article. Postgraduate students may also select a particular journal for review and prepare abstracts of all the articles for discussion. The selected journal should preferably be an indexed journal or a national journal.

The studied article needs to be presented with in-depth analysis and relevant information related to it from other sources. An original article can be reasonably analyzed well by understanding the general outline of an original article. The general outline of an original article is akin to information about preparation of articles for publication. Hence it is useful to know the guidelines for preparation of articles for publication.

Preparation of articles for publication:

Information about preparation of articles for publication was prepared by a small group of editors of general medical journals who met informally in Vancouver, British Columbia, in 1978(4). This group became known as Vancouver group. Invariably each journal provides its requirements under the heading-instruction to authors. Hence a researcher planning to submit an article to a particular journal should look for these instructions. However most of professional journals have following general outline for an original article.

General outline of an original article Abstract/Summary: Open type (150-200 words) Sub headings - Objectives / Aims - Background - Methodology - Results - Conclusion Main Article: Introduction: Background of study Review of published articles about the subject Need for current studies or Aims of the study Hypothesis ( if any) Methodology: Sample – size, selection, site Inclusion & exclusion Criteria 318 Psychiatry in India : Training & training centres Duration of study Instruments - scales, laboratory procedures, evaluation procedures Statistics: Relevant to nature of studies; Epidemiological, Experimental etc. Reporting of data in statistical language Significance Tests Relation between data - correlation, regression etc Results: Socio demographic Main results Tables and Figures usually are given separately. Repetition in text is usually avoided hence tables & figures need attention Discussion: Compares the results with the already published studies Explanations offered for variations Limitations of the study Conclusion: Main message Future direction Acknowledgement, source of support and Conflict of interest if any

REFERENCES The style of referencing or quoting the studies varies with the journals depending on type of the article, books, internet, news paper, number of authors and cross reference. References may also include unpublished data from under preparation, unsent or rejected articles, theses, personal communication with an expert in the field and papers read in conferences and symposia. However standard journals usually do not accept unpublished data. The style of referencing required for specific journals can be found in the instruction to authors of that specific journal. Harvard and Vancouver systems are two important reference systems. Harvard system – It involves writing the short versions of the names of the authors and the year of publication in parentheses at relevant places in the article and alphabetic listing at the end of the article. Vancouver system - It involves numbering the references as superscript or within the parentheses at relevant places in the article and numerical listing of the referred references at the end of the article. Currently this system is more prevalent than the Harvard system of referencing. Limitation of Journal articles: Not all articles meet academic standards. Articles published in preceding journals can be difficult to trace and locate. Relevant articles might appear in Rao : Professional Biomedical Journals 319 unlikely places due to so called Scatter phenomenon. There also exists publication bias in that the studies which prove hypotheses are more likely to be published so also the studies which show drugs to be superior to placebo. “Ultimately information literate people are those who have learned how to learn. They know how to learn because they know how information is organized, how to find information and how to use information in such a way that others can learn from them. They are people prepared for life- long learning, because they can always find the information needed for any task or decision at hand” - American Library Association (ALA) (1989) Presidential Committee on information Literacy: Final report.

REFERENCES: 1. Sackett, David L, Evidence based medicine: what it is and what it isn’t, BMJ, vol 312, Jan 1996, 71-72 2. http://en.wikipedia.org/wiki/Evidence-based_medicine#Evidence-based_guidelines 3. http://www.sciencegateway.org/rank/index.html. 4. Impactfactor. Weebly.com 5. International Committee of Medical Journal Editors: uniform Requirements for Manuscripts Submitted to Biomedical Journals. JAMA. 1997; (11): 927-934. Appendix; Journal as the resource of EBM “Evidence based medicine (EBM) is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research (1)”

Evidences are usually graded. Following hierarchy are two such examples.

Stratification of evidence for ranking evidence about the effectiveness of treatments or screening developed by the U.S. Preventive Services Task Force: l Level I: Evidence obtained from at least one properly designed randomized controlled trial. l Level II-1: Evidence obtained from well-designed controlled trials without randomization. l Level II-2: Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one center or research group. 320 Psychiatry in India : Training & training centres l Level II-3: Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled trials might also be regarded as this type of evidence. l Level III: Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.

Levels of evidence suggested by the Oxford Centre for Evidence-based Medicine according to the study designs and critical appraisal of prevention, diagnosis, prognosis, therapy, and harm studies: l Level A: Consistent Randomised Controlled Clinical Trial, cohort study, all or none, clinical decision rule validated in different populations. l Level B: Consistent Retrospective Cohort, Exploratory Cohort, Ecological Study, Outcomes Research, case-control study; or extrapolations from level A studies. l Level C: Case-series study or extrapolations from level B studies. l Level D: Expert opinion without explicit critical appraisal, or based on physiology, bench research or first principles.

Important source of Indexation:

INDEX MEDICUS & CUMULUS INDICUS MEDICUS

It is published annually by US dept of Health & Human Services; National library of Medicine, Maryland. It publishes the list of articles of important Journals. The list can also be obtained through the library’s Web site (http: // www. Nim.nih gov).

l First volume published in 1879

l Idea proposed by John shaw Billings 1865

l Upto 1960, only monthly updates in the name of index medicus were published

l Since 1960, along with this, a cumulated version of the monthly volumes – cumulated index medicus is published

l Materials are selected for inclusion by a board of analysts

l Materials selected are assigned terms from Medical Sub Headings

l Each year 13 volumes

l Volume 1 contains MESH (Medical subject Headings) – list of keywords used. MESH is to be seen first for keyword

l Volume 2-7 author index

l Volume 8-13 subject index Rao : Professional Biomedical Journals 321

l Index gives title, author’s name, abbreviated journal name, year volume, issue and page

Articles included are: Journals, Academic reviews epidemiologic reviews, Classical reviews, Consensus conferences, Published cases, State of art reviews.

Articles not included are:- articles with review of literature as adjunct, Surveys, Articles containing only references of other articles, Theses, Historical articles

CURRENT CONTENTS:

Reproduces contents page of about 1000 journal Published weekly in 6 editions Covers different areas Area of interest for Medicine – life science edition Each issue contains author index, author Address index (to help reprint request) and subject index.

ABSTRACT SERVICES:

In addition to indexes abstracts provides brief summary of the paper.

Excerpta medica

It is a comprehensive abstracting service for medicine and allied health sciences. Abstracts issued monthly in sections. Each section caters to particular specialty Ex: physiology, anatomy etc.

Searching the medical literature:

Recent advances in information technology have made it easier to search the medical literature. Access to electronic databases such as the PubMed, Medline, EAMBASE, PsycLit, etc., is widespread and simple. But they have limitations. Not all journals are indexed or the relevant articles can be difficult to locate, and the searcher’s access and time may be limited. One potential solution to overcome these limitations is to read review articles.

IMPORTANT COMPUTERISED RETRIEVAL SERVICES

1) Medline (Index Medicus) 2) Embase (Excerpta medica) 3) Current contents on diskette 4) Biosis (Biological abstracts) 322 Psychiatry in India : Training & training centres 5) Extra MED 6) Cancelit 7) Toxline

MEDLINE Is a computerized Medical Literature Analysis And Retrieval System. Most extensive and popular search system. Incorporates Index Medicus, Index Dental literature and international nursing index Covers more than 4300 journals. Medline is available on CD – ROM (compact disc – Read only memory). Each CD corresponds to one year. Year wise search can be done. After the search one can print out citations with/without abstracts.

K. Nagaraja Rao Prof & Head Department of Psychiatry JJM Medical college Davangere [email protected] 34 How to read a research paper

Sandeep Grover, Vineet Kumar

ABSTRACT Every clinician is required to keep herself/himself updated about the emerging scientific knowledge. One of the most important avenues for the same is reading articles published in various scientific journals. However, to use the emerging knowledge into practice requires proper understanding of the results of the studies available. This article outlines the approach to reading an article.

INTRODUCTION

As clinicians, every doctor is expected to be updated about the prevailing knowledge. Hence everyone is expected to read the articles appearing in various journals. However a major problem which everyone faces is the contradictory findings between papers appearing within short time. So what to accept? What to implement? What to retain and what to discard in day to day practice to provide optimal care to our patients?

Trainees are faced with more difficult situation, because prior to post- graduation most of them have confined themselves to reading standard textbooks and accepting things written in the standard text books as facts. When one starts preparing and appearing for the postgraduate entrance examination, thanks to the multiple choice questions, one starts realizing that there is no absolute truth with respect to many aspects of medicine and what holds true today may be absolutely useless tomorrow or what one book says, may be contradicted by another. As one enters the post-graduation training programme, he starts hearing about different types of articles, like original articles, research articles, review articles, systematic reviews, guidelines, meta-analyses, case series, case reports etc. However, the young trainee is left confused as to what he should rely on, to discuss with his colleagues and teachers. With sleepless nights spent on searching the internet and journal, to put across their case discussion on the next day, when some of the trainee end up quoting references and then are told by their 324 Psychiatry in India : Training & training centres teachers that the facts presented by him are incorrect. He feels dejected as to what is wrong with him, why his efforts have not been acknowledged and some may end up with the feeling that the professor himself is not updated and hence, doesn't know things. However, either of these scenarios is dangerous.

It is the responsibility of the mentors and teachers to guide the trainees as to how to read an article, how much importance to be given to the methodological issues before accepting the conclusions drawn by the authors, what has been hidden by the authors and what has been presented which is actually not true. In this article, basic principles as to how to read a paper are discussed under the heading of hierarchy of studies/evidence, components of critical evaluation of a study and how to critically evaluate a paper.

Basic concept of the current level of medicine and hierarchy of evidence

To overcome the problems discussed above, the concept of evidence-based medicine (EBM) has emerged which is defined as the “conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients”.1 In a more recent definition Sackett et al have defined (EBM) as “the integration of best research evidence with clinical expertise and patient values”.2 Basically EBM emphasizes that decision about appropriate treatment for a patient should be based on best available evidence. Hence it is important to understand what 'evidence' is. Evidence is the information which emerges through the research, i.e., the facts which are demonstrated objectively by scientific studies.3 However, everything which is demonstrated by objective scientific studies is again not same. Depending on the study design, available evidence can be divided into a hierarchy in which randomised controlled trials is placed at the top. This is followed by controlled trials without randomization, and other prospective experimental studies. This is followed by prospective cohort studies, case-control studies, and case series.3 For all kind of studies, a systematic review of the existing studies, with meta-analysis is preferred over the single study. The expert/personal opinions are placed at the lowest level of hierarchy.3,4 For example Cochrane Reviews are considered gold standard for systematic reviews.4 However, it is important to remember that this hierarchy is only a guide to evaluate the strength of the evidence and it is not a substitute to the critical appraisal of the various types of the studies.3 For example, case- control studies lie lower down the hierarchy of evidence, but this design is usually the only option when studying rare conditions. Similarly, a randomised controlled trial although lies higher in the hierarchy may be either unnecessary (e.g. when a clearly successful intervention for an otherwise fatal condition is discovered), or impractical (e.g. where it would Grover & Kumar: How to read a research paper 325 be unethical to seek consent to randomize) or inappropriate (e.g. where the study is looking at the prognosis of a disease) in certain circumstances. The experts of evidence-based medicine argue for the use of both hierarchies of study design and common-sense judgment when ranking research studies and assessing their relative contribution to a decision.5

Components for critical analysis of the studies

It is suggested that any critical evaluation of the studies should be based on a well formulated question and it is suggested that the question should have the 4 components: Patient, Intervention, Comparator and Outcome (Called as PICO). In general, this means defining the patient's/ a group of patients' health problem, the interventions which are to be compared for the patients' problem and what is expected as an outcome with the use of a specific intervention. 6 Another question which is often considered pertinent is the cost-effectiveness of the intervention.

How to evaluate a paper

Every article has components like: title, name of the authors including their affiliations, source of funding, introduction, methodology, statistical analysis and results section followed by a discussion section which may end with limitations and future direction. Besides the journal in which the article is published influences the acceptance of the findings.

Where was the article published?

The articles which are usually published in high impact factor journals are considered to be of sound methodology. However, when similar articles are published across two journals, it is important not to get carried away just by the impact factor of the journal and the readers should focus on the methodological issues to draw conclusions.

What does the title convey?

It is suggested that while deciding to go through a study, it is important to evaluate the 'Title' of the articles carefully. In most cases the title may provide you information about the study design and intervention done. For example an article is titled as “usefulness of sertraline in major depression” and other is titled as “Double blind parallel group randomised controlled trial of sertraline and imipramine in major depression”. As is evident from the example, the article with the second title appears to be of higher strength and would be more worthwhile reading compared to the first one. The second title also gives you the information about the comparator which is the standard medication for treatment of depression and is also likely to give 326 Psychiatry in India : Training & training centres information about the outcome.

Who are the authors?

If the list of authors include statisticians and clinicians, it is likely that the data collection would be more representative of the clinical situation and the data generated would have been analysed thoroughly and the findings would perhaps be more accurate.6 However, these facts are not absolutely true, as manuscripts arising from resource limited countries where statisticians may not always be available doesn't always lead to poor analysis of the data. Again it is important to know the standing of the authors in the fraternity as such. It is usually considered that well know researchers usually conduct good research.

In general it can be said that studies carried out by well known researchers, which are published in good journals are considered to be better. However, it is also important not to get carried away, just by the name of the authors and journals, as good researchers also commit mistakes and articles published in top journals also have flaws.6 Hence, none of these should be considered to be equivalent to a good study.

Who funded the research?

Another issue which should be closely evaluated is the source of funding. Many a times the published research is funded by a pharmaceutical company which may benefit from the outcome of the study. It is also important to look at the relationship between authors and the funding agency. i.e., is an author employee of the company or has the author received only an honorarium from the company. Similarly closely look at the relationship of the sponsor and the statistician. It is not always true that outcomes of all the pharmaceutical trials are influenced by the interest of the company, but this is neither absolutely untrue. Hence, the readers should carefully evaluate these studies based on other parameters, before implementing the outcome to their practice. The research funded by the government agencies which don't have any conflict of interest with the outcome of the study can be better relied upon.

What does abstract convey?

An abstract is intended to convey the information about the article in concise form. However, this requires skills and always an abstract may not convey what you are looking for. The reader should focus on the study design and depending on their need should proceed further or reject the article.

Article proper- what to look for in the methodology Grover & Kumar: How to read a research paper 327 Aims and Objective: The most important aspect of evaluating an article is looking at its aims and objectives and the methdology section. Go through the aims and objectives of the study to decipher as to whether it has attempted to answer a well defined question or not.6

What does the research add to the literature?: Usually the studies which are only replication of the previous methodology, doesn't contribute much to the science unless these are done with better methodology. The methodological improvements may be in the form of bigger sample size, longer duration of intervention, used more rigorous assessments and have studied different population (e.g. ethnic groups, ages or gender) than the previous studies. Hence, always compare new studies with the existing literature.

Sampling technique: While going through the methodology give importance to the sampling technique used. Studies which use purposive sampling would be considered inferior to those which randomized the subjects to different groups using a proper random assignment method. For the beginners it is important to remember that “randomly allocated” is quite different from “assigned by use of a randomization table”. Look for the information about concealment about the randomization information from the patients, clinicians, researchers, raters for the study. It is well known that when concealment is not proper, the results may be biased. Accordingly double blind studies in which both the patients and the researchers are blind to the type of intervention are considered to be better than single blind or open label randomized studies.

Sample- Who was part of the study?: We all know that the participants in a clinical trial may differ from patients in real life clinical situation in terms of severity of illness, co-morbidities, using/not using substances, ethnicity etc. Therefore, we should try to understand precisely whom the study is about. For this we should focus on the manner in which participants were recruited (whether adequate measures have been taken to avoid recruitment bias). It should be clear to us who have been included in and who have been excluded from the study before we can implement the results into our practice. Precisely speaking, various characteristics of the study population are important determinants of the applicability of study's findings to our own practice. Studies which include patient population with characteristics which are more close to the routine practice can be considered to be more useful than those which try to recruit “clean” patients.

Sample size: Another important aspect of the study is the sample size. In general larger the sample size of the study more is the chance that the results can be generalized. However it is important to remember that it is not the absolute number of subjects included in the study is the only important 328 Psychiatry in India : Training & training centres parameter. It is the power of the study, which is most important, which is basically understood as to whether the study included the sufficient number of subjects (which is determined by the available literature evidence and statistical measures) to evaluate the particular outcome. If the paper you are reading does not give a sample size calculation and it appears to show that there is no difference between the intervention and control arms of the trial, you should extract from the paper (or directly from the authors) the required information and do the calculation yourself. Underpowered studies are ubiquitous in the medical literature, and such studies typically lead to a Type II error i.e. the erroneous conclusion that an intervention has no effect.4

Study design: Double blind randomised controlled trial does not always mean that the study design is appropriate. As discussed above, the study design should be based on the condition under evaluation.

Measure of outcome: It is important to note what outcome(s) was/were measured and how. We should always look for evidence in the paper that the outcome measure has been objectively validated – that is that someone has demonstrated that the 'outcome measure' used in the study has been shown to measure what it purports to measure, and that changes in this outcome measure adequately reflect changes in the status of the patient.4

What to look for in the statistical analysis section

This is one of the important aspects of evaluating a paper and many of the clinicians are deficient in these skills. It is very important for the beginner to be well versed with the basic statistical methods used. Atleast, we should know which is the best test to use for common problems. We need to know which test is valid in particular circumstances when it becomes invalid or inappropriate. When not sure, it is always useful to read about the statistical methods along side reading the article. However, when not sure about the same, always consult a statistician or a knowledgeable senior colleague to discuss about the appropriateness of the statistical measures. Also look for the measures which authors have used to account for missing data, control for the effect of single or multiple covariates, statistics used for multiple serial evaluations etc. The points to be looked for in the statistical analysis section are - have the authors determined whether their groups are comparable, and, if necessary, adjusted for baseline differences; what sort of data have they got, and have they used appropriate statistical tests; if the statistical tests in the paper are obscure, why have the authors chosen to use them, and have they included a reference; have the data been analysed according to the original study protocol; were paired tests performed on paired data; was a two-tailed test performed whenever the effect of an intervention could conceivably be a negative one; has the correlation coefficient ('r-value') been calculated and Grover & Kumar: How to read a research paper 329 interpreted correctly; have assumptions been made about the nature and direction of causality; have 'p-values' been calculated and interpreted appropriately; have confidence intervals been calculated, and do the authors' conclusions reflect them; have the authors expressed the effects of an intervention in terms of the likely benefit or harm which an individual patient can expect.4

What to look for in the Results

An important aspect of evaluating the results is looking at the tables, figures and graphs closely. It is important to remember that having a statistically significant difference at the level of <0.05 is not equivalent to the clinical outcome. Many a times if some of the variables like effect of co-intervention are not controlled for, or when the dropouts are not taken into the analysis purposefully, the results may appear to be statistically significant. Again refresh your memory with respect to the primary outcome measure of the study and other outcome measures. Sometimes it may happen such that there is no difference between the primary outcome measures which were planned for the study and authors may harp upon the secondary outcome measures or one or two symptoms and claim the usefulness of the intervention.

Another important aspect of studies which involve evaluating the effect of an intervention is the number of patients available at the end of the study. Look for the information as to whether all the patients are accounted for at the end of the study.6 If some of the patients have dropped out of the study, how was the data analysed, as to whether their information was included in the analysis by using statistical methods like last observations carried forward (LOCF) or by using survival analysis or intent to treat approach in comparative studies. This is because ignoring everyone who has failed to complete a trial will bias the results usually in favor of the intervention. In such studies, it is important to be vigilant about how long have the participants been followed- up for the obvious reason that a study must be continued for long enough for the effect of the intervention to be reflected in the outcome variable.

Besides this other important aspects which should be kept in mind are- how the groups compared to each other at the baseline with respect to sociodemographic and clinical profile, use of concomitant medications while evaluating the effect of the intervention in question because these can also influence the outcome of the study.6 Look at the study design and result sections for the steps taken to avoid systematic bias (anything which erroneously influences the conclusions about groups and distorts comparisons). Whatever may be the design of a study, the aim should be for the groups being compared to be as like one another as possible except for the particular difference being examined. Different study designs call for 330 Psychiatry in India : Training & training centres different steps to reduce systematic bias. Biases can be introduced even in an randomised controlled trial, gold standard of clinical trial design, from various sources that should be checked for: incomplete randomization (selection bias), systematic differences in the care being provided apart from the intervention being evaluated (performance bias), in withdrawals from the trial (exclusion bias), and in outcome assessment (detection bias). The selection of a comparable control group is one of the most difficult decisions facing the authors of an observational (cohort or case-control) study. In practice, much of the 'controlling' in cohort studies occurs at the analysis stage, where complex statistical adjustment is made for baseline differences in key variables. Unless this is done adequately, statistical tests of probability and confidence intervals will be dangerously misleading.7 In case-control studies the process most open to bias is not the assessment of outcome, but the diagnosis of 'caseness' and the decision as to when the individual became a case. Therefore, assignment of 'caseness' in a case-control study must be done rigorously and objectively if systematic bias is to be avoided.4

Discussion and conclusion

It is important to go through the discussion section carefully, because it is where the authors are expected to present their findings in the light of the existing literature. Be certain that the findings which were statistically significant only are presented with respect to the outcome. At times the authors may use terms like “trend towards” to use the findings which were very close to the significant difference. It is usually advisable to avoid accepting such findings. Further the conclusion section should be carefully read and should be tallied with the result section to make sure that the conclusions drawn by the authors are actually true.

References

While going through the article it is always advisable to keep on ticking the references which you come across for the first time, so that you can later retrieve the same and read those articles to broaden your horizon about the topic.

Other important tips

It is always better to discuss an article after reading with a colleague who has also read the same. This will enhance your skills because many things are missed while reading, and only on discussion it becomes clear that this was an important aspect of the research. Another way to enhance the reading skills is participating in journal clubs which involves participation of faculty members and senior colleagues who themselves have experience of research and publication. Grover & Kumar: How to read a research paper 331 REFERENCE

1. Sackett DL, Rosenberg WMC, Muir Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. Br Med J 1996; 312:71-72. 2. Sackett DL, Straus SE, Richardson WS, Rosenberg W, Haynes RB. Evidence-based Medicine: How to Practice and Teach EBM. 2nd ed. Edinburgh: Churchill Livingstone, 2000. 3. Pwee KH. What is this thing called EBM? Singapore Med J 2004; 45: 413-417. 4. Greenhalgh T. How to read a paper. Fourth Edition, John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, UK, 2010. 5. Atkins D, Best D, Briss PA et al. Grading quality of evidence and strength of recommendations. BMJ 2004; 328:1490. 6. Makela M, Witt K. How to read a paper: critical appraisal of studies for application in healthcare. Singapore Med J 2005; 46: 108-114. 7. Britton A, McKee M, Black N, McPherson K, Sanderson C, Bain C. Choosing between randomised and non-randomised studies: a systematic review. Health Technol Assess 1998; 2:214–218.

Sandeep Grover Assistant Professor Department of Psychiatry Postgraduate Institute of Medical Education & Research Chandigarh 160 012, India [email protected]

Vineet Kumar Senior Resident Department of Psychiatry PGIMER, Chandigarh

35 How to write a research paper

Sandeep Grover, Archana Malik, Alakananda Dutt

ABSTRACT Every researcher is required to publish their results in reputed journals. However, due to lack of proper skills, many studies remain unpublished. This article gives an outline for the trainees as to how to write an original article. Some of the other basic issues like formulating a research question and how to choose a title and how to submit a manuscript are also given.

INTRODUCTION

Carrying out research is passion for some and compulsion for some. When I say it is a compulsion, because trainees are required to carry out thesis for completion of their degree, but in many cases it remains unpublished. Hence whatever research is carried out, one of the aim should be to publish in scientific peer-reviewed journal. Unfortunately, some of the research remains unpublished in the scientific journals because of poor planning and poor writing skills.

Writing a scientific paper is an art, which can only be learned with experience. For the beginners the basic rule is to learn the rules of the game systematically and master them skillfully. All this requires a proper supervision from senior colleagues. One needs to understand that writing a manuscript is not just doing copy paste from here and there. In fact this is the basic thing which is a big no, no to writing an article. This paper will discuss some of the points which must be kept in mind while writing an original article, however some of the basic principles also hold true for writing other types of articles. Before a research is carried out the basic principles involves formulating a research question, writing the protocol including the nuances of the methodology, analysis of data and how the data is going to be analysed.

Formulating a research question

Components of a research question include 4 parts: PICO that is Patient or 334 Psychiatry in India : Training & training centres Population that you want to study, Intervention that you plan to do, Comparative intervention that will be done and Outcome that you will measure.1 Before you start with your research question, formulate it appropriately and carry out a proper search for the review of literature as to what exists as a fact in the area of interest, what is the limitation of the current level of research and what kind of study design needs to be followed to overcome the limitations of the literature. The basic principles of reaching to a research question are given in table-1. A proper search of literature should be done as this can improve the quality of the research. In today’s world most of the students and researchers have access to the internet and it is important to understand as to how to use the same optimally. This has been discussed in one of the articles in this compilation and will not be discussed here.

Table-1: Basic rules before starting

1. Familiarize yourself with your library 2. Learn to do a proper internet search 3. Be a good reader yourself 4. Learn to critically analyse the available scientific data 5. Write a research protocol based on the available information specifically focusing on the limitations of the current research

Write the paper before you carryout the study

Some of you may consider this to be scientific misconduct or fraud. But when it is said that write the paper before you carryout the study, it actually means that you draw a clear protocol for the study which should include review of literature, limitations of the existing literature, need for the study in your and overall scientific community, methodology, analysis of data and the ethical considerations. This is important because while this is done you prepare a document which is updated at the time of initiation of your research and also guides you from time to time whenever there is a doubt about the methodology to be followed while carrying out the research project. Another obvious reason to write the protocol is to submit the same to the ethics committee for approval.

General principles of writing

Once the hard work of collection the data is accomplished, usual feeling is that the job is done. But the actual fact is that the job starts now, as it involves writing the report, entering the rat race of submission and resubmission, listening to the hard, at times unfounded and at times unscientific comments of the reviewers (which is actually not true on most occasions), revision of Grover et al: How to write a research paper 335 manuscript. Few lucky one's may get a chance to see the e-proofs of the manuscript and the unlucky one's will be handed over a correspondence involving a comment of a worthy colleague on their manuscript.

At the outset it is important to have a clear purpose of writing such a paper, an idea about the readership as to who is going to read the same and organise the material systematically to suit the format. Ideally it is suggested that the authors should be clear with respect to the journal in which they want to submit their manuscript and it should be prepared accordingly. However this has its own merit and demerit. If you focus yourself to a particular journal and unfortunately your article is rejected then you may end up with a feeling of frustration and would be put down to such an extent that you will never attempt writing a paper in future. However, keeping a journal as a focus can help you in organising your manuscript to the style and need of the journal.

Other approach would be to prepare a manuscript which fulfils the basic format of most journals (abstract, introduction, methodology, results and discussion) and then modify manuscript according to the journal in which you intend to submit.

While writing certain basic principle should be followed, which are provided in table-2.

Table-2: Basic principles of writing an article l Read few articles from the journal in which you intend to submit to familiarize yourself with the journal style. l Be concise in your expression and keep the word count to minimum l Write in short and simple sentences l Use past tense and not present tense l Use punctuations as per the requirement l Avoid excessive use of expression of information in brackets l Avoid using the capital letters in between the sentence except for expression of name of someone, name of the country etc. l If you are quoting the verbatim of some other author use quotation mark at the beginning and the end of the text and express the text in italics l Simple language to suit the journal- some journal specify American or British English l Use simple words than difficult jargon l Express the headings and subheadings in bold l Use appropriate symbols 336 Psychiatry in India : Training & training centres l Always provide footnote at the end of the table, explaining the abbreviations and symbols in the table l Don’t duplicate the information in the table and text 2 l Numbers under 10 should be spelt out in the text l If you are using numbers in the text, never start a sentence with a number (numerical) expression (for example – “10 were male”, rather it should be “ten were male”) l Use abbreviations wherever possible, but remember to use only the standard abbreviations l Write out the word in full on first mention, even if you think it is an established abbreviation. l Edit the manuscript time and again before submitting l Tally the manuscript with instruction to authors l No plagiarism l Use spell check to check for spelling errors and grammatical errors l While providing the manuscript to the senior author, always provide him all the supporting studies so that the conclusions drawn from the literature by a trainee can be verified and at the same time the issues of plagiarism if any are modified.

Basic structure of an article

The basic structure of most of the articles published in journals is that of 'IMRAD' format, which includes introduction, methodology, results and discussion.3 Besides these basic components other essential components are title page, abstract, keywords, tables, figures, acknowledgements and references. It is important to remember that when ever an article is submitted to the journal, first thing the editor looks at, is the organization and structure of the article and if these are found deficient and do not meet the guidelines of the journal, it is very likely that you will get your manuscript back.

Title of the paper

Title of a paper has many functions and it can also influence the decision of further processing of the article. It is the first thing which gets the attention of the editor. Further, if an article is published, title of the article appears on the table of the content and it is the main information about your article which is reflected in most of the electronic searches. A reader chooses an article to be read, depending on the suitability of the same to his need and this is mostly determined by the title.

The basic principle of choosing a title should be that it should convey the Grover et al: How to write a research paper 337 meaning of the whole article, should have the key words of the subject matter discussed and should be short, informative, catchy and concise. Again it is important to remember that, while finalizing the title an author should keep in mind the journal in which they are going to submit the manuscript. If the manuscript is intended to be submitted to a subject specific journal (for example to psychiatry journal) then some of the common terminologies can be avoided in the title. However if the manuscript is to be submitted to a general medicine journal, where it is intended for non-psychiatrist readership the title can be slightly elaborative to give the readership an idea about the content of the paper. Ideally a title should be drafted at the outset of writing the paper which can be modified and refined till the finalization of the manuscript.4

In addition to the title most journals require a short running title which is printed as a header at the top of each page of the manuscript. The running title is required to be more concise and is usually limited to certain specified number of characters, which varies from journal to journal Hence the author should review the “guidelines for the authors” and choose a running title accordingly. The basic principles again remain the same- to be concise and informative.

Title page

All journals require the author to submit a title page which usually contains the title, running title, name of the authors including their degree and affiliations, institution where the work was done and contact details of the corresponding author. Again it is important to remember that the content of the title page may vary a bit depending on the journal, for example some journals require submission of only one title page containing all the above outlined information, whereas other require submission of two title pages, one containing all the information for the journal editorial office record and other title page containing only the title of the manuscript, which is used for blind review process.4 Other important issue to remember is that some of the journals require full name (both the first name and surname), whereas others advise the author to write only the abbreviated first name and full surname. Be very careful about the spelling of your name and name of all the authors as any mistake here will be carried forward and when the manuscript is published and name of one of the author is misspelled or is in poor format , will leave a bad taste of all the efforts made to get the article published. A corresponding author should always confirm from the co-authors as to how they would prefer their name to appear and get the same approved from them before submitting the manuscript. Some journals emphasize that contact details of all the authors should be provided. It is advisable to follow the requirement of the journal strictly. 338 Psychiatry in India : Training & training centres

Authorship

Ideally the authorship issues should be decided prior to writing of the manuscript and the credit should be accorded on the basis of contribution to preparing the manuscript.5 Much has been written in the literature with respect to various types of authorships like –gifting authorships and ghost authorship and these issues are not dealt here. It is important to remember that merely collection of data doesn't qualify someone to be an author. Only those persons who have provided adequate intellectual contribution and are involved in drafting, redrafting and final editing of the manuscript should be listed as authors. International Committee of Medical Journal Editors (ICMJE) has given basic guidelines for authorship and this should be followed. According to ICMJE, authorship credit should be based on “substantial contributions to the conception and design of the study, acquisition of data, or analysis and interpretation of data; drafting the article or revising it critically for important intellectual content; and final approval of the version to be published”.6 In ideal situation all authors must fulfil this. Further ICMJE specifies that those who are just involved in getting the funding for the project, collection of data, or general supervision of the research group do not qualify for an authorship. However their names should appear in the acknowledgement.6

Ideally all the authorships should be resolved before writing the paper as no editor prefers to enter into this controversial area and this may at times lead to rejection of the manuscript.

Abstract

Besides the title and name of the authors, abstract is the first thing which encourages a reader to go through the full paper.8 Further it is the information which is listed in the search engine and the only information available to a reader to cite your work. Hence writing an abstract requires precision and modifications with every editing of the whole manuscript. Many journals require a structured abstract with headings as background/objectives, methodology, results and conclusion. However it is important to remember that even if the journals don't ask for a structured abstract, this broad outline should be followed as this will help in organizing the information in a concise manner. Always follow the specified word limit for the abstract. While fulfilling the word limit it is important to remember that more words should be devoted to expression of methodology and results, rather than writing 2-3 sentences in the background and conclusion section.

Writing the Introduction

Sometimes the introduction is the first section a reader chooses to read. Grover et al: How to write a research paper 339 Hence this should be written carefully. It should provide reasonable background information with respect to significance of the area, what is known in this area, what have been the converging findings, what have been the limitations of the studies, what is the hypothesis of the authors and what was the objective of the authors to carryout another study in this area. However, too much criticism of other works at the cost of highlighting the limitations of the previous studies should be avoided. It is important to remember that always a considerable lag period exists between writing the protocol and writing the manuscript and many new publications emerge in the meanwhile. Hence a thorough search of the literature must be done and the recent studies in the area must be quoted to the possible extent.8 The introduction section should not include the whole review of literature of the research protocol, but must be an updated summary of the findings.9

However, if the manuscript is targeted for non-specialist (for example, a non psychiatric journal), the introduction section should provide more details so as to introduce the topic in a better way.9

The second part of the introduction section should provide hypothesis for the study, how was the hypothesis drawn and what the authors intended to do. Usually studies trying to replicate the findings don't go well with the editors and reviewers. The aims and objectives should reflect the rationale for carrying out the research. 9

Many a times, authors end up picking the name of the reviewers by carrying out a last minute search, without quoting the published papers of the reviewer. This is an absolute “no”, while preparing a manuscript.

Writing the methodology

Methdology section of the manuscript is one section which actually determines whether the manuscript will be acceptable or not, because what has already been done during the collection of data can't be changed further. What others look in the methodology section is reproducibility/replicability. The authors should clearly mention what all measures were taken at each step. It is important to remember that all the measures or parameters described in the result section are discussed here.10 Some of the general guidelines for writing the methodology section have been given in table-3.10 If complex and multiple steps have been used to arrive at the final sample, consort diagram should be used to make the information more understandable.

Table-3: Basic principles for writing the methodology section l Studies involving the human subjects should include the information 340 Psychiatry in India : Training & training centres with respect to the approval from the ethics committee (along with the approval number) and informed consent. If not done, then this should be mentioned in as many words as to why these were not done. l Studies which involve only animals, information with respect to the approval from the ethics committee should be provided. l If a standard study design has been used, it should be expressed concisely and elaboration may not be required. l If a non-standard study design was used, it should be described appropriately. l Provide details of population and sampling method. Give the exact number of subjects approached, how they were approached, type of subjects (patients/ controls) included, how many consented, how many did not consent etc. l Provide information about the power calculation if done. l The inclusion and exclusion criteria should be given clearly. l Provide details of the diagnostic criteria which were followed for arriving at the diagnosis and what instruments were done to do so. l Provide details about matching procedure if used. l Provide in detail the description of the instruments used (along with the trade names and manufacturer’s name and location in parentheses). Provide information about the suitability of the instruments in different cultures, translated versions, adapted version and self designed instruments. l Provide details of the reagent used, methods used to interpret the findings l Provide details of the interventions done l Provide information about blinding, duration of follow-up, method of follow-up etc when appropriate l Describe each step of the procedure followed while collecting the data.

At the end of the methodology section details of the statistical analysis should be provided with respect to the software used, measures taken to control for the influence of multiple statistical testing, controlling for co-variate etc.

Writing the results

Results should be presented clearly, concisely and coherently. The writing of result section involves presenting the data in the form of table, text, figure, pictures and details as to how to handle each of these are provided in a series of articles by Ng & Peh.11-14 In brief, the basic principles which should be Grover et al: How to write a research paper 341 followed include: avoidance of duplication of data in the text and tables, text and figures, the results should be presented sequentially so that one can coherently link the same with methodology followed. A commonly asked question is how much data in tables and how much in text. Too many tables and too much data in tables with a cursory test should be avoided as this doesn't go well with readers. Further the tables should have appropriate legend, describing the content of the table, should have foot notes elaborating on the abbreviations, symbols used etc. Basically each table should be presented in such a way that it can be understood as stand alone information without referring to the text. It is advisable not to use internal horizontal and vertical lines for presentation of data in the tables. Don't forget to cite the tables in text. Further wherever possible use graphs to present the data, because pictorial representation is understood more clearly. While making graphs and using pictures ensure that good quality of the same is maintained. While giving pictures ensure patients confidentiality. While writing the results it is important that conclusions are not drawn in the section, neither the results are discussed in the light of existing literature. Provide the exact values of the tests used while analysing various variables and provide the absolute p values and 95% confidence interval.

Writing the discussion

This section should be utilized to summarize the findings of the study and putting the same in proper perspective.15 Its main aim is to provide interpretation of results which in turn would let the readers know whether the aim of the study has been fulfilled or not. A comparison between current and previous research findings must be done and attempt should be made to generate hypotheses to explain the similarities/ differences in the findings. It is also important to highlight any novelty in the study design and/ or the findings of the research in this section.

Conclusion section

The conclusion section should list the salient conclusions which could be drawn from the article. Presenting the conclusions as bullet points or with numbers can enhance the impact.

Limitations section

Many a time's authors hesitate to write the limitations of the study. However, it is important to be humble in acknowledging all the methodological limitations of the study. The limitation section should preferably be accompanied by a future direction section as to how methodology can be improved in the area to get better results. 342 Psychiatry in India : Training & training centres Preparing the reference list

There is no doubt that the accuracy of the references is the responsibility of the authors. Referencing style varies from journal to journal but the 2 common types of referencing style which are followed include Vancouver system and Harvard system.16 In the Vancouver system the references are expressed as numerical in the manuscript and the references are in the order in which they appear. In the Harvard system, the name of the first author is used along with the year in which the article was published. However, if there are only two authors then name of both the authors is given. While reading and writing many a times an author may come across the information about another previous publication in one of the published article. It is important to remember that if an author intends to use the information, rather than just relying on the cross-referenced information, it is always a must to cross check the information from the original publication.16 While expressing the references it is advisable that the authors should use the internet search to check the references for accuracy. While preparing the reference list check the requirement of the journal with respect to the names and number of authors to be given, where punctuation marks are to be given, how the name of the journal is to be written (abbreviated or full form), whether the issue number need to be given or not and as to how to write the page numbers. Some journals prefer that names of all the authors must be provided, some recommend use of “et al” after the name of three or six authors. Now a days the job of referencing has been standardized and made easy by “endnote” software which can help in generating the reference list and changing the expression of references in the manuscript and reference list from one style to the others.

Editing the manuscript

Once the draft of the manuscript is prepared by an author, other authors should go through it to make it more concise, more focused with respect to the message which is intended to be given, checking for the accuracy of the data, language, references etc. For the trainee authors it is always advisable that they handover the collected material to the senior author to verify the information and the conclusions drawn from the existing literature. The senior authors should also focus on the issue of plagiarism and it should be strongly discouraged. All the suggested changes should be mutually discussed before accepting the same. If there are more than two authors, it is always better if the editing is done one after the other, rather than 3-4 people editing the same manuscript simultaneously.

At the end, it may also be useful to ask a colleague who has not been involved in preparation of the manuscript to do a proof reading as this at times brings out surprise errors. Grover et al: How to write a research paper 343 Final check

Once a manuscript is ready in all the aspects, it is the responsibility of the corresponding author to do a final check with respect to the journal requirements before initiating the submission process. Depending on the requirement of the journal the corresponding author should have e-mail addresses of all the authors and atleast name and contact address of 4-5 authors who are considered to be the reviewers for the journal. The copyright forms and other disclosure issues should be addressed. Check the payment related issues prior to submission and if considered to be unaffordable, check for the waiver policy of the journal.

Searching for a Journal for submission

It is one of the most difficult jobs. However, the good news is that most of the journals encourage submission of manuscript online and provide decision early. There is no clear strategy with respect to selection of the journal, but in general every author aims to publish their work in high impact journal. However some prefer to publish the article in open access journals as this can pay dividend in the form of higher chance of article being cited in the future. The basic rules of the game are look for the journals which publish research in the area in which you intend to publish, look for an international journal which is more open to the manuscript from the developing countries and takes a shorter time to provide the decision.

What after submission

Although most of the journals acknowledge the receipt of the manuscript, if anything is not heard in 1-2 weeks, it is always advisable to check with the journal office with respect to the receipt of the manuscript. The corresponding authors should visit the journal website to check the progress of the manuscript and if anything is not heard further in next 12-16 weeks, it is always better to check with the editor's office. If an article enters the “under review” phase then it is to be understood that atleast one hurdle has been crossed and the article has not been axed by the editorial team. If you get a rejection after all the hard work please have a re-look at your writing style, methodological issues and selection of the journal. Please read the comments of the editor carefully as at times this can provide insight as to where this manuscript has more chances of getting accepted.

Revision

If you receive the manuscript for revision, the most important thing is to respond quickly as there is still a lag period of few months before the article appears in an issue of the journal. Respond to all the aspects raised by the 344 Psychiatry in India : Training & training centres reviewers/referees point by point and at the same time acknowledge the aspects which cannot be modified.

Tips for trainees

Usually a trainee is given a picture that getting an article published is the most difficult thing to do. However this is not an absolutely true fact. It is always difficult to get an original article published but other articles like letter to editor, book reviews, case reports, student's corner provide a good opportunity to the trainees to practice and enhance their writing skills and learning the rules of the game.17 Next step involves graduating to writing the review articles. However, it is important to remember that all the efforts should be put into these endeavours as there is no substitute to original research papers in curriculum vitae. It is important to remember that curriculum vitae of a trainee with a total number of publications as 30 with only 2 original research papers will be a no match to a curriculum vitae with a total number of publications as 10 with 8 original research papers. Hence all the trainees are encouraged to participate in original research and should have a good mix of all kind of publications. Some of the basic tips which can help the trainees enhance their skills are provided in table-4.

Table-4: Tips for trainees

1. Associate yourself with senior authors and initially try to be a co-author and learn how to convey the information. 2. Learn to collect information, read the available information 3. Read information in the form of books and journal articles with respect to writing skills 4. Attend workshops and training courses 5. Learn to write in your own language 6. Request the senior author to make changes in hard copy or by using track changes so that you are aware as to what changes have been made. This will help you in writing in a better way in future 7. Initially write letter to editors, under the supervision of senior authors. This will reflect both your reading and writing skills 8. Whenever you see an interesting case in terms of phenomenology, drug side effects, drug interaction- read about the same, you may come across an opportunity to write a case report or a small case series 9. Never be a hurry to submit the article without getting it approved from a senior author 10. Some journals provide student corners- write in these sections 11. While writing the case reports and original article where you can be a Grover et al: How to write a research paper 345 first author- look for journals which encourage trainees or early career researchers- you may have better chance of acceptance REFERENCES 1. Makela M, Witt K. How to read a paper: critical appraisal of studies for application in healthcare. Singapore Med J 2005; 46: 108-114. 2. Nicolaides A, Thornton E. The process of writing a scientific paper. Int Angiol 2000; 19: 184–90. 3. Peh WCG, Ng KH. Basic structure and types of scientific papers. Singapore Med J 2008; 49: 522-4. 4. Peh WCG, Ng KH. Title and title page. Singapore Med J 2008; 49: 607-8. 5. Peh WCG, Ng KH. Authorship and acknowledgement. Singapore Med J 2008; 49:563-5. 6. International Committee of Medical Journal Editors. Uniform requirements for manuscripts submitted to biomedical journals. Updated April 2010. Available at: www.icjme.org. Accessed Dec 24, 2010. 7. Welch HG. Preparing manuscripts for submission to medical journals: the paper trail. Effect Clin Pract 1999; 2: 131–7. 8. Cunningham S. J. How to . . . write a paper. Journal of Orthodontics, Vol. 31, 2004, 47–51 9. Peh WCG, Ng KH. Writing the introduction. Singapore Med J 2008; 49:756-7. 10. Ng KH, Peh WCG. Writing the material and methods. Singapore Med J 2008; 49:856-8. 11. Ng KH, Peh WCG. Writing the Results. Singapore Med J 2008; 49: 967-8. 12. Ng KH, Peh WCG. Preparing effective tables. Singapore Med J 2009; 49: 117-8. 13. Ng KH, Peh WCG. Preparing effective illustrations. Part 1: graphs. Singapore Med J 2009; 49: 117-8. 14. Ng KH, Peh WCG. Preparing effective illustrations. Part 2: photographs, images and diagrams. Singapore Med J 2009; 49: 330-4. 15. Ng KH, Peh WCG. Writing the discussion. Singapore Med J 2009; 49: 458-60. 16. Peh WCG, Ng KH. Preparing the references. Singapore Med J 2009; 50: 659-61. 17. George S, Moreira K. Publishing non-research papers as a trainee: a recipe for beginners. Singapore Med J 2009; 50: 756-8.

Sandeep Grover Assistant Professor Department of Psychiatry Postgraduate Institute of Medical Education & Research Chandigarh 160012, India [email protected] Alakananda Dutt Department of Psychiatry, PGIMER, Chandigarh Archana Malik Department of Ophthalmology Government Medical College and Hospital Chandigarh

36 How to carry out internet literature search: Basic tips

Sandeep Grover, Archana Malik

ABSTRACT

In today's world, internet is a major source of searching for scientific literature. However, many a times, the trainee doctors are faced with a difficult situation, because they are not able to search the relevant articles. This paper outlines the basics of how to carry out an internet search. Scientific literature can be searched across various search engines, and the most important steps are selection of appropriate key words, using appropriate key words in various combinations and refining and expanding the search.

Introduction

It is important for every clinician to be updated about the scientific literature. We all read text books which lay the foundation of our knowledge. However, with the everyday expanding world of scientific literature and changing facts, it is important to be aware as to how one can access the literature meaningfully. As a trainee, researcher, reviewer, editor, teacher and clinician we have to access the literature either to update ourselves, get literature to write a research protocol, write an original article/ review article/ case report etc, prepare for a seminar, case presentation, talk, journal club etc. However, accessing the available literature can be a daunting task, if not done properly. In this article some of the basic principles of internet search are given. It is important to remember that these are the basic principles and not the complete exhaustive list of steps and process of carrying out an internet search. Some of the basic aspects have been summarized in table-1.

The basic rule before carrying out a search

In today's world most of the students and researchers have access to the 348 Psychiatry in India : Training & training centres internet and it is important to understand to use the same optimally. However, before one starts with the internet search, it is important to have a basic understanding of the area in which you are interested. Hence for trainees it is important first to read about the topic from a basic textbook, so that they become familiar with the topic and also are able to select appropriate keywords. Before you sit down for your internet search, ensure that you have sufficient time, so that you can have liberty of carrying out multiple searches, across multiple engines, and are able to download the articles of your interest depending on the speed of your connection. Having a high speed internet connection can save you a lot of time, reduce your frustration and may keep you focussed.

Search Engines

For carrying out an internet search, it is important to be familiar with the available search engines and should use the same optimally to get good coverage of the data. Some of the common search engines include Pubmed, Scicentral, Google, Google Scholar, Medknow, Search Medica, Science Direct, Scopus, Embase, Cochrane database and Psychinfo etc. Usually a Good PUBMED search will yield good amount of literature. But it is important to understand that many of the journals are not indexed in the PUBMED and hence some of the articles, which may be of importance and relevance with respect to the local information, may not appear in PUBMED search. Hence a PUBMED search should be supplemented by searches in other engines.

As PUBMED is the most commonly used search engine, a brief background of the same is provided here. MEDLINE is produced by the U.S. National Library of Medicine (NLM) which is readily available for carrying out search free of charge at http://www.pubmed.gov. Whenever a search is done using certain key words in Pubmed, the key words are matched against MEDLINE records which consists of title, name of the authors , affiliation, abstract, language, publication date, name of the Journal and Medical Subject Heading (MeSH) terms. MeSH terms are assigned by expert indexers to best reflect article content. When a free-text search is done, records containing the given key word anywhere in the title or abstract are retrieved, even those not necessarily related to the subject. But if a search is done using MeSH terms, it retrieves records on that specific subject, regardless of the words used by the authors. 1

Selection of Keywords

For doing a proper search one of the important issues is selection of key words. Depending on the need, key words should be used in various permutations and combinations to get a more exhaustive literature. While Grover & Malik: Internet literature search-Basic tips 349 going through the search look at the material appearing with respect to the name of the journals, authors or group of authors which has published the articles consistently on the topic. This is important because this can help you in using the name of the author as a key word to search the literature. Similarly some journals focus on the particular area, hence the website of the journal can be accessed and a search option at the journal website could be used to see all the articles published in that journal. While using different key words it is important to be aware of the fact that you can select the area of the article, for example authors name, title, title and abstract, anywhere in the article. Also learn to use comma, and, or, not in combination with the key words to enhance the focus of your search.

Refining and expanding the search

It is important to look at the related article links in the PUBMED search and use of limits to expand or control the scope of your search. Searches can be limited by language, age, gender, and publication type etc. While doing a free- text search in PUBMED, use of expression such as key word [ti], will retrive only those references which have the key word in the title and accordingly different expression for title and abstract [tiab], author [au] and journal name [jour] can be used to refine the search. For Google search, it is important to carryout a general Google search and a Google Scholar search is a must. The general Google search can be supplemented with an advance search, which is somewhat similar to the limits option of the PUBMED and can give you more focused and limited literature. Again depending on the search engine which is being used, other selection options like advance search, limit articles to full text etc can be opted to get available literature. To increase the specificity of the search, truncation function (*) can be used, in which the last letters of a key word is replaced by a truncation, for example, schizophreni*. Further if the key word is a multiword term, it is advisable to enter the term using the quotation marks (e.g., “mood disorders”). Boolean operators can be used to improve search specificity which actually means using the connectors such as AND, OR, and NOT typed using capital letters. The AND operator retrieves all those records which contain all search keywords entered, regardless of where the terms are found. The OR operator retrieves records in which any of the terms appear. The NOT operator eliminates every citation that contains the term following it somewhere in its title or abstract. However it is important to remember that PubMed processes Boolean connectors in a left-to-right sequence, which means that it would give different sets of results depending on which word is used first and which is used second for example used the key words as “schizophrenia NOT efficacy” would yield different results than using the terms “efficacy NOT schizophrenia”. 1

Another option which is available with Google scholar and Scopus is to click 350 Psychiatry in India : Training & training centres the expression “cited by” which appears in the last line of the search list. It can provide the list of all the articles which have cited the article retrieved in the primary search.

Table-1: Basic rules of internet search

1. Have patience and enough time to carry out a proper search 2. Multiple searches in the same engine 3. Carry out search in multiple search engines 4. Use multiple words in various permutations and combinations 5. Use limits and related articles optimally 6. Use names of the established authors in the area as key words 7. Access the website of journals publishing the articles of your interest and carry out a search on the website of the journal 8. Be aware of the journals which provide free access (non-paid articles) 9. For the paid articles, approach your library, as many a times the library may have passwords for the journal and you may be able to get an access

Be aware about the free-access journals

It is always very important to be aware of the journals which provide free- access to the full text of the article. This usually comes with repeated searches and interaction with the colleagues.

What to do, done a proper search – but the article is from a paid journal

Yes, it is true that you have spent a lot of time in doing the search, but somehow are getting stumbled in that you have no access to the full text of the article. What to do? The options available are visit the journals website, visit/contact your library and contact the corresponding author or one of your senior colleagues. At times some of the paid journals have some of the free issues, and you may be able to access the article of your interest as part of one of the free issues. Libraries of many of the institutions in the country have passwords of various search engines or journals depending on the subscription and terms and conditions with the publishers and the journals. There is no harm in writing a mail to the corresponding author with details as to the purpose of use of the article. Many a times depending on the copyright issues between the journal and the author, you may be lucky to get a reprint from the author. Another option is that many a times some of the colleagues who work as reviewers for various journals have access to some of the Grover & Malik: Internet literature search-Basic tips 351 publishers and journals. You may be lucky if this works out.

What to choose and what to leave

More weightage should be given to articles which are higher in hierarchy of evidence. Depending on the study design available, evidence can be divided into a hierarchy in which randomised controlled trials is placed at the top. This is followed by controlled trials without randomization, and other prospective experimental studies. This is followed by prospective cohort studies, case-control studies, and case series. For all kind of studies, a systematic review of the existing studies, with meta-analysis is preferred over the single study. 2

Basic rule should be to focus only on the material which has been published in peer-review journals. In the next step, among the articles published in the peer-review journals, it is important to give weightage to the article depending on the study design and breadth of the article. For example an original research article usually will have more weightage than a case report. Among the various types of reviews a systematic review will have more value than a non- systematic review. Among the original articles, look at the sample size, sample allocation procedure, randomization, blinding etc. Depending on these, usually studies which include large sample size and allocate the subjects to the various groups by using a randomization table and maintain blinding for evaluation of outcome should be given more weightage in selection of the articles. Similarly guidelines drawn by various scientific associations would be more useful in drawing conclusions than non- systematic reviews.

Additional links

While downloading article, always have a look at the HTML version of the article as in the reference section, sometimes you would come across the links to the free full text articles. Further, also look at the section – ‘this article is cited by’, this can further enhance your search on a particular topic.

How to keep one self updated about the information accumulating in the area of interest

One of the easy steps is to be aware about the journals which publish the information on the topics. Visit the website of the journal from time to time and go through the table of content. Another option is to sign in for the table of content alert of the journal, so that you receive a mail from the journals website with publication of every new issue. 352 Psychiatry in India : Training & training centres REFERENCES:

1. Greenhalgh T. How to read a paper. Fourth Edition, John Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, UK, 2010. 2. Beatriz Vincent B, Vincent M, Ferreira CG. Making PubMed searching simple: learning to retrieve medical literature through interactive problem solving. The Oncologist 2006;11:243–251.

Sandeep Grover Assistant Professor Department of Psychiatry Postgraduate Institute of Medical Education & Research Chandigarh 160012, India [email protected]

Archana Malik Department of Ophthalmology Government Medical College and Hospital Chandigarh 37

Reshaping Journal clubs in Medical education: enhancing learning (A selective review of literature and a point of view)

Arun N.R. Kishore

Journal clubs have been defined as sessions where groups of people get together to discuss, review and appraise published literature (1).

Most postgraduate programs have two staple sessions that run in tandem as regular, repeated formal teaching sessions: Journal clubs and Case discussions. Of these Journal clubs have been less popular as compared to Case discussions.

This focused review looks at some of the factors that have been influential in shaping Journal clubs. It looks at ways of reshaping them into useful educational sessions.

A selective history of Journal clubs

Journal clubs have a long and chequered history in medical education. The first Journal club was reported to have been started by Sir James Paget around 1835(1). Journal clubs initially fulfilled a social function and served to disseminate information from the latest journals (1).

The advent of Evidence Based Medicine (EBM) in the 1980's brought about changes to this function. EBM shaped the way doctors read published literature. The purpose of Journal clubs shifted to critically reviewing published literature and evaluating evidence in order to change clinical practice and improve patient care (1). It was suggested that Journal clubs be modified into sessions where trainees learnt to practice EBM. There were five steps to this end: 1) Translation of uncertainty to an answerable question 2) Systematic retrieval of best evidence available 3) Critical appraisal of evidence for validity, clinical relevance, and applicability 4) Application of results in 354 Psychiatry in India : Training & training centres practice 5) Evaluation of performance

Sackett predicted the demise of Journal clubs when EBM became popular (2). On the converse, Journal clubs adapted themselves to this new science and created EBM Journal clubs (3).

At this juncture it would be important to look at the history of EBM especially the changes that have come about in the definition of the term. EBM was initially defined as ' ….the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients' ( 4).

The focus is on the evidence and its judicious application. This definition is based on a positivistic view of science and knowledge(5) and is epistemologically more rationalist in position.

Nine years later, Martin Dawes(6) suggested an evolution of the term to become Evidence-Based Practice (EBP) defined as “…decisions about health care made by those receiving care, informed by the tacit and explicit knowledge of those providing care, within the context of available resources” (6).

Evidence, in this definition, becomes just one of the tools on which the clinician bases decisions. Knowledge is viewed as being constructed within the clinical encounter; EBP is epistemologically more relativist.

The central organising principle in EBM is the evidence. There are three components in EBP: the evidence, clinicians' decision making and patients' views. From an educational angle, EBP is best defined by the second component-clinical decision making. This component is complex and resists being simplistically codified. De Cossart and Fish(7) described the concept of clinical judgment or decision-making to have several components: personal, professional judgment, deliberation or practical reasoning and professional judgment which results in practical wisdom.

EBM and EBP thus differ on issues characterised by a fundamental epistemological shift: EBM is epistemologically more rationalist while EBP is more relativist. Related to this is the shift of the central organising principle from the evidence to clinical decision-making. These shifts are often missed when the two terms are used interchangeably. It becomes important then to ask:

· Have these fundamental shifts affected practice of Journal clubs?

· What role have such shifts had in shaping Journal club sessions? Arun N.R. : Reshaping Journal clubs 355 Defining the purpose of Journal clubs

Doctors from various specialties have seen the core business of Journal clubs differently. In a review of Journal clubs in the USA, Alguire found that while some residents saw learning of critical appraisal skills as being the most important goal, others saw disseminating information as the primary task and ranked it above learning critical appraisal and improving clinical practice(8). The three important purposes of Journal clubs have thus been 1) Acquiring and disseminating current medical information 2) Teaching and assessing critical appraisal skills 3) Providing an interactive and social opportunity.

The priority given to each depends on several factors. For example it may depend on where the doctor is in their medical career (8). An important question to ask at this juncture is: who prioritises the purpose of Journal club sessions and equally, what influences this? Let us now examine these purposes' in further detail.

1) Acquiring and disseminating current medical information

Acquiring information was the primary aim with which Journal clubs were started (1). However, with the explosion in number of medical journals this task has become difficult. It has been estimated that an average doctor would need to read 627.5 hours a month to keep up with primary care literature (9). Some Journal clubs have attempted to overcome this problem by analysing a number of papers in one single session (9). This is done at the risk of snapshot summaries of papers with no attempts at in-depth analyses. There are several journals which give excellent summaries and analyses of current medical literature for those interested in this aspect. Several other methods have been suggested to develop focused reading of literature. It might be important to look at these in greater depth.

Methods of choosing papers for review

David Jewell identified several levels of reading a) browsing: looking for interesting information b) information seeking: looking for answers to specific questions and c) researching: seeking a comprehensive view(10). In practice most doctors get their information by browsing (11). EBM Journal clubs suggest that researching be used as a method of selecting papers. This implies that the paper for review be chosen based on a clinical question generated in practice and that doctors identify gaps in their knowledge (12). Doctors tend to generate at least one question for every two patients they see; the opportunity to explore these questions in the groups can stimulate development of ideas for future change (13,14). The problem with using clinical questions to generate searches is that most clinical questions generated in 356 Psychiatry in India : Training & training centres practise go unanswered. Primary care physicians only try to answer a limited number of their clinical questions, and when they do, they first consult colleagues and later other resources (15). Not all issues raised within clinical discussions can be formulated as clinical questions and often they do not need to be defined as such. Few find answers within literature. Viewing clinical practice, Journal clubs and Case discussions with a view towards generating clinical questions is at best reductionist. They serve many functions as educational sessions as we shall see later. Clinical decisions have to be made through negotiation within sessions and the use of best practice(15).

Spillane observed that whilst selecting a paper for presentation at a Journal club the selection may be done ad hoc and the paper chosen may not be the most suitable to cover the topic in question; the trainee may have no say in the choice and may not know why the paper has been chosen (16).

Does the journal in which an article appears affect physicians' perceptions of the quality of the research presented and hence their choice of paper for review? This phenomenon called 'Journal attribution bias' may play a large role in governing which articles physicians choose to read especially when people do not take the time to read articles carefully (17).

The question of how a paper needs to be chosen for review leads us to the issue of who should choose the paper to be presented in a Journal club; the trainee, the Consultant or a group of people designated for the purpose. This aspect is important, since it shapes the sessions. In a review of papers presented at Journal clubs at our local post graduate centre we found that most papers were from the 'positivistic' paradigm; there was a dearth of qualitative studies or studies from education. The choice of a paper is often governed by a trainees examination needs. The method of choice of a paper has been contested, yet has not been explored in any great detail.

There is little evidence to suggest that attending Journal clubs stimulate doctors to read though it might make them more critical of what they read (18). It might be interesting to look at this aspect of critical reading further.

2) Teaching and assessing critical appraisal skills

Learning to be critical in academic enquiry implies accepting a particular approach (19). In Journal clubs, this approach is at times narrowly defined to be the critical appraisal of statistics and research design of papers. It has been argued that the Journal club needs to focus on the teaching of epidemiology and statistics (20, 21). Such a narrow definition of critical appraisal would mean that trainees have to attempt to criticise papers that have passed through the able scrutiny of peer assessors and editors of reputed journals, a task that Arun N.R. : Reshaping Journal clubs 357 could be daunting in the least. Proponents of EBM have suggested the use of a structured checklist and explicitly defined written goals while critically appraising a paper (20). Use of a rigidly structured format could stifle independent thought. One of the limitations of a Journal club has also been that it is excessively focused on critical appraisal skills (22).

Learning the skills of critical appraisal is rated as an important goal by trainees in various settings (23). Within Psychiatry the addition of a critical review paper to exams could be one reason why trainees feel this is an important aim of Journal clubs (23). This leads them to focus on developing skills to pass exams, missing out on the broader issues of critical appraisal necessary for practice.

It is thus crucially important how we define critical appraisal. This can be narrowly defined as the learning of epidemiology and statistics or more broadly as the ability to learn clinical decision making. Clinical decision making requires evidence from research as well as knowledge from other sources (often tacit knowledge) to be integrated (7). It is often the endpoint of a process that may include reasoning, complex problem solving as well as an awareness of the context. The whole process is uncertain and correct answers may not exist (7). Evidence from literature serves to assist in decision making. This has to be translated into the clinicians' personalised knowledge and then applied to the context. In Journal clubs, at present, clinical decision making is often narrowly defined as critical appraisal skills i.e. the ability to judge the quality of research design, statistics and epidemiology. Journal clubs should redefine critical appraisal more broadly as discussed above. If we were to accept this then the primary purpose of Journal clubs should be to enhance this component in trainees.

This issue becomes important if we look at Journal clubs as sessions where there is a diverse group of learners at various stages of their medical career. As we have seen in our post graduate centre, an exclusive focus on critical appraisal skills training within Journal club sessions created a sense of disillusionment amongst the trainees and drove the consultants away. Thus while training in research design, statistics and epidemiology in Journal clubs would be useful to trainees, it could be quite boring to Consultants. Doctors, it has been argued, are consumers and not users of statistics (24).

The evidence as to whether trainees gain the ability to critically assess a paper through the Journal club sessions is not very strong. A Cochrane review concluded that Journal clubs probably do improve knowledge of biostatistics and clinical epidemiology, although the evidence base was small (25). There is conflicting evidence on whether Journal clubs enhance critical appraisal skills, and objective measurement of skills shows less improvement than self- 358 Psychiatry in India : Training & training centres assessment (18, 8).

Fu et al in 1999 conducted a controlled study to examine the effectiveness of a Journal club for teaching critical appraisal skills to residents in Psychiatry and their transfer of those skills to clinical scenarios. At follow-up the Journal club residents did not perform any better than the control residents on several measures (26).

We have so far examined what the purpose of Journal clubs from various viewpoints. What then should be the content or format of Journal clubs?

Components (Format) of successful Journal clubs

There are several formats to Journal clubs (27). They may be broadly divided into the conventional, alternative and EBM formats. In the conventional format one or several papers are chosen from recently published research and presented at the session. The focus is on critically reviewing the content of the paper, its research methodology and statistics. Discussion focuses on these aspects. In the unconventional format (more commonly seen in psychiatry) the review includes papers chosen from recent research, books, patient narratives video and films. Discussion includes, in addition to those in the conventional one, issues around psychotherapy, social and literary aspects of papers. In the EBM format described earlier, papers are chosen based on a clinical question generated in practice or in Case discussions, a systematic retrieval of best evidence, its critical appraisal and application to practice. An ideal format for Journal clubs may not exist. Rather, the format depends on the purpose of the Journal club, the parameters used to define success, and the available resources. It might be important to look at how 'success' is defined and what components of Journal club formats are associated with it.

Sidorov defined successful Journal clubs as those with longevity (at least 2 years) and high levels of resident participation (at least 50% attendance) (28). In his study, Journal club longevity was associated with the regular provision of food and the presentation of only original research articles. Interestingly, it was also associated with the lowest resident attendance rates. High resident attendance rates were associated with smaller programmes, mandatory attendance, session's independent from faculty, and formal instruction in biostatistics and clinical epidemiology. Journal clubs with both longevity and high attendance were characterised by mandatory attendance, availability of food, and association with smaller training programmes.

Support from programme directors could be important for longevity (29). If success is defined by satisfaction levels of the programme director, variables such as mandatory attendance and having a designated leader gain Arun N.R. : Reshaping Journal clubs 359 importance (30). A Journal club needs a dedicated, committed and skilled moderator to ensure the longevity of the session (28). The essential attributes of a moderator include the belief that Journal clubs have an important role in medical education (23).

Linzer demonstrated higher attendance rates in a Journal club led by a chief resident, with invited sub specialist faculty, as compared with one moderated by a general internist (1).

Having a formal consistent schedule and location along with protected and convenient time are factors that would ensure continuation of Journal clubs.

There have been several attempts to introduce changes to the format of Journal clubs to make them more interesting as learning experiences and make them more successful (31).

Interventions to change the format of Journal clubs have focused on the issue of critical appraisal and the teaching of epidemiology and biostatistics (27; 31; 32; 33). Some have attempted to contextualise learning by linking Journal clubs to Case discussions. The interventions have varied in a spectrum of an exclusive focus on critical appraisal (31) to doing away with it totally (27).

The success of Journal clubs has been measured using different yardsticks.

Success, I believe, needs to be defined by the way participants look at the purpose of Journal clubs. Hence if Journal clubs are to be reformed it would then be important to ask the question: What is the core business of Journal clubs as defined by those who participate in the sessions? The studies reviewed have not looked at the nature of learning in Journal clubs. This I believe is an important aspect. Journal clubs should be shaped around principles of learning and education.

What then is the nature of learning in Journal clubs? What intervention would help change the sessions into a useful educational activity?

3) Providing an interactive and social opportunity

The 'social' aspects of Journal clubs have been seen to be opportunities for people to meet, interact and form bonds. Spillane (34) reported that the informal format of their Journal clubs was seen as one of its major assets, with all of the respondents reporting high levels of satisfaction with the social value.

The provision of a meal may allow for a more relaxed learning environment and reflect the organized, advance planning necessary to establish the long, 360 Psychiatry in India : Training & training centres continuous existence of the Journal club. Sidorov (28) found there was an association between attendance and provision of food.

Do the 'social' aspects of Journal clubs have a meaning beyond the ability to meet and socialise? If learning is essentially a social phenomenon then the process of learning and participation in a community are inseparable. Knowledge may be seen as being integrated in the values, beliefs and languages of the community and practice (35). One could conceptualise the group that meets in Journal clubs as communities of practice in this sense.

A few studies have shown that trainee Journal clubs are best organised separate from faculty Journal clubs (20). If Journal clubs are seen as sessions where trainees can be taught critical appraisal, then they are best organised separately. However, if they are seen primarily as learning opportunities then a diverse group of learners is better. If this is accepted then there is a need to redefine the 'social' in Journal clubs and to ask the question: ”How can Journal clubs be made more useful to a diverse group of participants? “.

The nature of learning in Journal clubs

Over the last 25 years there have been significant changes to the concept of learning and teaching. The predominant one has been the shift in focus from the activities of the teacher to the way the student learns. This includes not just what the student learns but with their approaches to learning, the personal meanings they derive, the social context and value systems in which the learning occurs (36). Investigation into the social context of learning has resulted in significant paradigm shifts where knowledge is thought to be created in the social interactions of groups- the concept of constructivism. While learning in groups has been stimulated by interaction, participation and dialogue it has also thrown up issue of group learning in cultures where interaction and participation may not be culturally common(36) - in India for example.

Studies have been conducted into the most effective way of changing physician behaviour. Common continuing professional development (CPD) approaches (e.g., lectures and handouts) are less effective in changing physician behaviour(37). Didactic sessions have not been found to be very effective either. Whilst continuing medical education programme's have not been found to be effective, small group learning through interactive sessions has been thought to be effective in changing physician behaviour (38). Sessions that enhance participant activity and afford an opportunity to practice skills are most effective. Whilst interaction has been highlighted as being important for learning and changing physician behaviour, there are few studies to show how this is achieved. Arun N.R. : Reshaping Journal clubs 361 Learning in small groups provides interactive approaches, which can be effective in changing physician practice. They involve participation in groups that promote discussion of evidence relevant to real cases, provide feedback on performance, and offer opportunities for practising newly learned skills (38). Small groups also provide opportunities to learn information and how this can be applied to practice. These small groups provide an atmosphere of trust and enhance self appraisal (37). Journal clubs can be seen as formal, repeated, regular small groups where such learning occurs.

The issue of learning in Journal clubs is particularly caught between the conceptions of individual learners and the group learning as a unit together. Cole et al (39) in their study concluded that journal reading, structured as a continuing medical education activity, may be educational at all stages of the learning process (39). They were looking at individual learning in this study. Price et al (40) state that Journal clubs and Case conferences structured interactively are more likely to help change practice. In their study done over three years, they used the concept of communities of practice to designate the interaction that goes on in these two sessions. In their observation, they measured individual rather than group learning.

I would prefer to view this issue avoiding the dichotomy of individual versus group learning and look at one being complementary of the other. Journal clubs can be construed as small groups where members are brought together by joining in common activities and by “..what they have learned through their mutual engagement in these activities” (41). Wenger uses the term communities of practice to define social learning through participation and the formation of identities (41). Physicians and other health professionals in communities of practice not only support each other in the learning process, they also use the opinions of their peers to validate their own self- directed learning (42). Thus within small groups learning can be said to occur at two levels. At the group level knowledge is created through contextualising information and applying it to local and individual cases. At the individual level this knowledge is personalised through contextualisation and relating it to previous experience. Participation, interaction and negotiation are important to such learning processes. It would be important to state that practice knowledge is enhanced in such processes rather than theoretical knowledge being applied to practice. I believe that Journal clubs should be viewed as opportunities where theory (evidence from research) and practice interrogate each other. This is likely to occur through the complex process of clinical decision making.

Conclusion

Journal clubs began with the need to update knowledge and keep abreast 362 Psychiatry in India : Training & training centres with published literature. When this became difficult, the need to do focused reading led to critical appraisal of papers and EBM Journal clubs. Journal clubs do not help improve reading nor are they effective in teaching critical appraisal. The advent of EBM led to a narrow definition of critical appraisal and an excessive emphasis of this aspect within the sessions. EBM itself, as we have seen, has undergone fundamental conceptual shifts.

I have argued that Evidence Based Practice should revolve around the core value of clinical decision making rather than on evaluation of the 'evidence'. Critical appraisal should be defined broadly as the ability to develop clinical decision making, contextualising theoretical information and interrogating theory in the light of clinical practice.

Journal clubs in turn need to be organised around core values and principles. This can be done by defining the purposes of Journal clubs. This definition of values and principles is best done by the participants themselves. A key step in this process may be to carefully select the papers reviewed at the sessions.

Journal clubs are essentially learning opportunities where a group of people meet regularly to examine theory or evidence in the light of practice. The educational aspects of these sessions have been underplayed and have not been very influential in shaping them. We have seen that traditional continuing professional development programmes are not very effective in improving learning or practice. Journal clubs as small group, interactive sessions may be more effective. Journal clubs may be made more effective when organised around core learning principles. They are best viewed as small group sessions where learning occurs at both an individual level as well as a group.

References

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Resuscitating the cardiology journal club. Can J Cardiol, 8.pp. 520–2. 34. Spillane, A.J. & Crowe, P.J. 1998. The role of the Journal club in Surgical training. Aust NZ Journal of Surgery, 68.pp. 288-291. 35. Lave,J., & Wenger, E. 1991. Situated Learning. Legitimate peripheral participation, Cambridge: University of Cambridge Press. 36. Jacques, D.,Salmon, G. 2007. Learning in Groups: A handbook for face-to-face and online environments. Oxon.USA.Canada. Routledge 37. Armson, H., 2007. Translating learning into practice: Lessons from the practice-based small group learning program. Can Fam Physician, September, 53(9), pp. 1477–1485. 38. Forsetlund, L, et.al. 2009. Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2009 Apr 15;(2):CD003030. 39. Cole, T.B., Glass, R.M. 2004. Learning Associated with Participation in Journal-Based Continuing Medical Education. The Journal of Continuing Education in the Health Professions, Volume 24, pp. 205-212 40. Price, D.W., Kate, G., & Felix, K.G.(2008): Journal Clubs and Case Conferences: From Academic Tradition to Communities of Practice J. Continuing Educ in the Health professions , 28(3).pp.123–130 41. Wegner, E., McDermott, R., & Snyder,W. 2002. Cultivating communities of practice: a guide to managing knowledge. Cambridge, Mass.: Harvard Business School Press. 42. Eraut, M. 1994. Developing professional knowledge and competence. London: Palmer Press.

Arun N.R. Kishore Consultant Psychiatrist Sussex Partnership NHS Foundation Trust, U.K. Educational supervisor and SAS Tutor, Sussex Partnership NHS Foundation Trust , Sussex, U.K. Greenacres, Homefield Road, Worthing West Sussex BN11 2HS U.K. [email protected] 38 Neuroimaging in Psychiatry – An Overview

Ganesan Venkatasubramanian, Naren P. Rao

ABSTRACT

By virtue of their potential to offer in vivo exploration of brain, neuroimaging techniques play a unique role in unraveling the complex brain aberrations that underlie the pathogenesis of various psychiatric disorders. Contemporary imaging applications, especially in psychiatry, is dominated by the use of magnetic resonance based procedures which facilitate assessment of neuroanatomical, neurochemical, neuro- functional as well as connectivity architecture of brain in various disorders. These imaging research techniques and their specialized application paradigms like imaging genomics as well as neurophenomenology critically contribute to 'endophenotype-based research' in psychiatry.

Introduction

Recent developments in science have paved way for significant advances in our understanding of the genesis of psychiatric disorders; indeed, substantial progress has been made in understanding the bi-directional “vectors of influence” that link genes, brain and social behavior in health and disorder . By virtue of their potential to offer in vivo exploration of structural, neurochemical and functional brain abnormalities in psychiatric disorders, neuroimaging techniques play a unique role in unraveling the complex brain aberrations that underlie the pathogenesis of various psychiatric disorders. Nonetheless, current applications of neuroimaging in psychiatry are predominantly research-focused; clinically, the utility is limited – mostly, in the context of assessment of potential neurological co-morbidity. This is not surprising given the complexity of brain structure and function about which much more scientific progress is required. However, given the promising future avenues, it is important that the psychiatry trainees need to understand the basics of various neuroimaging techniques. 366 Psychiatry in India : Training & training centres Current Neuroimaging Techniques – A Glimpse

Contemporary imaging applications, especially in psychiatry, is dominated by the use of magnetic resonance based procedures namely – structural Magnetic Resonance Imaging (MRI) which helps in comprehensive assessment of brain anatomical changes; Magnetic Resonance Spectroscopy (MRS) which facilitates analysis of neurochemical architecture of brain; Diffusion Tensor Imaging (DTI) which paves way to infer the structural brain connectivity through examination of white matter tracts, and functional MRI (fMRI) which permits estimation of neural function by analysis of neuro- hemodynamic changes. Among these techniques, perhaps fMRI has elicited enormous interests in the recent past. The fMRI is a non-invasive imaging technique that is based upon the differential magnetization properties of hemoglobin. Hemoglobin is diamagnetic when oxygenated but paramagnetic when deoxygenated. The magnetic resonance (MR) signal of blood will therefore differ depending on the level of oxygenation of hemoglobin. These differential signals can be detected using an appropriate MR pulse sequence as Blood Oxygen Level Dependent (BOLD) contrast. By collecting data in a MRI scanner with parameters sensitive to changes in magnetic susceptibility, one can assess changes in BOLD contrast. These changes can be either positive or negative depending upon the relative changes in both cerebral blood flow (CBF) and oxygen consumption. Increases in CBF that outstrip changes in oxygen consumption will lead to increased BOLD signal; conversely, decreases in CBF that outstrip changes in oxygen consumption will cause decreased BOLD signal intensity . (for a good summary of the basics of other neuroimaging techniques please refer to a recent review).

The Importance of Neuroimaging in “Endophenotype-based Approach” in Psychiatry

Endophenotypes, measurable components unseen by the unaided eye along the pathway between disease and distal genotype, have emerged as an important concept in the study of complex neuropsychiatric diseases. An endophenotype may be neurophysiological, biochemical, endocrinological, neuroanatomical, cognitive, or neuropsychological in nature. Endophenotypes have potential uses in psychiatry including utility in diagnosis, classification, development of animal models and evaluation as well as understanding the mechanisms of psychopharmacological agents. Endophenotypes by means of their status as proxy markers of aetiopathogenesis will be helpful in dissecting the genetic subtypes of complex neuropsychiatric disorders. Advanced tools of neuroimaging such as functional magnetic resonance imaging (fMRI), morphometric MRI, diffusion tensor imaging, single photon emission computed tomography (SPECT), and positron emission tomography (PET) promise to expand the Venkatasubramanian & Rao: Neuroimaging in Psychiatry 367 possibilities even more.

Imaging genomics, which is an endophenotype-concept driven approach; it is a potential research paradigm that will be of great utility in facilitating further advances in understanding the etiopathogenesis of psychiatric disorders by elucidating the complex relationship between partitioned phenotypes as well as endophenotypes to genetic variations. Imaging genomics is a form of genetic association analysis, where the phenotype is not a disease phenotype but a physiological response of the brain during specific information processing. Application of this research principle has already shown promising results in understanding the relationship between apolipoprotein E & memory systems, catechol-o-methyl transferase & the prefrontal cortex, 5-HTT transporter gene & the amygdala.The results of these studies underscore the power of a direct assay of brain function like fMRI to identify phenotypes in brain related to functional polymorphisms in genes likely important for human behaviour and neuropsychiatric illness. They also provide a compelling evidence that the application of imaging genomics in light of the basic principles promises a unique opportunity to explore and evaluate the functional impact of brain-relevant genetic polymorphisms more rapidly and with greater sensitivity.

Some of the other important novel neuroimaging applications involve the principles of neurophenomenology . Neurophenomenology proposes that the phenomenological accounts of the structure of experience and their counterparts in cognitive science relate to each other through reciprocal constraints. Such a phenomenological approach that is informed by neuroscience would help in synthesizing neurocognitive models of schizophrenia. One of the widely researched paradigm is the neurocognitive model proposed by Christopher Frith. This model hypothesizes positive symptoms of schizophrenia to result from dysfunction of self-monitoring system and negative symptoms to result from defective spontaneous willed action. For example, first-rank symptoms like somatic passivity might be secondary to parietal lobe abnormalities, whereas spontaneous willed action deficits might result from hypofrontality . Recent functional MRI (fMRI) study has reported Schneiderian first-rank symptoms to be associated with parietal lobe hyperactivity in schizophrenia patients .

In summary, with promising future clinical applications, current neuroimaging techniques help one to dissect the pathogenesis of psychiatric disorders that might facilitate further diagnostic and possibly therapeutic implications.

REFERENCES

1. Robinson GE, Fernald RD, Clayton DF. Genes and social behavior. Science 2008 Nov 368 Psychiatry in India : Training & training centres 7;322(5903):896-900. 2. Brown GG, Perthen JE, Liu TT, Buxton RB. A primer on functional magnetic resonance imaging. Neuropsychol Rev 2007 Jun;17(2):107-125. 3. Malhi GS, Lagopoulos J. Making sense of neuroimaging in psychiatry. Acta Psychiatr Scand 2008 Feb;117(2):100-117. 4. Gottesman, II, Gould TD. The endophenotype concept in psychiatry: etymology and strategic intentions. Am J Psychiatry 2003 Apr;160(4):636-645. 5. Hariri AR, Weinberger DR. Imaging genomics. Br Med Bull 2003;65:259-270. 6. Lutz A. Neurophenomenology and the study of self-consciousness. Conscious Cogn 2007 Sep;16(3):765-767. 7. Venkatasubramanian Ganesan, Hunter MD, Spence SA. Schneiderian first-rank symptoms and right parietal hyperactivation: a replication using FMRI. Am J Psychiatry 2005 Aug;162(8):1545.

Ganesan Venkatasubramanian Associate Professor of Psychiatry Department of Psychiatry NIMHANS Bangalore – 560029 [email protected]

Naren P. Rao Senior Resident in Psychiatry National Institute of Mental Health & Neurosciences, Bangalore, India. 39 Clinical Neurology for Psychiatrists – An Overview

Naren P. Rao, Ganesan Venkatasubramanian

ABSTRACT

Significant advances in understanding of neurobiology of psychiatric disorders with this biologization of psychiatry have led to formation of a subspecialty – 'Neuropsychiatry' that deals with the psychological and behavioral manifestations of brain disease.This emphasizes the importance of sensitivity towards neurological manifestations in psychiatry. In this context, this write-up briefly outlines the essentials of clinical neurology for trainee psychiatrists.

Introduction

With advances in neurosciences, there has been a significant improvement in understanding the neurobiology of psychiatric disorders & the mind brain dichotomy is increasingly being challenged. 'Neuropsychiatry' as a sub speciality deals with the psychological and behavioral manifestations of brain disease. Dementia is a prototypical example for diseases to be treated under this sub speciality with inputs from both neurology and psychiatry. Moreover, most of the psychiatric conditions have shown to be having a brain abnormality in neuroimaging and other biological studies, further blurring the boundary between neurology and psychiatry. This also has significant impact on the clinical care of patient. To keep in pace with this new era of psychiatry, an adequate knowledge of neurology including clinical neurological examination and different investigative modalities is required for a psychiatrist . In this review we give a brief overview of the interface between neurology and psychiatry. Initially we discuss a clinical approach to a patient with neuropsychiatric symptoms and then discuss the interface between neurology and psychiatry. 370 Psychiatry in India : Training & training centres Clinical approach to Neurological examination in Psychiatry

To a neuropsychiatrist, detailed history and physical examination is an important aspect for evaluation of patient and thus a detailed examination will give vital information regarding the underlying disorder.

History: History is vital for the evaluation of a neuropsychiatric patient. Indicators of organicity can be elicited by a careful history and confirmed later by investigations and clinical examination. An abrupt onset of symptoms in the absence of stressor warrants further evaluation. Associated features like projectile vomiting, loss of consciousness, seizures, altered or fluctuating consciousness, disorientation, incontinence & fever are indicators of underlying neurological illness.

General examination: While inspecting the patient, one has to give importance to the minor physical anomalies & abnormal habitus. Elevated temperature could lead important clues to underlying infections. Typical neurocutaneous syndromes like tuberous sclerosis (adenoma sebaceum, ash leaf macules, shagreen patches), Sturge Weber syndrome (Port wine statin), neurofibromas can be diagnosed by careful examination of skin.

Eyes and cranial nerves: Pupillary examination gives an assessment of anticholinergic activity and also characteristic conditions like neurosyphilis (Argyll Robertson pupil). Decreased blink rate is an indicator of hypodopaminergia and is seen in antipsychotic treatment associated extrapyramidal symptoms. Papilledema indicates raised Intra cranial pressure and is extremely important in emergency psychiatric condition. It is important even while preparing the patient for electroconvulsive therapy. Cranial nerve examination helps in localization of the lesion in Central nervous system.

Speech: Mutism can occur in various psychiatric and neurological conditions. neurologic conditions like vascular lesions, primary progressive aphasia, fronto temporal dementia. An assessment of speech related musculature, namely swallowing, coughing and tongue movements will help in identifying neurological deficits resulting in dysarthria.

Motor system – Abnormal movements: This is an important area for which the psychiatrist has to pay particular attention. Weakness due to neurological conditions follows a characteristic distribution and is associated with atrophy, fasciculations, changed tone, brisk tendon reflexes and at times tenderness. Raised muscle tone due to extrapyramidal system results in cog wheel rigidity and pyramidal lesion result in clasp knife spasticity. Antipsychotics are associated with cog wheel rigidity and Froment's Rao & Venkatasubramanian: Clinical Neurology for Psychiatrists 371 maneuver is a sensitive test to elicit the same.

Different types of abnormal movements are of particular importance to psychiatrists. Dystonia is a sustained muscle contraction with twisting movements or maintenance of abnormal postures. Focal dystonia can occur independently as in writer's cramp, blepharospasm or induced by antipsychotics. Tremor is regular, rhythmic oscillating movement around joint. Rest tremors are characteristically seen in Parkinson's disease, intentional tremor in cerebellar lesions and postural tremor in essential tremor and metabolic encephalopathy. Many psychotropics like antipsychotics, lithium, anticonvulsants, antidepressants are associated with tremors and thus a drug history is essential. Myoclonus is a jerky movement and is associated with Creutzfeldt-Jakob disease, Hashimoto's encephalopathy. Asterixisis is sudden lapse in muscle contraction when the patient is actively attempting to maintain posture. Asterixis is never seen in psychiatric condition and when present indicates an organic disorder. Nocturnal myoclonus could be an early sign of clozapine associated seizure and warrants early identification for prevention. Tics are associated with Obsessive compulsive spectrum disorder and when present have important treatment implications in comorbid psychiatric condition.

Sensory abnormalities: In majority of neuropsychiatric conditions, examination of sensory system is difficult as the patient may not be cooperative for examination. Distal loss of sensations with loss of reflexes are indicative of peripheral neuropathy. Romberg's sign indicates loss of proprioception and when present an assessment of Vitamin B12 levels is important in strict vegetarians, as it is associated with various psychiatric manifestations. A strict midline location of sensory deficit indicates a psychogenic cause as sensory fibres overlap across the midline.

Primitive reflexes: These are present in many psychiatric conditions and in frontal lobe lesions. These include suck, snout, grasp and palmo-mental reflexes.

Neurology – Psychiatry interface

These can be comorbid psychiatric and neurologic condition or neurological condition presenting with psychiatric symptoms or psychiatric condition presenting with neurologic symptoms. We briefly discuss each of them.

Co-morbid Neurologic and Psychiatric disorders

Different neurological conditions are commonly comorbid with psychiatric disorders. We briefly discuss important examples namely epilepsy, movement 372 Psychiatry in India : Training & training centres disorders, stroke. Diagnosis and management of these conditions are a challenge to psychiatrist as one need to be cautious of the use of psychotropics and their interaction with other drugs. In addition, they give important clues on neurobiology of psychiatric disorder.

Epilepsy: Different studies report around 20 to 60 % of patients with epilepsy to have psychiatric comorbidity. The psychiatric comorbidity is common in those with temporal lobe focus. Those with left sided focus are at higher risk for psychosis. The psychotic symptoms could be ictal, post ictal or inter ictal. Depression is another common clinical comorbidity in epilepsy. Around 34% of patients have depressive symptoms. Personality changes, anxiety disorders have also been reported. One need to be cautious in treating this comorbidity in view of potential drug interactions and side effects; while psychotropics decrease seizure threshold, some anticonvulsants can worsen psychiatric symptoms .

Movement disorders: Cognitive impairments are a common manifestation in Parkinson's disease. In addition, mood disorders and anxiety disorders are also commonly reported. Treatment of Parkinson's disease poses a different challenge as dopaminergic drugs can result in psychotic reactions .

Stroke: Post stroke depression is a well known entity. Those with left cortical and subcortical lesions are at increased risk of developing depression. In addition, apathy, psychosis, anxiety, mania and cognitive deficits have also been reported .

Neurologic conditions presenting with Psychiatric symptomatology

This group of conditions could present with only psychiatric symptoms in the initial stages without focal neurological deficits. A strong clinical suspicion is needed to diagnose these conditions. Brain tumors, inflammatory and infectious conditions are to name a few. Frontal lobe tumors are associated with psychiatric symptoms in 90percent of cases; mood disturbances in the form of hypomania and depression, catatonia, delusions and hallucinations have been reported. Temporal lobe tumors are associated with schizophrenia like psychosis, personality changes, and anxiety symptoms. Presence of atypical symptoms for example, olfactory hallucinations are characteristic of these tumors. In some cases surgical removal of tumor can lead to complete remission of patient's behavioral and Neurocognitive symptoms. Otherwise controlling behavioral problems with appropriate medication therapy and psychological support will be helpful. In medication refractory conditions ECT may be a useful option . Rao & Venkatasubramanian: Clinical Neurology for Psychiatrists 373 Various infectious and non infectious inflammatory conditions can also present with psychiatric symptomatology. Multiple sclerosis is typically associated with mood disturbances, fatigue, cognitive impairment. Human immunodeficiency virus infection is associated with dementia like cognitive deficits, depression, mania and psychosis. It is worth noting that the interaction is bidirectional as patients with psychiatric disorders like schizophrenia and bipolar disorder leads to behaviors that are at high risk for HIV infection. In addition, those with substance dependence are at high risk for HIV infection .

Psychogenic neurological deficits – Psychiatric disorders presenting with neurologic symptoms

Dissociative disorders: Dissociative disorders typically present with symptoms suggestive of neurological deficits. Presence of stressors, atypical neurological deficits and psychogenic motor signs like face-hand test Hoover's sign, astasia – abasia can help in diagnosis of dissociative disorder. A psychiatrist should work in close liaison with neurologist in cases where the diagnosis is doubtful to avoid misdiagnosis .

Conclusion

Neurological and psychiatric conditions are closely associated and a working knowledge of neurology is essential for psychiatrist. Diagnosing and treating these comorbid conditions poses a clinical challenge. A multispecialty team with members from both psychiatry and neurology will enhance the care of patients with Neuropsychiatric conditions.

REFERENCES

1. Sachdev PS. Whither neuropsychiatry? J Neuropsychiatry Clin Neurosci. 2005;17:140-4. 2. Albucher RC, Maixner SM, Riba MB, Liberzon I. Neurology Training in Psychiatry Residency: Self-Assessment and Standardized Scores. Academic Psychiatry. 1999;23:77-81. 3. Ovsiew F. Neuropsychiatric approch to the patient. Eighth ed. Saddock B, Saddock V, editors. Lippincott Williams and Wilkins; 2005. 4. Kaufman DM. Clinical Neurology for Psychiatrists. Saunders; 2007. 5. Cascella NG, Schretlen DJ, Sawa A. Schizophrenia and epilepsy: is there a shared susceptibility? Neurosci Res. 2009;63:227-35. 6. LaFrance WC, Jr., Kanner AM, Hermann B. Psychiatric comorbidities in epilepsy. Int Rev Neurobiol. 2008;83:347-83. 7. Slaughter JR, Slaughter KA, Nichols D, Holmes SE, Martens MP. Prevalence, clinical manifestations, etiology, and treatment of depression in Parkinson’s disease. J Neuropsychiatry Clin Neurosci. 2001;13:187-96. 8. Glosser G. Neurobehavioral aspects of movement disorders. Neurol Clin. 2001;19:535-51, v. 374 Psychiatry in India : Training & training centres 9. Robinson RG, Spalletta G. Poststroke depression: a review. Can J Psychiatry ;55:341-9. 10. Madhusoodanan S, Opler MG, Moise D, Gordon J, Danan DM, Sinha A, et al. Brain tumor location and psychiatric symptoms: is there any association? A meta-analysis of published case studies. Expert Rev Neurother ;10:1529-36. 11. Price TR. Neuropsychiatric aspects of brain tumor. Eighth ed. Saddock B, Saddock V, editors. Lippincott Williams and Wilkins; 2005. 12. Pontrelli L, Pavlakis S, Krilov LR. Neurobehavioral manifestations and sequelae of HIV and other infections. Child Adolesc Psychiatr Clin N Am. 1999;8:869-78.

Naren P. Rao Senior Resident in Psychiatry Department of Psychiatry NIMHANS Bangalore – 560029 [email protected]

Ganesan Venkatasubramanian Associate Professor of Psychiatry Department of Psychiatry, National Institute of Mental Health & Neurosciences, Bangalore, India. 40 Redefining Psychological Assessment for Contemporary PG Clinical Training Programs in Psychiatry across India

S. Venkatesan

ABSTRACT

This theme paper initiates a critical review on the nature, content, characteristics and extent of inputs on psychological assessment in the typical curriculum of ongoing post graduate training program in psychiatry across India. The key terms of 'psychological assessment' and 'psychological testing' are differentiated, their meaning, assumptions, and approaches are elaborated as extensive preclude to clarifying how a redefinition is required on the subject matter between the two mental health professionals for the optimum benefit of the affected individuals. The importance of cultural adaptation, need for upgrading into technology assisted assessments, the currently changing perspectives on psychiatric help seeking behaviors in the general population vis-à-vis the challenges for the by and large westernized medical models of clinical training programs in psychiatry across India are presented and discussed. A short epilogue on content or textual analysis in terms of 'word frequency count' reveals dismal matches for key words with similar meanings or connotations to psychological assessment/testing in the ongoing curriculum for PG teaching programs in psychiatry. Reflections and suggestions are given in summary or conclusion.

Key Words: PG Training, Psychiatry, Psychological Testing, Content/Textual Analysis

INTRODUCTION

Clinical psychology and psychiatry are distant cousins in the world of mental health service delivery systems all over the world. Both professions specialize in identification and treatment of human behaviors and mental conditions. However, their background training and occupational perspectives are 376 Psychiatry in India : Training & training centres different. Clinical psychology with primary focus on diagnosis and treatment of psychological disorders share the same interests and remain as much a regulated mental health profession as is psychiatry as a branch of medicine with identical focus1.

The job tasks of clinical psychologists include identification of psychological, emotional, or behavioral issues and diagnose disorders, use information obtained from interviews, tests, records, and reference materials; develop and implement individual treatment plans, specify type, frequency, intensity, and duration of therapy; interact with clients to assist them in gaining insight, define goals, and plan actions to achieve effective personal, social, educational, and vocational development and adjustment of affected individuals. Further, they also discuss on treatment of problems with clients, use variety of treatment methods like psychotherapy, hypnosis, behavior modification, stress reduction therapy, psychodrama, and play therapy, individual or group counseling for problems like stress, substance abuse, and family situations, to modify behavior or improve personal, social, and vocational adjustment. They write reports on clients and maintain the required paperwork, evaluate effectiveness of their counseling or treatments or about the accuracy and completeness of their diagnoses. They may also modify plans and diagnoses as necessary, obtain and study medical, psychological, social, and family histories by interviewing individuals, couples, or families and by review records as well as consult reference material, such as textbooks, manuals, and journals, to identify symptoms, make diagnoses, and develop approaches to treatment2-3.

MEANING OF PSYCHOLOGICAL ASSESSMENT

Central to the practice of clinical psychology are the twin tasks of psychological assessment and psychotherapy. This is similar to the armaments in psychiatry like mental status examination, physical examination, neuroimaging, neurophysiological techniques, and treatments through medication, Transcranial Magnetic Stimulation, etc. At a general level, psychological assessment involves forming impressions and making judgments about others. It carries an evaluative flavor while dealing with the whole person4. At a technical level, psychological assessment is defined as the process of “systematic collection, organization and interpretation of information about a person and his situations”5, to which is added, “and the prediction of his behaviors in new situations”6. The key element in assessment is “the act of acquiring and analyzing information”7. The purpose of assessment varies from screening, identification, classification, placement and programming to certification and research8-11. Irrespective of its stated purpose, all psychological assessments are based on certain assumptions (Table 1). Venkatesan: Redefining Psychological Assessment 377 Table 1: Assumptions Underlying Psychological Assessment.

l Recognition of individual differences in measured phenomenon.

l Mandatory training is required for examiners before undertaking any assessment.

l Errors in assessment are inevitable and must be corrected wherever they occur.

l Developmental perspective is vital in interpretation of any assessment data.

l Assessment must be carried out in the context of cultural/experiential background of subjects.

APPROACHES TO ASSESSMENT

There are various approaches to psychological assessment depending on different types of decisions to be undertaken in clinical practice.

(a) Normative or Psychometric Approaches:

This approach involves comparative evaluation of individuals with others who are supposedly like them12. The procedure involves assessment of typical performance of groups/sub groups on given variable as against a large collectively representative sample of general population known as “norm or reference group”. The obtained raw scores are transformed into standard or transferred scores, such as, percentiles, stanines, point scales, grade equivalents, etc., to enable interpretations and comparisons of individual scores to those of group scores. There are various types of normative assessments, such as, intelligence tests, developmental schedules, adaptive behavior scales, achievement tests, etc. Normative assessment have historically evolved in the context of need to screen, identify, isolate and diagnose on the basis of statistical approach to defining abnormality, sub- normality, deviance or individuals with a difference. To this effect, they help diagnose and label the “exceptional”, “special”, “subnormal”, etc.

Law or administration frequently require normative decisions to certify persons for social/economic benefits13. Caregivers find it easy to understand normative comparisons of their affected kith and kin. Many times, telling parents that their child is in the lower five per cent of general population with respect to an ability makes more sense than providing individual based performance scores14. Normative research has yielded a vast body of technical/research data on behaviors in specific populations/sub-populations of affected individuals. This has in turn enabled large-scale policy decisions in several States. Although normative assessments lend themselves effectively 378 Psychiatry in India : Training & training centres to diagnostic decisions; they are only remotely connected to planning, programming or interventional decisions15. They possess low ecological validity, i.e., individual examinees may not be required to perform his natural behaviors to succeed on these tests. Normative tests invoke contrived situations and sample behaviors within specific artificial situations. Such items have excellent diagnostic validity. But, they are ineffective in guiding program planning16.

(b) Criterion Referenced Approaches:

This approach to psychological assessment follows the trend in special education and rehabilitation medicine17. It is not concerned with comparison of individual with a norm or standard. The point of reference is to an absolute standard in an individual rather than a population norm18-19. Criterion measures try to answer specific questions like: 'Does this child name color “red” 8 out of 10 times successfully?' In a sense, criterion approaches measure “achievements” or learnt skills/activities in an individual. The interest is to see whether a person can or cannot do a given skill or activity20. Since normative assessments place constraints on planning interventions, criterion approaches lend themselves directly to such decisions in individual cases. The term “criterion” itself is derived from experimental psychology of learning, wherein it refers to a “critical level of mastery beyond which additional learning trials are not helpful”. Unlike normative measures, criterion measures do not sample behaviors. They measure actual behaviors per se. The purpose is not to compare individuals but merely to state if the individual is master or non-master of a specific behavior or skill.

(c) Functional/Behavioral Approaches:

Clinical samples of individuals are frequently characterized by behaviors that can be viewed as the result of powerful influence of environmental variables. The environmental influences may be highly variable and subject to unique interaction effects between the individual and his setting. Each behavior is unique and bears a “functional-utilitarian” relationship in its consequences for the individual. The proponents of this approach view behavior as objective, observable and measurable units of action with precise functional consequences. Behavior assessments involve measurement of purposeful behaviors in their interaction with their environment21. Usually, the results of behavior assessment are very specific and cannot be automatically generalized across different situations. The interpretation of results must be in the context of their intended uses, whether it is for providing compensation, eligibility in terms of services, development of individualized instructional programs, charting prevalence or incidence of functional behavior profiles, etc. There is no single element that characterizes Venkatesan: Redefining Psychological Assessment 379 behavioral assessment22. Earlier approaches to behavior assessment involved specification of target behaviors intended for change and their change through arrangement / rearrangement of environmental contingencies in a manner loosely conforming to operant conditioning principles23-24. The procedure involved obtaining frequency, rate and duration of target behaviors by observing, recording and counting them. Later, with the concept of applied behavior analysis25, target behaviors as well as their antecedents and consequences came to be examined. In recent times, emphasis is placed on viewing the individual as part of a larger network of interacting systems26 and on the vital role of cognition and affect in mediating behavior change27. These developments have changed the very quality of behavior assessments from sheer measurement of target behaviors to general problem solving strategies based on ongoing functional analysis and encompassing a greater range of independent/dependent variables28-29.

(d) Idiometric/Neuropsychological Approaches

This approach draws inspiration from assessment of brain damaged persons in the field of neuro-psychology. The major theme is to identify specific areas of neuro-psychological functional assets/ deficits in individuals or groups for inter comparisons and for evolving tailor made curriculum based on the unique structure, content or modes of cognitive operations30-32.

In sum, no single approach to psychological assessment can enable all types of decisions. Each approach measures behavioral phenomena at different levels and answers different questions to varying lengths and/or depths of the phenomena under study. Ideally, a combination of all approaches to psychological assessment at varying levels or depths is required to provide a complete and integrated view of the assessed individuals11. Wherein the intended objective is to assess clinical samples for enabling program- planning or interventional decisions, it would be apt to combine use of a behavioral and criterion referenced functional approach rather than entirely relying upon normative evaluations for diagnostic decision making on these cases.

ISSUES FOR PSYCHOLOGICAL TESTING/ASSESSMENT IN CONTEMPORARY INDIA

Without attempting a post mortem of events and circumstances in the history of contemporary clinical psychology and psychiatry in India, it would suffice to note that the strengths of psychological assessment as an armamentarium for enabling diagnosis, certification for social security benefits, planning or monitoring therapeutic interventions, as well as for purposes of action oriented clinical research has not be fully exploited or mutually appreciated. 380 Psychiatry in India : Training & training centres To begin with, psychological assessment must be distinguished from psychological testing. Although related, both are not the same33. Psychological testing involves exposing an individual to a particular set of questions under specified and structured conditions to obtain a score. The score is end product of psychological testing, which is 'measure of the assessed variable' 34. According to the Joint Committee of the American Psychological Association (APAJ), the American Educational Research Association (AERA) and National Council on Measurement in Education (NCME), a psychological test is defined as 'a set of tasks or questions intended to elicit particular types of behaviors when presented under standard conditions and yield scores that have observable psychometric properties'. A psychological test is defined as 'a systematic procedure for observing behavior and describing it with the aid of numerical scales or fixed categories'35. Goldstein and Hersen define psychological test as 'a standardized stimulus situation, containing a defined instruction and mode of response in which a person is measured on the response in a predetermined way, the measure being used to predict or make inference about other behaviors of the person' 36. Thus, psychological testing becomes a part of the larger process of psychological assessment. Psychological assessment includes more than psychological testing.

(a) Mistaken Notions about Psychological Testing

Traditionally, western psychiatry as practiced in India has viewed the role of clinical psychology or its specialists as appendage to enable or clarify diagnosis of certain clinical conditions in individual cases37. The mainstay of professional interdisciplinary relationship is based on a medical model, wherein patient referrals are made by the psychiatrist for psychological testing. It is not uncommon for practicing psychiatrists to pass on referral notes to clinical psychologists seeking 'IQ Testing', 'Personality Testing', etc. The manner of such referrals distinctly smacks of similar notes sent for laboratory or pathology investigations like x-ray, blood, urine or stool examinations. Psychological assessment or testing cannot be equated with clinical lab testing. Psychological test reports are not same as reports on liver function tests, lipid profiles or endocrine assays with samples and reference ranges. Yet, the expectation of many referrals are precisely so. Unfortunately, some naïve clinical psychologists pander to the tastes, styles and expectations of such requests by giving intelligence/ memory quotients, achievement grades, personality profiles, and anxiety scores on individual clients. It does not end there. Many diagnostic assessment tools are avidly developed or standardized to answer whether individual clients are 'normal' or 'abnormal'. A recent review of clinimetric contributions in Indian Journal of Psychiatry reveled 105 research articles in about 2582 research papers (4.07 %) surveyed across a span of over fifty years (1958-2009) covering details on Venkatesan: Redefining Psychological Assessment 381 development and standardization of psychological tests pertaining to measurement of personality, cognition, or other psychosocial dimensions. The developed psychological tests were mainly to establish, reinforce or support the diagnosis of referring psychiatrists38. It appears that concurrence or happy wedding between results of a psychological test and clinical diagnosis was the ultimate or critical check for final acceptance of the given psychological test. Obviously, psychological tests are not and cannot be equated with bio-chemistry laboratory tests, nor the sampling of human behaviors is the same as collecting serum samples, estimating glucose, sodium, potassium and/or creatinine levels. The so called 'normal' or 'reference ranges' reported in pathology reports cannot simply exist in psychological reports. The clinical psychologist is not a lab technician. The client is neither sample specimen under a microscope. The client is a full fledged living individual with blood and bones, feelings and thoughts and the reflection of a culture or social circumstance. The psychological assessment and the consequent report must take into account these living realities39-40.

(b) Beyond Diagnostic Testing:

It was once thought that the goal of psychological testing vis-à-vis psychiatric practice was merely to enable diagnosis41-42. So much so, in clinical psychology, serious attempts were made solely to enable neuro-diagnosis of brain lesions based on simple paper-pencil tests. In the radio-graphically 'pre- modern days', before advent of CT/MRI, the major search of clinicians was for tests or techniques that would effectively discriminate between 'organic' and 'functional' psychiatric disturbances. The clinical psychologists of the day attempted to answer these hard diagnostic questions by devising single or battery of tests that would be sensitive indicators of brain damage or organicity43. At that time, clinicians were reluctant to employ painful, potentially dangerous and invasive diagnostic procedures. Hence, they turned eagerly to psychology for help with the difficult-to-diagnose patients44.

The usual procedure of standardizing such diagnostic indicators was to device a test or battery of tests, administer them on two or more diagnostic groups (including one group with manifest disorder) and attempt to predict the patients diagnosis. The predictive accuracy of test(s) or 'hit rate' was expressed in terms of the combined percentage of 'true' predictions, both, positive (i.e. correct identification of patients carrying the diagnosis) and negative (i.e. correct test identification of patients not diagnosed as such)43. The implicit assumption was test(s) with high predictive validity were acceptable. Predictive validation of tests continues to be a popular endeavor among psychologists even now. Diagnostic psychiatry await for psychometric tools to be the look alike of pathology tests, to aid in screening and 382 Psychiatry in India : Training & training centres identification of quick diagnosis of various clinical conditions. In this pursuit, one can distinctly see several paper pencil tests or clinical scales emerging even in our country, such as, Middlesex Hospital Questionnaire45-48, PGI Health Questionnaire49-50, Beck Depression Inventory51, General Health Questionnaire52-54, Goldberg General Health Questionnaire55, Depression- Happiness Scale56, Hamilton Depression Scale57. The purpose and expectation from these tests/measures was to tell the diagnostician whether a given patient had a particular disorder or not based on a numerical score or cut off point. No wonder, this expectation from psychometric tests to parallel pathology tests in medicine to decide whether a patient has a particular disease is reflected in the highest number of 16 such psychometric instruments researched by contributors to Indian Journal of Psychiatry38.

Such attempts appear redundant after the advent of advanced radiological techniques now easily available for making accurate neuro-diagnosis of brain damage in specific cases. An implicit, but now discredited, notion underlying the emphasis of neuro-diagnosis as sole purpose of neuropsychological assessment appears to be the understanding that brain damage reflects some kind of a unitary dysfunction58-59. The inter relationships between brain- behavior is not a simplistic binary classification between brain damage or not. The better approaches have invariably looked upon cerebral functioning from a multidimensional point of view60-61. In the contemporary scene, test data is only supplementary information to the diagnostic arsenal. The purpose of psychological testing cannot be diagnosis alone. Even though such an emphasis has been a historical necessity, this has been somewhat detrimental to the growth of this discipline62-65, Current researches on psychological assessment focus pertinently on its direct use in treatment or rehabilitation44. Another purpose of testing is to evaluate the affected individual's cognitive, behavioral and psychological strengths and weaknesses66. This information is useful in planning or programming intervention strategies or for assessing the level and rate of improvement or deterioration in behavioral functions for clinical and research purposes67.

The real work of psychological assessment/testing for planning structured, systematic and standardized intervention packages for persons with mental ill health is being increasingly advocated. Such packages have to be comprehensive, flexible, field tested, viable, functional, objective, observable and measurable-all and at the same time Indian at heart. A few attempted answers on these lines are, 'Behavior Assessment Scales for Children with Mental Retardation'68, 'Activity Checklist for Preschool Children with Developmental Disabilities'69-70, 'Assessment of Kids with Special Handicaps in Arithmetic and Reading-Writing Activities'71-72. More such intervention based ready-made/easy-to-use Indian scales are required to meet exclusive needs of affected individuals and/or their families. Further, this entire package must Venkatesan: Redefining Psychological Assessment 383 come in regional languages as has been in the case of the now popular 'Toy Kit for Kids with Developmental Disabilities' made available in English and Kannada69. Things are definitely changing. Take the instance of the claimed phenomenon of increase in numbers of autism and learning disabilities (a terrible term word for kids with average intelligence and a cruel curriculum imposed on them). Psychological assessments have a far greater role and responsibility towards several thousands of such conditions out there in every nook and corner-more than simply issuing a certificate/report of illness or disability73!

A calamitous fall out of the erroneous notions on or about psychological testing has been also the pre-testing attitudes and apprehensions of prospective test takers in the country. To begin with, the culture of psychological testing is itself alien to most Indian test takers. Further, both, children and adults alike referred for such evaluations apprehend psychological testing to involve similar or some kind of semi-invasive procedures like EEG or invasive techniques like extraction of blood or CSF. It takes a while to convince patients or their caregivers that psychological test procedures involve merely asking oral questions, making paper-pencil transactions; and, at the most, solving puzzles or manipulating peg boards. After the testing experience is completed, some clients are relieved or others are shattered as to how their intra-psychic problems could be resolved by such means. A serious clinical psychometrician is frequently questioned by the eager test taker if 'that's all' or would they take another round of CAT scans and MRI just to confirm if anything was visibly wrong in the heads!

Psychological testing must be viewed much more than an aide to diagnosis, screening or selection decisions. It is also meant to facilitate classification decisions, planning or programming therapeutic goals, instruction or intervention, monitoring progress, and for making evaluation decisions after implementation of treatments. Further, in recent times, the value of such assessments in undertaking administrative or policy decisions is being increasingly acknowledged74. A handy example is the current need to objectively assess mental illness as a growing permanent or semi-permanent handicap than a transient affliction to be simply resolved by mere use of antipsychotic medicines75.

(c) Changing Culture:

A critical feature to be taken note during psychological assessment or testing in the contemporary Indian scene is the ongoing inter-mingling of cultures, groups of people or communities. For example, in a recent study on reasons for school drop outs, it was found that there are acute differences between perceptions of parents, teachers and the affected children themselves. The 384 Psychiatry in India : Training & training centres teachers gave reasons faulting parents or parenting, while the parents reversed the coin on inadequacies in teachers. The drop out children blamed their parents, teachers as well as the impoverished school environment for their disinterest in continuing schooling76. A similar report was made on differential perceptions in parents, teachers and clinically affected with scholastic/academic problems71-72. The idea of differential cultural perceptions was innovatively and gainfully used in the understanding or analysis of problem behaviors in children77. In this study, the routine steps in behavior analysis was modified to add two more steps on parent/caregiver perceptions on or about their perceived 'causes' and their 'actual use of management techniques' for handling problem behaviors in children. The findings revealed some uniquely idiosyncratic and culture bound perceptions that enabled optimize the intervention programs for benefit of the problem behavior children and their parents. For example, the finding that a parent believes in a supposedly evil star or one's fate as 'cause' for problem behaviors in his/her child may simply delay or deny the behavioral remediation program. In the same investigation, it was also found that parents made use of several techniques-all at once, for management of problem behaviors in their children; thereby not yielding any fruitful results. All these observations strongly recommend the need to incorporate a cultural dimension within every clinical assessment practice in the country78-81.

Another theme for consideration in the context of clinical psychological testing is cultural symbols. In a way, culture itself is an embodiment of various constellations of symbols. Cultural symbols have idiosyncratic but shared meanings of their own for representative members of that group or community. Workers in clinical practice must be conversant with their meaning, significance and functional importance. A patient, for example, may prefer to rely on a talisman or wrist band offered by a family guru to derive immense subjective strength-and yet, may seek a second opinion, self- disclosure or approval for the same from the clinician. A strong cultural symbol and client expectation from family gurus, wayside astrologers, soothsayers, fortune tellers or such other common man's helping professionals in Indian society is ego comforting guidance and directive prescriptions for their personal problems. The more directive, commanding and authoritative the guide is, blended with a façade of grey hair, seniority and age, the more accepting they are for the client. Unlike in the west, younger age or higher educational qualifications is no guarantee for public acceptance82.

The newfound onslaught of visual media, continuing attack of messages from the television or films, vulnerabilities to media stereotypes, subliminal messages, concealed instructions or subtle suggestions, the media created hype of a 'perfect or complete gentleman' donning particular apparel or riding Venkatesan: Redefining Psychological Assessment 385 a given brand of car are not to be considered as fictitious imagery. They are as real or live cultural typecasts as is the naïve question of a mother who once asked us as to why her child had developed the habit of persistent lying despite her giving him a particular make of toothpaste which promised that kids who use that brand never tell lies! Although seemingly exaggerated, the web world of fascination, fashion and fiction created by mass media and now the web world is a real culture in the minds of the modern masses, whether it is related to movies depicting expensive wedding ceremonies, serials on elaborate emotional exchanges between the ladies-in-law in typical Indian households, the glorification of negative heroes and crime through their repeated telecast, or the denying of child development by rushing kids into premature adulthood by holding song, dance, drama or humor contests and reality shows for the new breed of 'kidults', or the proliferation of passive spectator play by broadcasting large doses of a game played by some active few and watched by several millions of passive viewers, or even the vicarious satisfaction of viewing others winning huge prize moneys in gamble shows83-84.

(d) Need for Cultural Adaptations:

Against this background, contemporary clinical psychometrics must update, invent, innovate and modernize their testing tools or procedures. Already, calls are underway to render the few psychological tests available in the country more appropriate or relevant for the contemporary Indian culture, settings and languages. Gone are the times, when tests standardized for or during an antiquated era could be used in present times. The norms and manuals prepared in the west or those prepared in bye gone era or for so called 'normal' persons cannot be directly used now on clinical populations. In most instances, there are no adaptable or adjustable norms for mentally ill, those with special needs, minority groups, the rural, under privileged, neglected, discriminated and marginalized. In a way, the use of archaic norms is equally unfair as it is to use the norms of another nation or community for making comparisons of clinical cases in a contemporary generation. The importance of culture fair and culture free tests require no reiteration at this junction. What is needed currently is culture upgraded versions too. An extensive plea on this matter has been recorded elsewhere80. Updates and revalidation of normative or diagnostic tests not withstanding, there is equal need to keep upgrading intervention based tests, scales, procedures and batteries81. There is need for psychological tests with greater ecological validity than even the traditional pillars of standardization viz., reliability, validity, standardization, and bias85. The contemporary changing culture in the country is already denting practice of psychiatry and/or clinical psychology. Even as these disciplines are struggling to establish themselves as distinct health delivery system, the laymen preoccupation or first 386 Psychiatry in India : Training & training centres preference is for magic-religious traditional treatments. Combine this with the grim situation of growing rural-urban or rich-poor divide, varying life styles, gaping illiteracy, multiplicity of castes and sub-cultures, linguistic plurality, religious jingoism and gender differences in the larger populations- all of which contribute to the poor understanding of westernized mental health providers86-87.

(e) Technology Assisted Assessments

The time is up when archaic individualized paper-pencil tests are to be abandoned in favor of online, software driven, user friendly, e-based and well networked local or nation wide databases on clinical assessments. Online assessments, chat rooms, e-based discussions, consultations and therapeutic self help groups are becoming increasingly popular. Formal testing devices are needed to explore consumer demand for services in areas of mental health, problems and issues related to management of mentally ill persons in home settings. There are differential self and other perceptions regarding affected individuals, their caregivers, siblings and family which need to be explored in the local context. In this era of information age, contemporary clinimetrics needs to re-adapt, shed ancient attitudes and ways of testing, blend with available gadgetry. A sample of this kind is ongoing works on development and standardization of a software program and expert system to enable computerized testing, diagnostic decision making apart from intervention planning and programming for individual children with developmental disabilities88-89. The inter-cultural difference and challenge between the westernized professional and his typical Indian client becomes pronounced especially when dealing with ethnic-bound psychological disturbances like functional disorders. There are many instances when as a clinician, one has to innovate and resort to ingenious ways of interviewing, case history taking, collection of anecdotal reports, field/home visits, proxy information from significant others, neighbor information, use of challenging and confrontation techniques to collect details on the psycho-social fabric behind an apparently innocuous psychogenic aphonic. Frequently, one is confronted with an unresolved power game followed by an emotional crisis in a daughter in law or mother in law showing up as a lost/ hoarse voice, or even as a possession attack!

(f) Westernized Training

The ongoing clinical training programs, procedures and content for mental health segment in India is largely founded on a western medical model. Graduate, post graduate, pre-doctoral and doctoral students are trained in national/regional level institutions on western schools of thought, theories, paradigms and models for understanding or treating human behavior. While Venkatesan: Redefining Psychological Assessment 387 this is appreciable, there are few missing or wanting links when it comes to inputs on cross cultural perspectives, ethnographic studies, phenomenological researches, and adaptation of tools or techniques to local conditions, translations of clinical practices or procedures, etc. These shortcomings become evident only when a neophyte confronts clients in actual clinical practice. It is not unusual for the rural, semi-literate, or economically weak psychologically affected client to avoid direct consultations with western educated psychiatrist. There is an intellectual and emotional disconnect between the professionals and such clients. Beginning from dress, appearance, to differences in dialect (if not the language too), to value systems, etiquette, manners, customs, or other habits; there is often a clear or visible line of demarcation between the typical semi-westernized professional clinician and his client. It is quite a challenge to dispel the aura of authority as service provider which comes with such exalted position and simultaneously the feeling of subservience or service receiver by the patient. The clinician-client relationship seldom slips to an evenhanded platform for meaningful transactions or therapeutic counseling practices to occur. Traditionally, the doctor-patient relationship in Indian culture has been on a sloped platform involving a giver and receiver. The patient is always at the receiving end in terms of getting advice, lectures, sermons, exhorts or instructions, commands, orders and homilies from the doctor. The same is expected in mental health practice. Many enthusiastic caregivers bring their errant wards to the counseling clinics pleading the psychologist to give an 'advice or two' (in the manner of dispensing tablets!) to better the wrong behaviors of their child. Such requests are often accompanied by an admission that they have 'tried everything in their hands but nothing seems to work'. Therefore, they expect the clinician's advice may at least fall properly into the 'deaf ears' of the affected child.

The sought 'advice giving' (euphemism for their notion of counseling or psychotherapy) may not be always be for an erring adolescent or children alone. It could also be for aged person addicted to drugs or alcohol, or for another middle aged entangled in faulty office or extra-marital relationships, retirement blues, etc. The western notions of non-directive, self-determined, independent choice making, free will and/or autonomous decision making by the affected individual does not simply seem to exist in the psychological framework of these clients. It is vital to realize that the elitist, convent or western educated clinician is no match in the phenomenological existence or world view of the typical Indian native as much as would the dictates of any local saffron clad, hairy and ash smeared religious/ spiritual leader reciting esoteric hymns and dispensing advice. Even the most severely angry or agitated psychotic can be temporarily subdued by the gaze or touch of such dispensers where even a few shots or vials of sedatives may fail to induce calm in such individuals. 388 Psychiatry in India : Training & training centres (g) Changing Models & Paradigm Shifts: Redefining Handicaps

The importance of social and cultural dimensions in clinical assessment becomes apparent when we consider the history of changing models and paradigm shifts with respect to understanding of persons with a difference in any society. Much earlier, in the history of mankind, either in India or outside, the persons who were deformed, disfigured, disabled, deviant, delayed or different was seen as 'outsiders' or 'others'. The criminals, beggars, sex workers, transvestites, disabled, sick and paupers were all belonging to the same lot. They were seen as victims of their own wrongs in their previous births, or embodiments of evil spirits. Hence, they were looked down, despised and disliked by one and all. For example, it is believed even now that telling lies would render one mute or hearing evil makes one deaf. Obviously, these dictums are means of social control to have checks on the conduct of citizens. These systems continue to thrive even today albeit in disguised forms.

In recent times, the situation is changing. Clear distinctions are being made between impairment, disability and handicaps90-91 While 'impairments' are recognized as a 'physical or anatomical loss', 'disabilities' are termed as the resulting 'functional deficits', 'handicaps' are viewed as a social/cultural disadvantage resulting or consequence of impairment as well as disability. In being defined from the socio-cultural perspective, it is obvious that there are a host of environmental or contextual factors that commonly impact on the participation of the affected individual in several socio-cultural activities. Arguments are now on whether the problems and issues faced by affected persons are the intentional or unintentional making of the majority group of non-affected persons. In recent times, greater importance is being given to such cultural or environmental access issues. They are issues related to inclusion or integration rather than seclusion or segregation of these individuals. Where access is inappropriate, inadequate, difficult or ignored, advocacy processes are being initiated to address situations and promote the rights of these persons. In many instances, viewed from this human rights perspective, most problems faced by the segment of called clinical population emanate from ones membership in a given culture. A benevolent, accommodative, barrier free and accessible milieu minimizes the experience of handicap as compared to another hostile, negative, and cursing cultural environment. The notion of disability and handicap is currently being extended even to chronic mental illness as different and distinct from the burden of mental retardation. Two lines of research are currently needed and ongoing in the country: One is the development or modification of scales for assessment of disability; and, second, is disability evaluation in persons with chronic mental illnesses. Disability assessed in psychiatric patients needs to be different for hospital based samples, and those in the community, or those Venkatesan: Redefining Psychological Assessment 389 on regular follow up. Ground work has been initiated with the development of 'Indian Disability Evaluation Assessment Scale' (IDEAS) for purpose of measuring and certifying disability92-94.

EPILOGUE ON PG TRAINING PROGRAM IN PSYCHIATRY

Going by the extensive review of psychological assessment and testing, its problems, scope of practice, relevance, needed changes, adaptations to contemporary culture, and uninitiated agenda for the forthcoming decade; it is high time that a redefinition and rephrasing of the ongoing training programs in the area of mental health is reflected. There is need to redo the lines of demarcation between the twin disciplines of psychiatry and clinical psychology. As a starter, although not the avowed objective of this paper, a content or textual analysis95-97 of a sample curriculum for post graduate training in psychiatry as approved by the Medical Council of India in terms of the commonly used 'word frequency count' and/or 'coding and categorizing' techniques of grouping words was attempted for terms with similar meanings or connotations as 'psychological assessment', 'psychological testing', 'psychometry', 'clinimetry', etc. A perusal of the 16-page document on the post graduate curriculum for MD in psychiatry covering themes like goals, objectives, syllabus, teaching program, postings, thesis, assessment, job responsibilities, suggested books and model test papers revealed the mention of only the following as reproduced in Table 2.

Table 2: Content/Textual Analysis of PG Curriculum in Psychiatry

Under 3.1 ‘Theory’ a portion on Clinical Neuropsychological Testing: Clinical Neuropsychological Testing of Intelligence and Personality - Clinical Neuropsychological Assessment of Adults

Under 3.2 ‘Practical’ Diagnostic Work up Psychological Testing: IQ Test – Memory Test – Personality Test Psychological Treatment: Psychotherapy–Behavior Therapy–Cognitive Behavior Therapy

EXTRACT FROM 16-PAGE DOCUMENT

A key word search did not bring any counts for related terms like 'behavioral assessments', 'idiometric assessment', 'interventional assessments', 'problem behavior assessment', 'counseling needs assessment', 'achievement testing', 'aptitude testing', 'behavior analysis', 'grade level assessment', etc. The curriculum content related to special psychological testing for children, adolescents and geriatrics is conspicuous in its absence. Needless to say, computer searches for textual analysis of the contents in the syllabus for themes related to 'cultural aspects of psychometry' as relevant to the Indian 390 Psychiatry in India : Training & training centres settings and as addressed by this paper were also greeted promptly by a 'No Matches Found'!.

In sum, the foregoing calls for a serious rethinking, rephrasing, redoing and reorientation between the twin disciplines of psychiatry as well as clinical psychology with regards to inputs at the level of undergraduate and post graduate training programs in their respective fields of specialization. Although the roads or approaches chosen for travel, or the means to carry them selves during the itinerary may be different; their destination in terms of reaching out for the positive mental health of the human kind are after all identical!

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Inter-rater reliability of Hamilton Depression Rating Scale using video-recorded interviews-Focus on rater-blinding, Indian J Psychiatry 2009;51:3:191. 58 Klebanoff sg Psychological changes in organic brain lesions and ablations. Psychological Bulletin. 1945; 42, 585-623. 59. Reitan RM Problems and prospects in studying the psychological correlates of brain lesions. Cortex. 1966; 2, 127-154. 60. Armitage SG. An analysis of certain psychological tests used for evaluation of brain injury. Psychological Monographs. 1946; 60 61. Halstead W. Brain and intelligence. 1947; Chicago: University of Chicago Press. 62. Boll TJ. Clinical diagnosis of mental disorders. 1978; New York: Plenum Publishing Corporation. 63. Boll TJ. The Halstead Reitan neuropsychological battery. In S.B. Filskov and T.J. Boll. (Eds.). Handbook of clinical Neuropsychology. 1981; New York: John Wiley. 64. Golden CJ. Clinical interpretation of objective psychological tests. 1979; New York: Grune and Stratton. 65. Barth JT Boll TJ. Rehabilitation and treatment of central nervous system dysfunction: A perspective. In CK Prokap LA Bradley. (Eds.). Medical Psychology: Contributions to behavioral medicine. 1981; New York: Grune and Stratton. 66. Barth JT Macciocchi SN. The Halstead Reitan Neuropsychological test battery. Chap. 10. In S Charles. (Ed.). 1985; Major Psychological Assessment Instruments, 382-414. 67. Boll TJ. A rationale for neuropsychological evaluation. 1977; Professional Psychology, 2, Venkatesan: Redefining Psychological Assessment 393 64-71. 68. Peshawaria R, Venkatesan S. Behavior Assessment Scales for Indian Children with Mental Retardation. 1992; Secunderabad: National Institute for the Mentally Handicapped. 69. Venkatesan S. Toy Kit for Kids with Developmental Disabilities: User Manual. 2004; Mysore: AIISH. 70. Venkatesan S. Children with Developmental Disabilities: A Training Guide for Parents, Teachers & Caregivers. 2004; New Delhi: Sage (India) Publications 71. Venkatesan, S. Academic Problems in School Children: Training Manual. 2010; Mysore/Bangalore: All India Institute of Speech and Hearing/Sarva Sikshana Abhiyaan. 72. Venkatesan, S. Sensitivity Training on academic problems in school children enrolled under SSA in Karnataka: Instructor Manual. 2010; Mysore/Bangalore: All India Institute of Speech and Hearing/Sarva Sikshana Abhiyaan 73. Venkatesan, S. Autism Behavior Checklist for Disability Estimation (A2E). 2010; Mysore: All India Institute of Speech and Hearing. 74. Rotatori AF Galloway GH Rotatori RE. Assessment for regular and special education teachers: a case study approach. 1980; Texas: Pro Ed, 1-26. 75. Markova, I Farr, R. Representations of health, illness and handicap. 1995; Switzerland: Harwood Academic Publishers. 76. Govindaraju R, Venkatesan S. A Study on School Drop Outs in Rural Settings. Journal of Psychology. 2010; 1.1.47-53. 77. Venkatesan S Vepuri VGD. Parental Perceptions of Causes and Management of Problem Behaviors in Individuals with Mental Handicap. 1992; Disabilities & Impairments. 7. 2. 29-37. 78. Wen-Shing T. Culture and Psychopathology: A Guide to Clinical Assessment. 1997; New York: Brunner/Mazel. 79. Westermeyer J. Cultural Factors in Clinical Assessment. 1987; J. Cons. Clin. Psy. 55. 4. 479- 487. 80. Venkatesan S. Cultural Factors in Clinical Assessment: The Indian Perspective. Indian J. Clinical Psychology. 2010; 37.1.75-85. 81. Venkatesan S. Psycho Oration Award Address: A Pilgrims Progress. Indian J. Clinical Psychology. 2009; 36. 1. 4-9. 82. Bhugra D, Kamaldeep B. (Ed.). Textbook of cultural psychiatry. 2007; Cambridge: Cambridge University Press. 83. Tseng WS. Clinician's guide to cultural psychiatry. 2003; California: Academic Press. 84. Kleinman A. Rethinking psychiatry: From cultural category to personal experience. 1988; New York: The Free Press. 85. Anastasi A, Urbina S. Psychological Testing (7th edn.) 1997; New York: Macmillan 86. Incayawar M Wintrob R Bouchard L. Psychiatrists and traditional healers: Unwitting partners in global mental health. 2009; West Sussex, UK: John Wiley & Sons. 87. Ernst W. Mad tales from the Raj: Colonial psychiatry in south Asia (800-58). 2010; New York: Anthem Press. 88. Venkatesan S. Development & Standardization of Computer Assisted Software on 'Behavioral Assessment & Learning Activities for Kids with Communication Disorders' (BALAK-CD). Ongoing ARF Project: 2009-11; Mysore: All India Institute of Speech and Hearing. 89. Venkatesan S. Development & Standardization of Computer Assisted Software on Autism Behavior Checklist for Disability Estimation' (A2E). 2010-11; Mysore: All India Institute of Speech and Hearing. 90. World Health Organization. International Classification of Impairments, Disabilities & 394 Psychiatry in India : Training & training centres Handicaps. 1980; Geneva: WHO. 91. World Health Organization. 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Basic Content Analysis. 2nd edition. 1990; California: Newbury Park.

S. Venkatesan Professor in Clinical Psychology All India Institute of Speech and Hearing, Mysore 570 006 (Karnataka). Email: [email protected] [email protected] 41 Clinical Psychology Training in India

L.S.S. Manickam

Clinical psychology is an applied branch of psychology that integrates science, theory, and practice to understand, predict, and alleviate maladjustment, disability, and discomfort as well as to promote human adaptation, adjustment, and personal development. It also focuses on the intellectual, emotional, cognitive, biological, psychological, social, and behavioral aspects of human functioning across the life span, in varying cultures, and at all socioeconomic levels[1]

As an independent discipline, clinical psychology was started in the year 1955 at the Department of Clinical Psychology, All India Institute of Medical Sciences (NIMHANS). The program was titled as DMP (Diploma in Medical Psychology) and was recognized by the Medical Council of India [2] Similar program was later started at the Central Institute of Psychiatry, Ranchi in 1962. This two year course was offered in different titles until 1996 it was titled as M.Phil in Clinical Psychology. In 1997 the Rehabilitation Council of India (RCI) started regulating this two year regular, full time program that is to be pursued after obtaining regular Masters in Psychology degree and selected to the program through an entrance examination. Following this several other institutions started offering this program and currently there are 11 centers in the country that are offering this program ( Appendix1).

Though American Psychological Association views Clinical Psychology as a general practice and health service provider specialty in professional psychology, in India it is yet to get the appropriate recognition due to the paucity of clinical psychologists [3] The role of Clinical psychologists is to assess, diagnose, predict, prevent, and treat psychopathology, mental disorders and other individual or group problems to improve behavior adjustment, adaptation, personal effectiveness and satisfaction. The current M.Phil in clinical psychology program envisages a person with Masters in Psychology to become a service provider as well as a scientist.

What distinguishes Clinical Psychology as a general practice specialty is the breadth of problems addressed and of populations served. Clinical 396 Psychiatry in India : Training & training centres Psychology, in research, education, training and practice, focuses on individual differences, abnormal behavior and mental disorders and their prevention as well as lifestyle enhancement. However the present two year training is inadequate and it may be replaced with a 3 year Psy.D program in Clinical Psychology after sufficient revamping and /or 4 year PhD in Clinical Psychology after the Masters in Psychology. This may prevent brain drain and would also ensure appropriate employment opportunities in par with the other specialties. While making changes care has to be taken so that the trained clinical psychologists could also be motivated to take up research as well as teaching assignments in Universities which need a Ph.D degree as the basic qualification for employment as per the current rules and regulations.

Clinical Psychology Training Models in India

If one evaluates the different training programs that are offered in India, there are 4 models of Clinical Psychology training in India [1]

1. Mental Hospital Model: This is the oldest model that was started in 1955, at the All India Institute of Mental Health (now NIMHANS), which was associated with the mental hospital. The students get supervised training while working with inpatients and out patients attending the mental hospital and later got extended to the Neurology Departments. Currently it is followed in institutes like CIP, Ranchi, IHBAS Delhi, and RINPAS, Ranchi. In addition, in view of the guidelines of training provided by RCI, the trainees get rotatory supervised training in General Hospital set up. There are more centers that have evinced to start this model of training in centers attached to the Mental hospitals /Institutes of Mental Health at Agra, Chandigarh, Chennai and Hyderabad.

2. Super Specialty Model: This model was started in 1999 at Manipal University and was based on the guidelines of RCI. The program is offered at the independent department of clinical psychology under the faculty of Allied Health Sciences and in close link with other departments of medical college hospital, including department of psychiatry. The students get supervised training at different departments like Pediatrics, Cardiology and Neurology. Training programs at RIMPS, Manipal and Sri Ramachandra University, Chennai follow this model. There are more centers in the South including JSS University, Mysore that had taken initiative to start programs based on this model.

3. Rehabilitation Institute Model: The program of this nature was started at Sweekar, Secunderabad in 2005. The training occurs primarily in a rehabilitation center, with exposure to other areas of clinical psychology, including mandatory posting in rotation in different L.S.S. Manickam: Clinical Psychology Training in India 397 medical specialties including psychiatry. More Non Governmental Organizations working in the area of mental health and disability can initiate similar programs, that largely cater to the disabled population.

4. University Department Model- This is primarily the model that is followed in US, popularly known as the Boulder Model. In the past it was opined that this model has to be experimented in India since it provides greater opportunity for the clinical psychologists to grow. However it was started at the University of Kolkata in 2006 and later at Amity University, UP. The program although based at the University department, includes the mandatory postings in different medical specialties including psychiatry, as specified by the regulatory council, RCI. This gives the opportunity for the trainees to acquire the skills to provide help to the student community at large through clinics established within the University campus.

We are yet to evaluate the different models of training. However considering the vastness and the diversity of our country, we need to make more innovative approaches in our training. Community based model and school based model can be tried out. As in the developed countries, the specialties like school psychology and community psychology, as distinct disciplines may not emerge soon in our country. Therefore, we may have to experiment with different models of clinical psychology training. Non-governmental organizations providing clinical psychology service in rural settings and that has facilities to provide mandatory training in hospital setting may start the program with emphasis on rural mental health.

Clinical Psychology And The Emerging Fields

Clinical Child Psychologists who work with children and who help the learning disabled children in their assessment as well as in providing psychological support and remedial training have already established themselves like the psychotherapists and those who work in addiction centers. However there are some other fields that are emerging in our country.

Clinical Health Psychology

The training programs that were offered in the medical college setting has brought out research relating to different health conditions. Research in this area helped to develop specialties like, psycho oncology, psycho nephrology, cardiac rehabilitation, and also develop programs for changing life styles related to cardiac patients and other disciplines related to medicine. It had also promoted research and service related to dental health. 398 Psychiatry in India : Training & training centres Clinical Forensic Psychology

The family courts as well as other courts including High Courts seek the expert opinion of the clinical psychologists. With the increase in use of the brain mapping and profiling procedures and with the introduction of various forensic psychological investigative procedures the branch of clinical forensic psychology is emerging. The scope is high since the homegrown terrorism as well as international terrorism is posing challenge to the people of our nation. Interrogation of the suspects has to be done carefully and the clinical forensic psychologists are trained in that skill. With the starting of clinical psychology program at the forensic setting at Gujrat, yet another model of training is likely to emerge.

Rehabilitation Psychology

Working with disabled persons, and focusing on the assessment and caring for them, the branch of rehabilitation psychology has already emerged. Though, the rehabilitation psychologists are trained by the clinical psychologists, their training takes place in the setting where the service delivery to the intellectually challenged occurs. However it may take some time for the rehabilitation psychologists to get focused on the chronically mentally ill as well as those who need neuropsychological rehabilitation.

Clinical Neuropsychology

From administration of 'imported' neuropsychological tests in the eighties, we have grown to a phase where we have developed different neuropsychological batteries in several indigeneous languages for the different populations that help us to assess the extent as well as the area of dysfunction. Cognitive science is emerging as a distinct discipline of much significance and therefore the clinical neuropsychologists have a larger stake. Moreover the advancements made in the area of nuero psychological rehabilitation is very helpful for a wide variety of population.

The Need of the Hour

The "Status of Disability in India- 2000” report provided by the RCI estimated that India required 20,000 clinical psychologists in 2000 to meet the exclusive needs of the disabled persons[4] The number of clinical psychologists that is required to meet the challenges of disabled persons as projected in this report by 2020 could be double this figure- about 40,000. However the role of the clinical psychologists are not limited to the disabled alone. If the clinical psychologists have to render services as a general practice health provider, the number required even to meet the present needs is far higher than what is estimated. L.S.S. Manickam: Clinical Psychology Training in India 399 The country would have trained around 2000 clinical psychologists so far. But the number available in the country for providing service is far less. Clinical psychology training has to take a big leap in India in the second decade of this century. The Ministry of Health and Family Welfare of the Government of India is well aware of the need for increasing the number of trained mental health professionals in the country. Therefore directives have been given for starting clinical psychology training programs in centers of excellence in different parts of the country. However to materialize this in increasing pace requires the support of all the mental health professionals as well as the other health professionals.

The IACP has about 650 professional members and another 280 associated members including other professionals such as psychologists who are specialists in other areas including counseling, education etc and psychiatrists, social workers, lawyers and other professionals interested in clinical psychology. As a NGO it has got consultative status with some of the Ministries of the Government of India and as a result the representatives of the association are called for consultations. We are hopeful that Rehabilitation Council of India or another new council that is likely regulate the clinical psychology training programs in future, do consult IACP in molding and nurturing the training program. The changes that are in anvil in restructuring the councils, we trust would bring about the desirable results that help the growth of the profession of clinical psychology and psychology in a larger perspective- in taking up the challenges of this great country.

REFERENCE

1. Manickam L S S. Enabling the Disabled, Ind J of Clin. Psy 2009: 36;7-10. 2. Handbook of All India Institute of Mental Health, Bangalore: All India Institute of Mental Health (NIMHANS) 1959. 3. American Psychological Association. 2009 Presidential Task Force on the Future of Psychology Practice Final Report. Washington: American Psychological Association;2009. 4. Singh JP. Ten Years of Progress: RCI towards Nation Building. New Delhi: Rehabilitation Council of India, 2004.

Appendix 1 (iacp.in)

RCI Recognized Training Centers offering M.Phil In Clinical Psychology in India

1. Sweekar Rehabilitation Institute for Handicapped, Secunderabad- Andhra Pradesh sweekaar.org/secbad.html 2. Post Graduate Institute of Behavioural and Medical Sciences, Raipur, Chatishgarh 3. Institute of Human Behavior And Allied Sciences, Delhi. ihbas.delhigovt.nic.in 400 Psychiatry in India : Training & training centres 4. Central Institute of Psychiatry, Ranchi, 834006, Jharkand cipranchi.nic.in/Index.html 5. Ranchi Institute of Neuro-Psychiatry & Allied Sciences (RINPAS), Ranchi Jharkhand rinpas.nic.in/index.html 6. Kasturba Medical College, Manipal University, Manipal, Karnataka manipal.edu 7. National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka. nimhans.kar.nic.in 8. Regional Institute of Medical Sciences, Imphal, Manipur, www.rims.edu.in 9. Sri Ramachandra University, Chennai, Tamil Nadu, www.srmc.edu 10. Amity Institute of Behavioural Health & Allied Science, Noida, UP amity.edu 11. Department of Psychology, University of Calcutta, Kolkata,700009.: [email protected]

L.S.S. Manickam Professor in Clinical Psychology Department of Psychiatry JSS University Mysore

Hon. General Secretary of the Indian Association of Clinical Psychologists. [email protected] 42 Psychiatric epidemiology: What do post-graduate psychiatric residents need to know?

Suresh Bada Math, Janardhanan Narayanaswamy, Dhanya Raveendranathan ABSTRACT In the past few decades, research in psychiatric epidemiology has been focusing on concerns of a larger magnitude like, distribution of illness, burden, disability, quality of life and cost of treatment. However, training programs in psychiatry have not been updated with the latest happenings and trends. This has been reflected in the lack of an adequate investment by policy makers in the area of mental health. Psychiatry epidemiology also lags behind, when compared to other branches of epidemiology. Hence, there is an urgent need to inculcate training in psychiatric epidemiology in the post-graduate and also in undergraduate curricula in the medical field. The aim of this article is to create awareness about the application of epidemiological methods in the area of mental health, so that interested graduate students can undertake careers in research on the aetiology, classification, distribution, course and outcome of mental disorders and maladaptive behaviours in the community. This article introduces the vast field of psychiatric epidemiology for the benefit of postgraduate trainees by focusing in a simplified manner on definitions, measures used, basic epidemiology research types, determinants of psychiatric disorders, relevance for epidemiological research and issues in epidemiological research. This article is not a comprehensive review of existing literature but attempts to provide an overview about psychiatric epidemiology to trainees in psychiatry to stimulate their interest and generate more research in this field, which would help leverage policy making in the area of mental health. INTRODUCTION The term epidemiology is derived from the Greek words, ‘Epi’- which means upon or on, ‘demos’ – which means human beings and ‘logy’- which means 402 Psychiatry in India : Training & training centres study.[1] Epidemiology can be defined as the study of the distribution and determinants of disease frequency in human populations[2] Psychiatric epidemiology is study of the distribution and determinants of mental illness frequency in human beings with the fundamental aim to understand and control the occurrence of mental illness[3]

Mental disorders constitute a wide spectrum ranging from sub-clinical states to very severe forms of disorders. Mental health problems can attain the disorder/disease/syndrome level, which are usually considered easy to recognize, define, diagnose and treat . Hence, they can be called as Visible Mental Health Problems’ in a community. These visible mental health problems again can be classified into Major mental disorders and Minor mental disorders. Another group of mental health problems remain at sub-clinical/ non-clinical/ sub-syndromal level and are usually related to behavior of an individual. Hence, they can be called as ‘Invisible Mental Health Problems’ in a community (figure 1). Understanding the nature and prevalence of mental health problems is very essential from policy making to allocation of meager resources to the needy.

This article focuses on the definition and various components of psychiatric epidemiology, measurement of the psychiatric disorders, basic epidemiologic research designs, and the determinants of psychiatric disorders. This article is not a comprehensive review but the aim is to provide an overview regarding the scope of psychiatric epidemiology to postgraduate trainees in psychiatry to stimulate interest and generate research in this field.

Importance of psychiatric epidemiology Etiological model of illness in psychiatric disorder is still far from conceptualization. Hence, psychiatric epidemiology is still in the stage of describing, classifying, and investigating the determinants of a psychiatric illness. The importance of psychiatric epidemiology lies in the objectives of the field of epidemiology which are as follows:

l To know the magnitude of a psychiatric disorder in a given population

l To identify the risk factors closely associated with a psychiatric disorder

l To plan interventions (primary, secondary and tertiary)

l To evaluate the efficacy of the interventions

l To explore the predictors of the course and outcome of the Math et al: Psychiatric epidemiology for residents 403

psychiatric disorder in the community

l To identify the cause of the psychiatric disorder through genetic epidemiological studies

l Evidence based investment of sparse resources in the field of mental health at a national level

Defining a “Case” in psychiatric epidemiology

The figure 2 shows the various steps involved in an epidemiological study. Psychiatric epidemiology has focused on description in recent years because of the continuing debates that exist in the mental health field on what constitutes a “case” [4-7] If the threshold for diagnosis of a disease is high, 404 Psychiatry in India : Training & training centres occurrence of the disorder decreases dramatically and vice versa. The wide variations reported in the prevalence rates across epidemiological studies may be due to the difference in the case definition used by various studies. Defining of ‘case’ depends on various factors like perception of illness, availability & acceptability of treatment, distress, disability and burden. To determine the presence of a disorder, the need for treatment, distress, dysfunction, disability and availability of resources need to be established[8, 9] To overcome the hurdle of defining ‘a case’ various initiatives were undertaken in the form of developing diagnostic guidelines, schedules and scales.

Commonly used instruments are listed in table No 1.

Psychiatric instruments can be classified into a) screening instruments, b) diagnostic schedules and c) specific scales.

Screening instruments are those instruments used to screen probable psychiatric cases in community. When a person meets certain cut-off points on the screening instrument then a complete diagnostic schedule is used for confirming the diagnosis.

Diagnostic schedules are comprehensive instruments used to arrive at a diagnosis. A diagnostic schedule follows a diagnostic algorithm that requires the presence of essential features of the disorder and determines the syndrome’s completeness by a threshold for the associated symptoms. There are diagnostic schedules developed that can be used by lay interviewers also. These schedules will be highly structured and will not allow the lay- interviewer to ask his/her questions. There are some semi-structured diagnostic schedules which allow the interviewer to frame his/her own relevant questions to arrive at the diagnosis. These are used only by clinicians or trained personnel only. Specific scales are simpler than schedules. They are just symptom inventories, or questionnaires to arrive at a diagnosis. Specific scales are targeted to identify specific diagnosis or syndromes alone such as depression or alcohol use. These specific scales are simple, less time consuming and majority of the time they are self administered. Epidemiological approaches to measure disease/case Popular approaches to measure the disease frequency in a given population are (i) hospital catchment population approach and (ii) community survey[28] Math et al: Psychiatric epidemiology for residents 405

for DSM IV [19]

Cut down, Annoyed, Guilty, Eye Opener [22]

for DSM IV [24]

Hospital based approach counts the number of cases diagnosed by a clinician (as numerator) and the catchment population served by the hospital facilities (as denominator). The pathway to care pyramid is shown in the figure no 3. At the bottom of the pyramid remains a huge population of mentally ill patients 406 Psychiatry in India : Training & training centres Math et al: Psychiatric epidemiology for residents 407 who may not receive treatment at all. Hence, to get the true picture community sampling is advocated. Basic measures used in epidemiological studies Disease status is a very dynamic process. Once a population is defined various parameters are used to determine the occurrence of a case in a population. These can be understood in a very simplistic manner using the figure (figure 4) as depicted. Various outcome measures used are improvement, recovery, remission etc. based on the type, purpose and feasibility of the study. Determinants of psychiatric disorders Dimensions of diseases have various aspects like external and internal factors which act in concert to influence the occurrence and outcome of illness. Internal factors such as genetic makeup, gender, age, coping skills, premorbid personality and need for treatment play a role in the development of illness. External factors such as family, stigma, literacy, health policy and legal provisions also play an essential role in the development of illness. This can be easily understood on the basis of web of causation of psychiatric disorders as shown in the figure no 5. Types of psychiatric epidemiological studies Epidemiologic study designs comprise of both observational (non- experimental) and experimental studies (Figure 6).[29] Investigator manipulates the exposure (intervention) assigned to participants in the study in experimental study where as in observational studies, the researcher is just a passive observer.

Observational studies have two fundamental objectives— a) to describe the occurrence of disease or disease-related phenomena, which is called descriptive studies and b) to explain them, which is called, analytical studies[30]. Descriptive studies provide information on the frequency of occurrence of a particular condition and on patterns of occurrence. Descriptive epidemiological data are, in fact, being heavily used in these ways, to help support revisions of the DSM and ICD diagnostic systems[31] Studies attempting to identify the causes of disease are generally called analytical epidemiologic studies. Analytical studies address the question of why diseases are distributed the way they are[30, 32] Clinical epidemiology is additionally used in clinical settings to evaluate the validity of diagnostic tests and to study predictors of treatment response that might be targeted in subsequent interventions[33]. The five main types of observational (non-experimental) psychiatric epidemiologic studies are case report/series, cohort studies, case-control studies, cross-sectional studies and ecological studies[34, 35]. 408 Psychiatry in India : Training & training centres

Incidence: The occurrence of new cases of disease

Prevalence: Total number of cases of disease in a given population Diseases process in the community

Outcome: Recovery / remission / improved / death

General Population Math et al: Psychiatric epidemiology for residents 409

Psychiatric epidemiological studies

Observational studies Experimental studies

Surveys Case Reports Cohort studies Ecological Case control studies Cohort studies

Prospective Retrospective Prospective

Classic Cross over Factorial Solomon

Case report /series - in which cases arising from any source of population are, reported to describe the signs and symptoms. These reports are usually a starting point and initiate large scale studies. Cohort studies—in which all subjects in a source population are classified according to their exposure status and followed over time to ascertain disease incidence and outcome. The word cohort designates a group of people who share a common experience or condition[35]. The aim is to determine whether initial exposure status influences risk of subsequent disease. Two particular types of cohort study are the prospective cohort study and the retrospective cohort study (figure 7)[1, 29]. Case-control studies—in this design, cases arising from a source population and a sample of the source population are classified according to their exposure history. [34]. The cases and controls are then compared with respect to their exposure to risk factors such as family related stressors. Surveys or Cross-sectional studies—here one ascertains exposure and disease status as of a particular time. This gives the snap shot of the health status of the population. It is the method therefore to determine the point or period prevalence of a disease. Ecologic studies— it is also called as correlation study. In this type of study, information is collected not on individuals but on groups of people. Correlation studies use data from entire populations to compare disease frequencies either between different groups during the same period of time or in the same population at different points in time. This is particularly true 410 Psychiatry in India : Training & training centres

when considering the relative roles of genetic and environmental factors on the disease[29]

Experimental studies Typical experimental studies are those where participants are exposed to different treatments or interventions (figure 8). For example, in a two-group experiment, one group receives a treatment and the other does not (may receive placebo) [29]. In these studies, exposure (to any kind of intervention) occurs after the initiation of study and outcomes are assessed after specified duration of time prospectively. These studies are strong methodologically but time and resource consuming. Four commonly used experimental study designs are a) Classic b) Cross-over c) Solomon four group and d) factorial studies. Most common design is the Math et al: Psychiatric epidemiology for residents 411 Pretest-Post test Group Design with random assignment. This design is used very frequently; hence, it is often referred to as, “classic” experimental design. In cross-over experiment, the same experimental unit receives more than one treatment during non-overlapping time period. For example, in a pre-test & post-test design, group ‘A’ receives treatment ‘X’ and control group ‘B’ will receive placebo. After certain specified period post-assessment is done. A wash out period is allowed and now the group ‘A’ will receive placebo and group ‘B’ will receive treatment ‘X’. This is called cross-over design. Another important experimental design is the Solomon Four-Group Design which is more sophisticated. The major advantage of the Solomon design is that it can tell us whether changes in the dependent variable are due to some interaction effect between the pretest and the treatment. For example, if a study is conducted to know the effect of cannabis on depression. During baseline assessment of group X (X cases & X controls), the assessment may 412 Psychiatry in India : Training & training centres

cause inherent bias on the participants and may result in life style change and many participants may decrease the cannabis intake during the study. This may give false results. Hence, to overcome this bias another group Y (Y cases & Y controls) will be added without any pretest assessments. There will be only post-test assessments done to assess if the change is produced only by the intervention or treatment.

In a factorial design each level of a factor occurs with every level of every other factor. Experimental units are assigned randomly to treatment combinations. For example to assess the effectiveness of treatment combination in OCD, the appropriate method can be factorial design Math et al: Psychiatric epidemiology for residents 413 methods.

Does psychiatric epidemiology lag behind other branches?

A disheartening, but unavoidable answer is “yes”. Psychiatric epidemiology traditionally lags behind other branches of epidemiology[36] because of difficulties encountered in conceptualizing and measuring mental disorders. As a result, much contemporary psychiatric epidemiology continues to be descriptive, focusing on the estimation of disorder prevalence and subtypes at a time when other branches of epidemiology are making progress in documenting risk factors and developing preventive interventions.

A wide variation in results of psychiatric epidemiological studies: seeking an explanation

Table 2 shows the important epidemiological studies conducted in India. This shows largely discrepant results of measuring even the basic estimates such as prevalence of illness[37-45]. The evident reasons are variations in defining cases, screening methods used, the type of population studied such as urban and rural, differences in the sampling methods used, varying estimates of under reporting, differing informant characteristics etc[37].

Prevalence rate of mental disorders vary within population over a period of time and also across populations at the same time. What could be the reason for this? Mental disorders tend to display a dynamic nature. Within a population, varying rates of prevalence across time can be attributed to availability of resources, socio-economic changes and stress factors within the population. Across-population variation can be attributed to socio- economic changes and genetic variations[37] (table 3).

Location:

R= Rural, U= Urban, M= Mixed,

Sampling:

H-H = House To House Survey, SRS=Stratified Random Sampling,

3SPS=3 Stage Probability Sampling,

RS=Random Sampling, SS=Systematic Sampling,

Tools:

MHSQ= Mental health Screening Questionnaire,

QAPF=Questionnaire for the Assessment of Psychiatric State of the family, 414 Psychiatry in India : Training & training centres Table 2

DCP = Diagnosis confirmed by CHM = Case History Method a psychiatrist(s)

CHQ = Case History Questionnaire IPSS=Indian Psychiatric Survey Schedule

SFQ=Social Functioning Questionnaire MHIS=Mental health item sheet,

PSQ=Psychiatric screening questionnaire PHQ=Psychiatric health questionnaire,

HS=Household Schedule QS=Questionnaire Schedule,

CRS=Case Record Schedule, CDS = Case Detection Schedule,

SESS=Socio-Economic Status Schedule RPES= Rapid psychiatric examination schedule.

Relevance and scope of the future epidemiological studies

Future epidemiological studies should be more analytical and experimental. High-risk individuals (survivors of disaster, people suffering from chronic Math et al: Psychiatric epidemiology for residents 415 general medical conditions, the destitute and homeless) with modifiable risk factors need to be identified and included in the studies. The effects of modifying risk factors on prevalence rates have to be explored. Studies to document the impact of organizing mental health services and preventive strategies are required. The effectiveness of various techniques and programmes of stress management and life skill implementation on individuals also need to be included as a part of epidemiological studies [37]. Longitudinal epidemiological studies need to be carried out, in which the natural course of all the disorders in the community can be studied and modifiable risk factors identified. Awareness of the lacunae existing at present in psychiatric epidemiology would encourage new ideas that could help in advancement of this field.

(Source: Math and Srinivasaraju. Indian J Psychiatry 2010; 52:S95-103)[55]

The most important areas of integration needed for future development of psychiatric epidemiology appear to be naturalistic and quasi-experimental epidemiological studies of illness course and treatment response in clinical 416 Psychiatry in India : Training & training centres samples. Thus, a basic understanding of epidemiological principles during psychiatric training is important to foster the interest in trainees and to increase manpower for the development of this area. Psychiatry epidemiology still has a long way to go when compared to other branches of epidemiology. It will help sensitize post-graduate and undergraduate students in medicine to put their potential contribution to this field by their research efforts. Hence, there is an urgent need to inculcate psychiatric epidemiological training during post-graduate as well as in undergraduate curricula.

References 1. Timmreck TC, An Introduction to epidemiology. Pub; Jones and Bartlett Inc, Sudbury, Massacusetts 2002. 2. Mac Mahon B and Pugh TF, Epidemiology: principles and methods. Boston: Little, Brown, 1970: 137–198. 3. Tsuang MT and Tohen M, Textbook in Psychiatric Epidemiology 2nd ed. New York, Wiley-Liss, 2002. 4. Kendell R and Jablensky A. Distinguishing between the validity and utility of psychiatric diagnoses. Am J Psychiatr 2003;160(1): 4-12. 5. Kessler RC et al., Mild disorders should not be eliminated from the DSM-V. Arch Gen Psychiatry, 2003;60(11): 1117-22. 6. Regier, D.A., et al. Limitations of diagnostic criteria and assessment instruments for mental disorders. Implications for research and policy. Arch Gen Psychiatry 1998; 55(2): 109-15. 7. Wakefield, J.C. and R.L. Spitzer, Lowered estimates—but of what? Arch Gen Psychiatry 2002; 59(2): 129-30. 8. Regier DA, et al.Limitations of diagnostic criteria and assessment instruments for mental disorders: implications for research and policy. Arch Gen Psychiatry 1998; 55: 109-115. 9. Pincus, H.A., D.A. Zarin, and M. First, “Clinical significance” and DSM-IV. Arch Gen Psychiatry 1998; 55(12): 1145; author reply 1147-8. 10. Goldberg DP and Williams P. A user’s guide to the general health questionnaire. Windsor: NFER- Nelson 1998. 11. Beusenberg M and Orley J, A user’s guide to the self reporting questionnaire. Geneva: WHO (WHO/MNH/PSF/94.8) 1994. 12. Janca A et al. The ICD-10 Symptom Checklist, Version 2.0. World Health Organization, Geneva 1994. 13. World Health Organization. ICD-10 Classification of Mental and Behavioural Disorders. Geneva: World Health Organization 1992. 14. American Psychiatric Association, Diagnostic and statistical manual. Fourth edition (DSM-IV). American Psychiatric Association, Washington, DC 1994. 15. Wing JK, Cooper JE, and Sartorius N. The Measurement and Classification of Psychiatric Symptoms. Cambridge: Cambridge University Press 1974. 16. World Health Organization. Schedules for Clinical Assessment in Neuropsychiatry (SCAN), Version 2.0. American Psychiatric Press, Washington, DC, for the World Health Organization 1994. 17. World Health Organization. Composite International Diagnostic Interview (CIDI). American Psychiatric Press, Washington, DC, for the World Health Organization 1993. Math et al: Psychiatric epidemiology for residents 417 18. Sheehan DV et al. The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. J Clin Psychiatry 1998; 59(Suppl 20): 22-33:quiz 34-57. 19. Spitzer RL et al. The Structured Clinical Interview for DSM-III-R (SCID). I: History, rationale, and description. Arch Gen Psychiatry 1992. 49(8): 624-9. 20. Robins, L.N., et al., National Institute of Mental Health Diagnostic Interview Schedule. Its history, characteristics, and validity. Arch Gen Psychiatry 1981; 38(4): 381-9. 21. Conigrave, K.M., J.B. Saunders, and R.B. Reznik, Predictive capacity of the AUDIT questionnaire for alcohol-related harm. Addiction, 1995; 90(11): 1479-85. 22. Ewing JA. Detecting alcoholism. The CAGE questionnaire. Jama 1984; 252(14): 1905-7. 23. World Health Organization., International Personality Disorder Examination (IPDE). ICD-10 Geneva: WHO 1992. 24. First MB, et al., The Structured Clinical Interview for DSM-III-R Personality Disorders (SCID-II). Part II: Multi-site Test-retest Reliability Study. Journal of Personality Disorders 1995; 9(2): 92- 104. 25. World Health Organization., Psychiatric disability assessment schedule (WHO/DAS). World Health Organization, Geneva 1988. 26. Patterson DA and MS Lee. Field trial of the Global Assessment of Functioning Scale—Modified. Am J Psychiatry 1995; 152(9): 1386-8. 27. Von Korff M et al.Self-report disability in an international primary care study of psychological illness. J Clin Epidemiol 1996; 49(3): 297-303. 28. Silman AJ and Macfarlane GJ, Epidemiological studies; a practical guide. 2nd edition published by Cambridged university Press, Cambridged, UK 2002. 29. Rothman KJ, Greenland S, and Lash TL, Modern Epidemiology. 3rd Edition. Pub: Lippincott, Williams & Wilkins. Philadelphia 2008. 30. Ross BC and Diana BP, Applied Epidemiology; Theory to practice. Pub: Oxford University Press, New York 1998. 31. Kessler, R.C., Psychiatric epidemiology: challenges and opportunities. Int Rev Psychiatry 2007.; 19(5): 509-21. 32. Fletcher RH and Fletcher SW, Clinical Epidemiology: The Essentials. Lippincott Williams & Wilkins; Philadelphia, 2005. 33. Greenberg RS, et al., Medical Epidemiology. Lange; Norwalk 2000. 34. Beaglehole R, Bonita R, and K. T., Basic epidemiology. World Health Organisation. Geneva 2006. 35. Geoffrey NR and D. SL., PDQ Epidemiology PDQ Series. B.C. Decker, Inc, Hamilton, Ontario 1998. 36. Kessler, R.C., Psychiatric epidemiology: selected recent advances and future directions. Bull World Health Organ 2000;78(4): 464-74. 37. Math, S.B., C.R. Chandrashekar, and D. Bhugra, Psychiatric epidemiology in India. Indian J Med Res 2007;126(3): 183-92. 38. Premrajan KC, et al. Prevalence of psychiatric morbidity in an urban community of Pondicherry. Indian Journal of Psychiatry 1993; 35: 99-102. 39. Reddy MV and Chandrasekar CR, Prevalence of mental and behavioural disorders in India : A metaanalysis. Indian Journal of Psychiatr 1998; 40: 149-157. 40. Sachdeva JS, et al., An epidemiological study of psychiatric disorders in rural Faridkot (Punjab). Indian J Psychiatry 1986;28: 317-323. 41. Shaji S, et al., Prevalence of priority psychiatric disorders in a rural area of Kerala. Indian J Psychiatry, 1995; 37: 91-96. 42. Sharma S and Singh MM, Prevalence of mental disorders: An epidemiological study In Goa. 418 Psychiatry in India : Training & training centres Indian J Psychiatry 2001;43: 118-126. 43. Surya NC. Mental morbidity in Pondicherry. Transaction-4, Bangalore: All India Institute of Mental Health 1964. 44. Thacore VR, Gupta SC, and Suriya M. Psychiatric Morbidity in North Indian Community. Br J Psychiatry 1975;126: 364-369. 45. Verghese A, et al. A social and psychiatric study of a representative group of families in Vellore town. Indian J Med Res 1973; 61: 608-620. 46. Sethi BB, Gupta SC, and Rajkumar S. Three hundred urban families - a psychiatric study. Indian J Psychiatry, 1967; 9: 280-302. 47. Dube KC. A Study of prevalence and biosocial variables in mental illness in rural and urban community in Uttar Pradesh, India. Acta Psychiatr Scand, 1970;46: 327-359. 48. Elnager MN, Maitra P, and Rao MN. Mental health in an Indian rural community. Br J Psychiatry, 1971. 118: p. 499-503. 49. Sethi BB, et al., A psychiatric survey of 500 rural families. Indian J Psychiatry, 1972. 14: p. 183- 196. 50. Sethi BB, et al. Mental Health and urban life: A study of 850 families Br J Psychiatry 1974; 124: 243-246. 51. Nandi DN, et al., Psychiatric disorders in a rural community in West Bengal - an epidemiological study. Indian J Psychiatry 1975; 17: 87-99. 52. Nandi DN, et al., Socio-economic status and prevalence of mental disorders in certain rural communities in India. Acta Psychiatr Scand 1979;59: 276-293. 53. Shah A V, et al., Prevalence of psychiatric disorders in Ahmedabad: an epidemiological study. Indian J Psychiatry 1980; 22: 384-388. 54. Mehta P, Joseph A, and Verghese A. An epidemiological study of psychiatric disorders in a rural area in Tamil Nadu. Indian J Psychiatry, 1985;27: 153-158. 55. Math SB and Srinivasaraju R, Indian Psychiatric epidemiological studies: Learning from the past Indian J Psychiatry 2010; 52: S95-103.

Suresh Bada Math Associate Professor of Psychiatry Department of Psychiatry National Institute of Mental Health and Neuro Sciences, (Deemed University), Bangalore, 560029 India. [email protected], [email protected]

Janardhanan Narayanaswamy Senior Resident of Psychiatry

Dhanya Raveendranathan Senior Resident of Psychiatry 43 Relevance of Genetics to the Psychiatric Post Graduate Curriculum

Smita N. Deshpande

INTRODUCTION

Human beings have long been fascinated by similarities between parent and children, relatives and non-relatives. In practical terms they have also been concerned with improving yields of farm crops and domestic animals. These traits, passed from parents to offspring- human, other animals and plants- have been the focus of study down the ages. While environment clearly determines our physical characteristics, inherited traits passed down the generations and 'residing' in our genes are just as important. Genes may thus be deemed the fountain of life- the functional and physical bricks of heredity passed from parent to offspring. Genetics, the science of study of genes, is essential for psychiatric trainees.

Genetic inheritance could occur through one single gene, a finite number of genes, or unknown multiple numbers interacting with the environment. While single gene traits are easy to study, most psychiatric disorders are complex traits where multiple genes, as well as environmental factors, play significant and interactive roles. So a study of environment in association with genes is likely to yield the most fruitful results. [1]

Genetics in Psychiatry Training could be broadly divided into clinical teaching and theory. Both are important.

'Clinical' genetics:

All genetic studies began with asking the relevant research questions. In the clinic mental health workers asked one crucial question- does anyone in your family have the same or similar problems. Common knowledge tells us that many disorders run in families and the rule of thumb could be that 'more the affected members, more the chances of the trait being passed on'. This is not entirely true, unless this is a single gene disorder and even these would 420 Psychiatry in India : Training & training centres depend on the mode of inheritance. So it is important not merely to ask for inheritance but also to map it using our tool of family history and drawing a pedigree. This creates written records needed to help us unravel the mystery of inheritance of both normal traits and abnormal traits.

The pedigree gives us information about the diseases, living conditions, and psycho-social status of three generations of a family. It is short, can be reviewed at a glance and can be used to determine patterns of transmission of familial disorders. Family therapy physicians use the family tree to determine strength of relationships, individual needs for support, and if shared with the patient may clarify issues for them too. [2]

Drawing a pedigree:

Always use a three generation format, with the index person shown with an arrow. Males are shown as squares and females as circles. Some basic details must be included for each member of the pedigree- age, disease status (physical and mental) or cause of death, educational and occupational status. Congenital anomalies, developmental delays and mental retardation should also be asked for. People with target illnesses (physical and mental) must be shaded, dead people must be crossed and the patient must be arrowed. Were the illnesses/causes of death recorded i.e. proved? Use or dependence of many commonly used drugs such as alcohol and tobacco may lead to congenital anomalies or familial use in offspring (modelling). These should be asked and recorded.

Family therapy practitioners draw a circle around family members living together, two slashes where divorces have occurred, or one slash where separation is present.

A simple example of a pedigree is given below. Students could begin by drawing their own pedigree as an exercise. Knowing familial traits and diseases, state of interpersonal relationships, and other details will give personal insights and help improve their own health. Deshpande: Genetics in Psychiatric PG Curriculum 421 Genetics for theoretical study:

Beginning with clinical pedigrees coupled with bench side lab research, we must take our genetic knowledge forward. Several large scale genetic mapping projects have taken place all over the world beginning with the Human Genome Project, completed in 2003. India has not been a partner in these projects so the genetic map over our population is unknown. Hence, beginning with and drawing inferences from, pedigree drawing is important to map the transmission and mode of inheritance of mental illnesses in our population. These may be different from published studies, and there may be small groups where prevalence may differ from the general population. Study of these populations may help us gain insights in the illness as a whole. Based on genetic transmission data, companies in the West are offering over the counter technology for gene mapping. These home tests are available on the net and can be ordered by anyone. However we may not be able to benefit because of lack of population transmission data.

Disease based lab genetic research has also proceeded apace. New technologies are emerging and older ones are becoming cheaper. Identification of risk factors using genome wide linkage scans, candidate gene based association analysis, genome wide association study (GWAS) have all emerged as tools to identify risk factors of major/minor gene effect. Genetics of reproduction, pharmacogenetics, epigenetics, and gene therapy are all newer areas of genetics we should have a basic knowledge of. Addiction genetics is a rapidly developing science. Contrarily, emerging research also emphasizes the importance of familial factors that need not be inherited through DNA.

Since psychiatric disorders have no 'cure', the clamour for a genetic solution is bound to grow over time. Hence our theoretical training must also focus on advances in genetics. Beginning with patient education on marriage and progeny, we should work on the ethics of genetic work and research. Genetic counselling for psychiatric disorders needs to emerge as a teaching topic, because questions about marriage and reproduction are the most frequently asked.[3]

Conclusion:

The need for primary prevention of mental disorders is growing, given their high cost. These diseases, which result in high mortality and morbidity, are diseases of complex aetiology where biological factors- genetic or environmental or as yet unknown- interact with our changing environment. If we knew the exact role these various factors play in disease causation, we could prevent these diseases. 422 Psychiatry in India : Training & training centres One of the greatest obstacles in treating or even identifying the mental disorders with certainty has been the lack of external validating 'biological' tests. Diagnosis is still based on history, interview and observation. As the disorder progresses, new observations may emerge. Devising a bench based laboratory test may eliminate many of these personal requirements and biases. Hence the extensive search for biological determinants of mental disease must begin with the basics, which will not only improve treatment but also reduce stigma of mental diseases.

REFERENCES

1. http://support.infotechsoft.com/aspect/forms/pdf/FIGS_GSQ.pdf (24/12/2010) 2. Sadock BJ, Sadock VA, Ruiz P, Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 9th edition, 2007, Lippincott Williams and Wilkins. 3. Bhatia T. (2009) Introduction to genetic counseling, from http://www.indouspgp.info/ (24/12/2010).

Smita N. Deshpande Consultant, Professor & Head Dept. of Psychiatry & De-addiction Services, PGIMER- Dr. RML Hospital, New Delhi [email protected] 44 Metabolic Syndrome with Special Reference to Schizophrenia

Shiv Gautam, P.S. Meena, Anita Gautam, Manaswi Gautam, I.D. Gupta

ABSTRACT

The terms "Metabolic syndrome," "Insulin resistance syndrome" and "Syndrome X" are now used specifically to define a constellation of abnormalities that is associated with increased risk for the development of type 2diabetes and atherosclerotic vascular disease. In recent years, mental health providers have been grappling with issues pertaining to metabolic disturbance in schizophrenia as well as the adverse effects of antipsychotic treatments. Olanzapine is the compound associated with the greater incidence of weight gain, abnormalities in glucose-insulin homeostasis and lipid metabolism, thus resulting in the development of metabolic syndrome. Risperidone and quetiapine are less likely to cause this side effect, while ziprasidone appears having no impact in the development of metabolic syndrome. There was no sufficient data for amisulpride and aripiprazole. Clozapine has been strongly associated with metabolic adverse events, but is the most effective compound for the treatment of refractory schizophrenia.

Metabolic syndrome, a term unfamiliar to some of us just a few years ago, has become a dominant theme in psychiatric discussions. The term "metabolic syndrome" dates back to at least the late 1950s, but came into common usage in the late 1970s to describe various associations of risk factors with diabetes, that had been noted as early as the 1920s.

The terms "metabolic syndrome," "insulin resistance syndrome," and "syndrome X" are now used specifically to define a constellation of abnormalities that is associated with increased risk for the development of type 2 diabetes and atherosclerotic vascular disease. 424 Psychiatry in India : Training & training centres In the general adult population, the metabolic syndrome is an intermediate step toward the final endpoint of Type II diabetes and CVD.

In 2001, the Third Report of the National Cholesterol Education Program Adult Treatment Panel (ATP III) included diagnostic guidelines for the metabolic syndrome and proposed that it should be a secondary target of intervention. The ATP III criteria requires the presence of more than three of the following for the diagnosis of the metabolic syndrome:

1) Abdominal obesity 2) Elevated triglyceride level 3) Low high-density lipoprotein level (HDL) 4) High blood pressure 5) Elevated fasting glucose level.

The other two popular criteria commonly used to diagnose metabolic syndrome are W.H.O. criteria and International Diabetes Federation (I.D.F) criteria.

Cross-sectional data from NHANES III showed the prevalence of coronary heart disease (CHD) to be significantly higher among non-diabetic patients with the metabolic syndrome (13.9%) than in diabetic patients who did not meet criteria for the syndrome (7.5%) (Alexander CM et al 2003); moreover, data from a large Scandinavian trial revealed that a diagnosis of the metabolic syndrome was associated with a 3-fold increased risk for both CHD and stroke (Isomaa B et al 2001).1

The metabolic syndrome also represents a pre-diabetic state which progresses over time to overt diabetes in a significant proportion of individuals. Evidence for this progression comes from NHANES III, which found that only 13% of diabetics did not meet criteria for the metabolic syndrome among the cohort over age 50 years (Alexander CM et al 2003)2.

Lakka et al. found that men with the metabolic syndrome were 2–4 times more likely to die from coronary heart disease and twice more likely to die of any cause than those without the metabolic syndrome, even after adjustment for conventional cardiovascular risk factors.

Bobes and colleagues(2007)3 showed that the prevalence of coronary heart disease and metabolic syndrome in patients with schizophrenia who were treated with antipsychotics was the same as that in persons from the general population who were 10 to 15 years older.

In recent years, mental health providers have been grappling with issues pertaining to metabolic disturbance in schizophrenia as well as the adverse Shiv Gautam et al: Metabolic Syndrome 425 effects of antipsychotic treatments. Recent trials estimate that rates of obesity and diabetes in those with schizophrenia are nearly twice that in the general population, and dyslipidemias are more common (Cohn T et al 2004).4

It has been suggested that patients with schizophrenia may have an inherent predisposition toward metabolic syndrome that is further complicated by their sedentary lifestyle, poor dietary habits, lack of access to care, poor insight, and medication-induced adverse effects. The Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study, one of the largest studies of schizophrenia to date, compared metabolic syndrome in its sample with an age-matched sample from the general population drawn from the National Health and Nutrition Examination Survey (NHANES). The prevalence of metabolic syndrome at baseline was higher in the CATIE participants than in the NHANES participants. In the CATIE study, the overall prevalence of hypertension was 33.2%. The prevalence of diabetes was 10.4% for the entire cohort, with a prevalence of 10.9% in patients with fasting glucose results obtained 8 hours or more after their last meal. Dyslipidemia, as defined by elevated serum triglyceride levels, was found in 47.3% of fasting patients and when defined as low serum levels of high-density lipoprotein (HDL) cholesterol, it was found in 48.3% of all patients( McEvoy JP et al 2005)5

Metabolic derangements and schizophrenia

Arranz B et al (2004)6 conducted a study to determine the glucose metabolism parameters in noncompliant unmedicated schizophrenic patients (antipsychotic-free) and first-episode antipsychotic-naive schizophrenic patients to investigate whether there is a preexisting impairment of glucose metabolism in never-medicated schizophrenic patients. Plasma glucose, insulin, C-peptide, and leptin concentrations were determined in 50 antipsychotic-free and 50 antipsychotic-naive DSM-IV schizophrenia patients and 50 healthy control subjects. Insulin resistance was calculated through the homeostatic model assessment (HOMA). It was found that antipsychotic-free patients showed significantly increased insulin (p = .001) and C-peptide (p = .02) concentrations and a significantly higher degree of insulin resistance (p = .003), as measured with the HOMA index, in comparison with the antipsychotic-naive patients and the control group. Significantly increased leptin concentrations were also noted in the antipsychotic-free patients and were attributed to the effects of body mass index and sex.

The results reported in this study suggest the effect of previous antipsychotic treatment on glucose metabolism parameters and weight-related hormones such as leptin, while ruling out a preexisting impairment of glucose metabolism in never-medicated first-episode schizophrenic patients. 426 Psychiatry in India : Training & training centres Most of the evidence indicating that type II diabetes mellitus occurs more commonly in schizophrenia has come from studies in which patients were either receiving neuroleptics or had been exposed to neuroleptics in the past (Dynes JB 1969, McKee HA et al 1986, Haupt DW et al 2001)7. It is difficult to determine whether schizophrenia per se has an independent role in the development of abnormal glucose metabolism. Support for the hypothesis that schizophrenia and diabetes may be linked independently of medication comes from the observation that the rate of type II diabetes mellitus in family members of schizophrenic patients is between 18% and 30% (Mukherjee S et al 1989)8 , which is far higher than the rate in the population at large (1.2%–6.3%) (Adams PF et al 1994)9.

Therefore, patients with schizophrenia and their first-degree relatives appear to be predisposed to developing type II diabetes mellitus.

First-episode, drug-naïve patients with schizophrenia have impaired fasting glucose tolerance and are more insulin resistant and have higher levels of plasma glucose, insulin, and cortisol than healthy comparison subjects.

Metabolic syndrome and schizophrenia

There is relative paucity of studies addressing the issue of development of metabolic syndrome among patients having schizophrenia attributed to the disease itself.

De Hert Marc A. et al10 conducted a prospective study to find out whether patients suffering from schizophrenia are at higher risk for developing metabolic syndrome. All consecutive patients with schizophrenia at University Center St Jozef, Catholic University Louvain, Leuvense Steenweg, psychiatric hospital, (Belgium) and affiliate services were entered in an extensive prospective metabolic study including an oral glucose tolerance test. The prevalence of the metabolic syndrome was assessed based on the National Cholesterol Education Program criteria (NCEP, Adult Treatment Protocol, ATP-III), adapted ATP-III criteria using a fasting glucose threshold of 100 mg/dl (AHA) and on the recently proposed criteria from the International Diabetes Federation (IDF). The analysis of 430 patients showed a prevalence of the metabolic syndrome of 28.4% (ATP-III), 32.3% (ATP-III A) and 36% (IDF), respectively. The prevalence of the metabolic syndrome in the sample of patients with schizophrenia is at least twice as high compared to an age- adjusted community sample in Belgium. It was concluded that the metabolic syndrome is highly prevalent among treated patients with schizophrenia. It represents an important risk for cardiovascular and metabolic disorders. The study group recommended assessment of the presence and monitoring of the associated risks of the metabolic syndrome should be part of the clinical Shiv Gautam et al: Metabolic Syndrome 427 management of patients treated with antipsychotics.

Richard A Bermudes et al (2006)11 assessed the prevalence of the metabolic syndrome by surveying hospital records of psychiatric inpatients with severe mood and psychotic disorders. The study group was 102 consecutively admitted adult patients with a primary DSM-IV diagnosis of a mood or psychotic disorder. Criteria for comorbid metabolic syndrome required at least three of the five factors defined by the National Cholesterol Education Program.

In the sample of severely mentally ill patients, 38.6% met criteria for the metabolic syndrome as defined by ATP III guidelines. The rate is elevated, compared with the rate of 21.4% found by Ford and others in the United States general population during the Third National Health and Nutrition Examination Survey (NHANES III, 1988–1994).

To determine the prevalence and characteristics of coronary heart disease (CHD) risk factors in patients with chronic schizophrenia or schizoaffective disorder Cohn T et al (2004)12 compared individual CHD risk factors and Framingham risk predictions in a group of 240 patients with a large national sample (Canadian Heart Health Survey) matched for age and sex. In addition, they compared rates of the metabolic syndrome with recently published rates in the US adult population.

Prevalence rates of the metabolic syndrome in the patients (42.6% of men and 48.5% of women) were approximately 2 times published rates in the US adult population. Further, the syndrome appears to occur at a younger age than in the general population. These long-term patients have increased CHD risks best captured by the metabolic syndrome conceptualization.

One of the first and most extensive epidemiological studies conducted to explore various risk factors associated with schizophrenia leading to excessive and early mortalities was the northern Finland 1966 birth cohort (Saari KM et al 2005).13

5613 participants of the Northern Finland 1966 Birth Cohort who took part in the current field study from 1997 to 1998 were analysed. The Northern Finland 1966 Birth Cohort is an unselected, general population based sample of births in the provinces Lapland and Oulu.

The Finnish hospital discharge register was used to obtain information which members of the sample suffered from schizophrenia and the sample was divided into four diagnostic categories according to DSM-III-R: 1. schizophrenia (N = 31) 2. Other functional psychoses (N = 22) 3.nonpsychotic disorders (N = 105) 4. No psychiatric hospital treatment (N = 428 Psychiatry in India : Training & training centres 5455, i.e. the comparison group). The presence of metabolic syndrome was assessed in all participants using the criteria of the Finish National Cholesterol Education Program.

Participants with schizophrenia had a statistically significant increased prevalence of metabolic syndrome compared to normal controls (19% vs. 6%, p = .010). Subjects with "other psychoses" and "nonpsychotic psychiatric disorders" did not have an increased risk for metabolic syndrome (5% and 9%, respectively).

According to a logistic regression analysis that controlled for sex, the risk of metabolic syndrome in schizophrenia was shown to be 3.7 higher than in normal controls (95% CI = 1.5 to 9.0). Among the single components of metabolic syndrome indicated above only abdominal obesity and hypertriglyceridemia were significantly increased.

The report is one of the first epidemiological studies trying to assess risk factors that may explain the well-known increased mortality rates of people with schizophrenia. Methodological strong points are the use of a population based sample and of a cohort with the same year of birth, thus eliminating age as a source of bias.

The authors state that almost all patients with schizophrenia are at some stage hospitalised in Finland so that the results should be representative for schizophrenia.

Furthermore, although the authors started out with a high number of participants, there were relatively few cases with schizophrenia due to the low-prevalence of the disorder.

Nevertheless, the high prevalence of metabolic syndrome in schizophrenia identified already at the beginning of the patients' thirties highlights the importance of the problem.

Omer Boke et al (2008)14 conducted a cross-sectional study was to assess the prevalence of MetS in schizophrenic Turkish inpatients. The study was conducted from January 2006 to June 2006, and included 231 patients with schizophrenia. All participants were enrolled from inpatients attending the Samsun Mental Health Hospital psychiatry clinic. The subjects were aged between 18 and 65 and met the DSM IV criteria for schizophrenia. The study group consisted Mean age was 38.5 ± 10.5 and mean duration of illness was 15.76 ± 9.95 years. The overall prevalence of MetS diagnosed according to the IDF criteria was 32.0% (n = 74) and was higher in females (61.4%) than in males (22.4%; p = 0.0001). The study shows that the prevalence of MetS in Turkish patients with schizophrenia is similar to that of the general Shiv Gautam et al: Metabolic Syndrome 429 population, but lower than in other reports regarding the schizophrenia population.

Heiskanen T et al (2003)15 conducted a study that consisted of 35 outpatients with long-term schizophrenia defined by DSM-IV criteria. Patients were assessed for the presence of metabolic syndrome, which was defined by the criteria of the National Cholesterol Education Program. All patients were on antipsychotic medication. Metabolic syndrome was found in 37% (N = 13) of the patients, and it was associated inversely with the total daily dose of, but not with any specific type of, antipsychotic drug. The results suggest that metabolic syndrome is common among patients with schizophrenia, and it may be far more common than in general populations.

De Hert M et al. (2006)16 et al conducted a prospective study to find out prevalence metabolic syndrome in patients suffering from schizophrenia taking typical and atypical antipsychotics so as to find out which category of antipsychotic drugs are metabolically more detrimental. Data from a historic cohort of consecutively admitted first-episode patients with schizophrenia treated with first-generation antipsychotics (FGAs) were compared with an age and sex matched 5series of consecutive first-episode patients treated only with second-generation antipsychotics (SGAs). Rates of metabolic syndrome were compared at baseline and after on average 3 years of treatment exposure. At first episode there was no difference in the prevalence of metabolic syndrome between the historic and the current cohort. Rates of metabolic syndrome increased over time in both groups, but patients started on SGAs had a three times higher incidence rate of metabolic syndrome (Odds Ratio 3.6, CI 1.7-7.5). The average increase in weight and body mass index was twice as high in patients started on SGA. The difference between the FGA and SGA group was no longer significant when patients started on clozapine and olanzapine were excluded.

Rates of metabolic syndrome at the first episode of schizophrenia today are not different from those of patients 15 to 20 years ago. This finding counters the notion that the high rates of metabolic abnormalities in patients with schizophrenia currently reported are mainly due to lifestyle changes over time in the general population. Some SGAs have a significantly more negative impact on the incidence of metabolic syndrome compared to FGAs in first- episode patients.

Metabolic derangements with atypical antipsychotics

The introduction of second generation antipsychotics provided mental health professionals effective first line agents for the treatment of schizophrenia and other psychoses, which cause less neurological side 430 Psychiatry in India : Training & training centres effects(Parkinsonism, movement disorders etc) than first generation ones. The expanding use of these drugs is strongly correlated with the development of metabolic syndrome in the long-term, resulting in serious medical comorbidities of psychotic patients, such as cardiovascular events.

Patients first receiving antipsychotic drugs experience substantial deposition of both subcutaneous and intra-abdominal fat, reflecting a loss of the normal inhibitory control of leptin on body mass. Along with fat deposition, the increase in levels of fasting lipids and in non-fasting glucose may provide early signs of drug-induced progression towards the metabolic syndrome.

Douglas L. Leslie et al17 conducted a study to determine the proportion of patients with schizophrenia with a stable regimen of antipsychotic monotherapy who developed diabetes or were hospitalized for ketoacidosis.

Patients with schizophrenia for whom a stable regimen of antipsychotic monotherapy was consistently prescribed during any 3-month period between June 1999 and September 2000 and who had no diabetes were followed through September 2001 by using administrative data from the Department of Veterans Affairs. Cox proportional hazards models were developed to identify the characteristics associated with newly diagnosed diabetes and ketoacidosis.

Of the 56,849 patients identified, 4,132 (7.3%) developed diabetes and 88 (0.2%) were hospitalized for ketoacidosis. Diabetes risk was highest for clozapine (hazard ratio=1.57) and olanzapine (hazard ratio=1.15); the diabetes risks for quetiapine (hazard ratio=1.20) and risperidone (hazard ratio=1.01) were not significantly different from that for conventional antipsychotics. The attributable risks of diabetes mellitus associated with atypical antipsychotics were small, ranging from 0.05% (risperidone) to 2.03% (clozapine).

It was concluded that although clozapine and olanzapine have greater diabetes risk, the attributable risk of diabetes mellitus with atypical antipsychotics is small.

In the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) study, one of the largest studies of schizophrenia to date patients were randomly assigned to receive olanzapine, perphenazine, quetiapine, risperidone, or ziprasidone. CATIE's phase 1 results showed that patients in the olanzapine group gained more weight than patients in any other group. The study found that patients being treated with olanzapine gained an average of 2 lb per month, while patients being treated with risperidone and quetiapine gained an average of 0.4 and 0.5 lb per month, respectively. Patients who were being treated with ziprasidone lost an average of 0.3 lb per month; however, most Shiv Gautam et al: Metabolic Syndrome 431 of the patients were taking another antipsychotic before switching to ziprasidone, which may account for the result. In this study, olanzapine and clozapine demonstrated the highest risk for metabolic dysfunction. Ziprasidone appeared metabolically neutral. The CATIE study showed that olanzapine and quetiapine are associated with increase in total cholesterol levels of 9.4 mg/dL and 6.6 mg/dL, respectively; and increase in triglyceride levels of 40.5 mg/dL and 21.2 mg/dL, respectively. Risperidone and ziprasidone are associated with decrease in cholesterol levels of 1.3 mg/dL and 8.2 mg/dL and decrease in triglyceride levels of 2.4 mg/dL and 16.5 mg/dL, respectively.

Further, a larger proportion of patients in the olanzapine group than in the other groups gained 7 percent or more of their baseline body weight.

"Olanzapine had effects consistent with the potential development of the metabolic syndrome and was associated with greater increase in glycosylated hemoglobin, total cholesterol, and triglycerides after randomization than the other study drugs, even after adjustment for the duration of treatment," the CATIE authors wrote. The initial report from the CATIE study appeared in the September 22, 2005, New England Journal of Medicine.( Lieberman JA et al 2005).18

P. Mackin et al (2005)19 investigated the hypothesis that atypical antipsychotics are associated with a greater degree of metabolic dysfunction than typical agents.

Metabolic parameters were measured in 103 diagnostically heterogeneous psychiatric out-patients. Patients had been taking typical or atypical antipsychotic drugs for a minimum of six months. Sixty-nine patients were taking atypical agents, 20 typical agents and 14 a combination. Mean values (±SD) for the whole group were: age 43.8 years (11.4); BMI 29.1 kg/m2 (5.1); W:H ratio 0.88 (0.09). Metabolic parameters, including beta cell function and insulin sensitivity, measured by HOMA, did not differ with regard to the prescribed antipsychotic drug. Six patients had undiagnosed diabetes, six patients had impaired fasting glucose, and eight fulfilled criteria for the metabolic syndrome, all of whom were taking atypical agents (p=0.07 vs. typical agents). Subgroup analyses of those taking atypical agents revealed differences in BMI (mean, ±SD) between olanzapine (27.3 kg/m2±5.1) and quetiapine (31.9 kg/m2±5.1), p=0.01, and HbA1c (olanzapine, 5.1%±0.6 vs quetiapine, 5.6%±0.6; p=0.03). Other atypical agents were intermediate with regard to these parameters. The study concluded that obesity, dyslipidemia and abnormalities of glucose homeostasis are more prevalent in patients taking atypical antipsychotics20 432 Psychiatry in India : Training & training centres Perez-Iglesias R et al (2007)21 at Marqués de Valdecilla University Hospital, University of Cantabria, Santander, Spain examined the main metabolic side effects induced by antipsychotic treatment in a cohort of first-episode drug- naive subjects.

A randomized, open-label, prospective clinical trial was conducted. Participants were 145 consecutive subjects included in a first-episode psychosis program (PAFIP) from February 2002 to February 2005, experiencing their first episode of psychosis (DSM-IV codes 295, 297, and 298), and never treated with antipsychotic medication. Patients were assigned to haloperidol, olanzapine, or risperidone treatment during 12 weeks. The main outcome measures were changes at 12 weeks in body weight; body mass index; and 12-hours-fasting morning levels of total cholesterol, tri-glycerides, low-density lipoprotein (LDL) cholesterol, high- density lipoprotein cholesterol, glucose, homeostasis model assessment (HOMA) index, and insulin.

At the endpoint, 128 patients were evaluated (88.3%). The mean doses were haloperidol = 4.2 mg/day, olanzapine = 12.7 mg/day, and risperidone = 3.6 mg/day. A significant weight gain was observed with the 3 antipsychotics: haloperidol = 3.8 kg, olanzapine = 7.5 kg, and risperidone = 5.6 kg. Metabolic parameters showed a worsening lipid profile with the 3 treatments (statistically significant increase in total cholesterol and LDL cholesterol levels). Only the olanzapine group showed significant increases in triglyceride levels. After the 12-week study period, there were no significant changes in parameters involving glucose metabolism for any group.

Drug-naive patients experienced an extraordinary weight gain with first-and second-generation antipsychotics after the first 12 weeks of treatment. Significant increases in total cholesterol and LDL cholesterol levels are associated with the 3 treatments. Weight gain and metabolic disturbances induced by antipsychotics may increase the risk of developing cardiovascular disease.

Kelly DL et al (2008)22 in a 8 weeks randomized control trial studied weight and metabolic changes with two widely used antipsychotics, risperidone and olanzapine; addressing the issue of early monitoring for metabolic side effects. This 8-week double blind randomized trial included patients with schizophrenia or schizoaffective disorder (N = 377) randomly assigned to risperidone (2-6 mg/day) or olanzapine (5-20 mg/day). Weight, BMI, HbA1C, total cholesterol (TC), LDL-C, HDL-C and triglycerides (TG) were monitored. Mean BMI increases were higher in the olanzapine group as compared to risperidone (1.3 kg/m vs. 0.7 kg/m2) (p < 0.001).

Increase in mean TC (13.5 mg/dl), LDL-C (11.0 mg/dl) and TG (14.8 mg/dl) Shiv Gautam et al: Metabolic Syndrome 433 occurred in the olanzapine group while significant changes in TC (-3.9 mg/dl) and TG (-32.8 mg/dl) were noted in the risperidone group. Men (not women) on olanzapine had higher than expected increases in lipids given the amount of weight gain. Baseline values and prior therapy did not contribute to the significant differences, however BMI increases (p = 0.0002) were linked to study discontinuation in both drug groups. The fact that significant metabolic changes occurred (both positive and negative) in eight weeks is important to clinical care. Monitoring for metabolic changes may be important within the first eight weeks of treatment, as changes can be determined very early in antipsychotic treatment.

Simpson MM et al (2001)23 performed a retrospective analysis of data involving 121 inpatients to examine the rate of weight gain during antipsychotic-free periods and during treatment with various antipsychotic drugs. Data were analyzed to determine differences in weekly weight change during antipsychotic-free (N = 65), typical antipsychotic (N = 51), or atypical antipsychotic (N = 130) treatment periods. Atypical antipsychotic treatment periods were further subdivided into olanzapine (N = 45), clozapine (N = 47), or risperidone (N = 36) treatment periods. A paired comparison was conducted on 65 patients who had an antipsychotic-free treatment period preceding or following a neuroleptic drug treatment period. Across all treatment periods, weekly weight gain was as follows: 0.89 lb/wk (0.40 kg/wk) on atypical antipsychotic medication, 0.61 lb/wk (0.27 kg/wk) on typical antipsychotic medication, and 0.21 lb/wk (0.09 kg/wk) on no antipsychotic medications. The atypical antipsychotic versus antipsychotic-free comparison was significant (F = 3.51; df = 2,231; p = .031), while the typical antipsychotic versus antipsychotic-free comparison was not. Among the individual atypical antipsychotic medications, significantly more weight gain occurred during olanzapine treatment (1.70 lb/wk) (0.76 kg/wk) than with either clozapine (0.50 lb/wk) (0.22 kg/wk) or risperidone (0.34 lb/wk) (0.15 kg/wk) treatments (F = 7.77; df = 2,117; p = .001). In the paired analysis with patients serving as their own controls, the difference between weekly weight gain during atypical antipsychotic treatment and antipsychotic-free treatment was significant (t = -3.91; df = 44; p = .001), while the difference between weight gain during typical antipsychotic treatment and antipsychotic-free treatment was not significant. During treatment with the individual drugs both olanzapine and clozapine caused significantly higher weekly weight gain than antipsychotic-free treatment (p = .001 and p = .036, respectively), while treatment with risperidone did not.

Sanjay Jain et al (2006)24 conducted a prospective study at psychiatric centre Jaipur, to find out weight gain associated with olanzapine intake. 80 consecutive patients suffering from schizophrenia were included in this study after confirming diagnosis using ICD-10 criteria. 434 Psychiatry in India : Training & training centres After one month of commencement of antipsychotic medication it was found that out of 80 patients 66.6% had a gain in weight of 1-5 kg. Gain in weight was significantly associated with age >40yrs and female sex, suggesting that women of age >40yrs are more prone to weight gain when given olanzapine.

Saddichha S, Manjunatha N et al at (2007)25 Central Institute of Psychiatry, Ranchi, India studied examined the effects of olanzapine, risperidone, and haloperidol on weight, body mass index (BMI), and development of obesity in a drug-naive population compared with a matched healthy control group.

Consecutive patients during the period from June through October 2006 with DSM-IV schizophrenia at our referral psychiatric hospital were recruited for an extensive prospective study that included anthropometric measures of weight, waist circumference, waist-hip ratio, and BMI. Subjects were randomly assigned to receive haloperidol, olanzapine, or risperidone and compared with a matched healthy control group. The prevalence of obesity, which was the main outcome measure, was assessed on the basis of 2 criteria: revised World Health Organization (WHO) definition for Asians and criteria of the International Diabetes Federation (IDF). Inclusions started in June 2006, and patients were followed for a period of 6 weeks.

The analysis of 66 patients showed a prevalence of overweight (WHO criteria) at 22.7% and obesity at 31.8% (IDF criteria). The prevalence of obesity (IDF criteria) in our patients is over 30 times as high as that of the matched healthy control group (p < .001). Subjects in the olanzapine group had the greatest weight gain at 5.1 kg, followed by risperidone at 4.1 kg and haloperidol at 2.8 kg. Obesity is highly prevalent among patients treated with atypical antipsychotics for schizophrenia. Assessment and monitoring of obesity along with preventive and curative measures should be part of the clinical management of patients treated with antipsychotics.

Metabolic syndrome and atypical antipsychotic medication

Gautam S et al (2011)26 Studied Drug-emergent metabolic syndrome in patients with schizophrenia receiving antipsychotics, thirty patients were given conventional antipsychotics and 90 were given second-generation antipsychotics, including risperidone, olanzapine and clozapine. Metabolic parameters were taken before onset of drug treatment therapy and after 4 months. The changes in metabolic parameters were compared, it was observed that Second-generation antipsychotics cause significantly more changes in the metabolic parameters, increasing the chances of developing metabolic syndrome and associated disorder like diabetes mellitus type-II and Cerebrovascular accidents. Olanzapine is the antipsychotic drug that has the maximum potential to cause metabolic syndrome. Shiv Gautam et al: Metabolic Syndrome 435 Vaios Peritogiannis et al (2006)27 conducted a meta-analysis of studies concerning metabolic syndrome as a result of antipsychotic treatment.

A Medline search was conducted in order to retrieve papers concerning metabolic syndrome as a result of antipsychotic treatment. The key words were antipsychotics, schizophrenia, diabetes, hyperlipidemia, hypertriglyceridemia, metabolic syndrome. A total of 110 papers was revealed. 35 of them were used for the purpose of this study.

Second generation antipsychotics were found to be more likely than first generation ones to cause metabolic syndrome. The possible mechanisms are weight gain, insulin resistance, or a combination of these. It is possible that drugs with increased histamine H1 receptor affinity are more likely to cause metabolic syndrome (Bray GA 2005). There are differences among them with this respect (Masand PS 1999, Meyer JM 2001, Wetterling T 2001)28.

In a landmark study J.Steven Lamberti et al (2006)29 compared the prevalence of the metabolic syndrome among outpatients with schizophrenia and schizoaffective disorder receiving clozapine with a matched comparison group from the National Health and Nutrition Examination Survey.

Ninety-three outpatients and a matched group of 2,701 comparison subjects were compared according to National Cholesterol Education Program criteria. Outpatient data were obtained through physical assessments, laboratory testing, and reviews of medical records.

The prevalence of the metabolic syndrome was significantly higher among clozapine patients (53.8%) than among the comparison group (20.7%). For clozapine patients, logistic regression analysis revealed significant associations with age, body mass index, and duration of clozapine treatment. Only age and body mass index were associated with the prevalence of metabolic syndrome in both groups.

Metabolic syndrome in Thai schizophrenic patients: a naturalistic one-year follow-up study. Manit Srisurapanont et al (2007)30 assessed the progress of metabolic abnormalities in Thai individuals with schizophrenia by estimating their one-year incidence rate of metabolic syndrome (MetS). All schizophrenic patients who visited the psychiatric clinic were screened. After the exclusion of participants with MetS at baseline, each subject was reassessed at 6 and 12 months to determine the occurrence of MetS. The definition of MetS, as proposed by the International Diabetes Federation (IDF), was applied.

At baseline, 13 subjects met the MetS definition. Of 44 subjects who had no MetS at baseline, 35 could be followed up. Seven of these 35 subjects (20.0%) 436 Psychiatry in India : Training & training centres had developed MetS at the 6- or 12-month visit, after already having 2 MetS components at baseline. The demographic data and characteristics of those developing and not developing MetS were not different in any respect.

There are limited data on the prevalence of Metabolic Syndrome in patients with schizophrenia at the onset of the disorder and specifically no data on patients treated in the era when only first-generation antipsychotics were available.

Olanzapine is the compound associated with the greater incidence of weight gain, abnormalities in glucose-insulin homeostasis and lipid metabolism, thus resulting in the development of metabolic syndrome. Risperidone and quetiapine are less likely to cause this side effect, while ziprasidone appears having no impact in the development of metabolic syndrome. There was no sufficient data for amisulpride and aripiprazole. Clozapine has been strongly associated with metabolic adverse events, but is the most effective compound for the treatment of refractory schizophrenia.

References:

1. Isomaa B, Almgren P, Tuomi T, et al. Cardiovascular morbidity and mortality associated with the metabolic syndrome. Diabetes Care. 2001;24:683-89. 2. Alexander CM, Landsman PB, Teutsch SM, et al. NCEP-defined metabolic syndrome, diabetes, and prevalence of coronary heart disease among NHANES III participants age 50 years and older. Diabetes. 2003;52:1210-1214 3. Bobes J, Arango C, Aranda P, et al. Cardiovascular and metabolic risk in outpatients with schizophrenia treated with antipsychotics: results of the CLAMORS Study. Schizophr Res. 2007;90:162-173. 4. Cohn T, Prud'homme D, Streiner D, et al. Characterizing coronary heart disease risk in chronic schizophrenia: high prevalence of the metabolic syndrome. Can J Psychiatry. 2004;49:753-760 5. McEvoy JP, Meyer JM, Goff DC, et al. Prevalence of the metabolic syndrome in patients with schizophrenia: baseline results from the Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) schizophrenia trial and comparison with national estimates from NHANES III. Schizophr Res. 2005;80:19-32 6. Arranz B, Rosel P, Ramírez N, Dueñas R, Fernández P, Sanchez JM, Navarro MA, San L. Insulin resistance and increased leptin concentrations in noncompliant schizophrenia patients but not in antipsychotic-naive first-episode schizophrenia patients. J Clin Psychiatry. 2004 Oct;65(10):1335-42. 7. Dynes JB: Diabetes in schizophrenia and diabetes in nonpsychotic 8. Mukherjee S, Schnur DB, Reddy R: Family history of type 2 diabetes in schizophrenic patients (letter). Lancet 1989; 1:495 9. Adams PF, Marano MA: Current Estimates From the National Health Interview Survey, 1994: Vital and Health Statistics Series 10, Number 193. DHHS Publication PHS 96-1521. Hyattsville, Md, National Center for Health Statistics, 1995 10. De Hert Marc A, Van Winkel Ruud, Van Eyck Dominique, Hanssens Linda, Wampers Martien, Scheen Andre, Peuskens Joseph: Prevalence of the metabolic syndrome in patients with schizophrenia treated with antipsychotic medication. Schizophrenia Shiv Gautam et al: Metabolic Syndrome 437 research ISSN 0920-9964 11. Richard A Bermudes, Paul E. Keck, jr., Jeffrey A. Welge: The Prevalence of the Metabolic Syndrome in Psychiatric Inpatients With Primary Psychotic and Mood Disorders. Psychosomatics 2006; 47:491–497 12. Cohn T, Prud'homme D, Streiner D, et al. Characterizing coronary heart disease risk in chronic schizophrenia: high prevalence of the metabolic syndrome. Can J Psychiatry. 2004;49:753-760 13. Saari KM, Lindeman SM, Viilo KM, Isohanni MK, Jarvelin MR, Lauren LH, et al: A 4-Fold Risk of Metabolic Syndrome in Patients With Schizophrenia: The Northern Finland 1966 Birth Cohort Study. Journal of Clinical Psychiatry 2005; 66 (5); 559-563 14. Omer Boke, Servet Aker, Gokhan Sarisoy, Esin Boke Saricicek, Ahmet Rifat Sahin: Prevalence of Metabolic Syndrome among Inpatients with Schizophrenia. The International Journal of Psychiatry in Medicine: Volume 38, Number 1 / 2008 :103 - 112 15. Heiskanen T; Niskanen L; Lyytikäinen R; Saarinen PI; Hintikka J: Metabolic syndrome in patients with schizophrenia. J Clin Psychiatry. 2003; 64(5):575-9 16. De Hert Marc, Schreurs Vincent, Sweers Kim, Van Eyck Dominique, Hanssens Linda, Sinko Sebastjan, Wampers Martien, Scheen Andre, Peuskens Joseph, Van Winkel Ruud: Typical and atypical antipsychotics differentially affect long-term incidence rates of the metabolic syndrome in first-episode patients with schizophrenia : A retrospective chart review. Schizophrenia research ISSN 0920-9964 17. Douglas L. Leslie, and Robert A. Rosenheck: Incidence of Newly Diagnosed Diabetes Attributable to Atypical Antipsychotic Medications. Am J Psychiatry September 2004, 161:1709-1711. 18. Lieberman JA, Stroup TS, McEvoy JP, et al. Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. N Engl J Med. 2005;353:1209-1223 19. P. Mackin . H. M. Watkinson . A. H. Young: Prevalence of obesity, glucose homeostasis disorders and metabolic syndrome in psychiatric patients taking typical or atypical antipsychotic drugs: a cross-sectional study. Diabetologia (2005) 48: 215–221 20. Diabetologia (2005) 48: 215–221. 21. Perez-Iglesias R, Crespo-Facorro B, Amado JA, Garcia-Unzueta MT, Ramirez-Bonilla ML, Gonzalez-Blanch C, Martinez-Garcia O, Vazquez-Barquero JL. A 12-week randomized clinical trial to evaluate metabolic changes in drug-naive, first-episode psychosis patients treated with haloperidol, olanzapine, or risperidone. J Clin Psychiatry. 2007; 68:1733-40 22. Deanna L. Kelly, Robert R. Conley, Raymond C. Love, John A. Morrison, Robert P. Mcmahon: Metabolic Risk with Second-Generation Antipsychotic Treatment: A Double- Blind Randomized 8-Week Trial of Risperidone and Olanzapine. Ann Clin Psychiatry. 2008 Apr-Jun;20(2):71-8 23. Simpson MM; Goetz RR; Devlin MJ; Goetz SA; Walsh BT: Weight gain and antipsychotic medication: differences between antipsychotic-free and treatment periods. J Clin Psychiatry. 2001; 62(9):694-700 24. Sanjay Jain, Manish Bhargava, Shiv Guatam: weight gain with olanzapine: Drug, gender or age? Indian journal of psychiatry 2008: 48;39-42 25. Saddichha S, Manjunatha N, Ameen S, Akhtar S :Effect of olanzapine, risperidone, and haloperidol treatment on weight and body mass index in first episode schizophrenia patients in India: a randomized, double-blind, controlled, prospective study. J Clin Psychiatry. 2007 Nov;68(11):1793-8. 26. Gautam S, Meena PS. (2011) Drug-emergent metabolic syndrome in patients with schizophrenia receiving atypical antipsychotics 27. Vaios Peritogiannis, Sofia Tsouli, Spyros Zafiris, Dimitrios Pappas and Venetsanos 438 Psychiatry in India : Training & training centres Mavreas: Metabolic syndrome and the use of antipsychotics. Annals of General Psychiatry 2006, 5(Suppl 1):S269 doi:10.1186/1744-859X-5-S1-S269 Bray GA. Drug insight: appetite suppressants. Nat Clin Pract Gastroenterol Hepatol.2005;2:89-95. 28. Masand PS. Relative weight gain among antipsychotics. J Clin Psychiatry. 1999;60:706- 708. Meyer JM. Effects of atypical antipsychotics on weight and serum lipid levels. J Clin Psychiatry. 2001;62(suppl 27):27-34. 29. J. Steven Lamberti, David Olson, John F. Crilly, Telva Olivares, Geoffrey C. Williams, Xin Tu, Wan Tang, Karen Wiener, Steven Dvorin, Marci B. Dietz: Prevalence of the Metabolic Syndrome Among Patients Receiving Clozapine. Am J Psychiatry 2006; 163:1273–1276. 30. Manit Srisurapanont, Surinporn Likhitsathian, Vudhichai Boonyanaruthee, Chawanun Charnsilp, Ngamwong Jarusuraisin: Metabolic syndrome in Thai schizophrenic patients: a naturalistic one-year follow-up study. BMC Psychiatry 2007, 7:14doi:10.1186/1471- 244X-7-14

Shiv Gautam Director, Professor Gautam Hospital & Research Center and Institute of Behavioural Sciences and Alternative Medicine, Jaipur. [email protected]

P.S. Meena Psychiatric Center SMS Medical College, Jaipur

Anita Gautam Gautam Hospital & Research Center and Institute of Behavioural Sciences and Alternative Medicine, Jaipur.

Manaswi Gautam Gautam Hospital & Research Center and Institute of Behavioural Sciences and Alternative Medicine, Jaipur.

I.D. Gupta Psychiatric Center SMS Medical College, Jaipur 45 Postgraduate psychotherapy training can rise from the ashes.

Anna Tharyan

ABSTRACT

Psychotherapy as it is traditionally taught is losing ground in clinical psychiatry. The basic principles of psychotherapy can be taught effectively and efficiently through a problem based approach using group supervision. The lack of adherence to theory is balanced by the advantages of greater acceptability to students and the enrichment of clinical skills through a closer integration of biology and psychology.

In the era of evidence based, pharmaceutical driven, fast paced, rapid turn over practice of psychiatry, the practice and teaching of psychotherapy receives less attention than it should. Psychotherapy has evolved into sharply disparate schools requiring intensive and expensive training. Formal, structured psychotherapy of any school has become irrelevant to most mental health care settings in India especially those outside academic centers.

There are numerous reasons for the relative neglect of psychological strategies in psychiatric education. The imperatives of the management of severe psychiatric disorders over ride those that typically respond to psychotherapy. Unless supported by a department of psychology, psychotherapy teaching generally falls victim to the competing responsibilities of 'managing patient loads' in acute care, generating income, administration and research. Traditional psychotherapy training requires protected time for student as well as teacher, which is virtually impossible to find within a general psychiatry unit. Wide variations in language, culture, socioeconomic and educational backgrounds confound the application of therapies across cultures. Therefore, it is not surprising that there is very little enthusiasm about learning psychotherapy or conviction that it actually works. 440 Psychiatry in India : Training & training centres The relevance of psychotherapy in clinical psychiatry

Comparison between psychotherapy and pharmacotherapy as treatment strategies relevant to cases presenting to a teaching hospital would clearly show pharmacotherapy to be more 'efficient'. What is not revealed by such comparison is that there are vast arenas of the human mind where currently available biological therapies alone are not effective in remedying pathology.

Schizophrenia could be considered the stronghold of biological therapies. However, while delusion or hallucination can be traced to underlying biochemical pathology and treated with antipsychotics, post psychotic depression, high expressed emotion or the effects of stigma also triggered by schizophrenia cannot be managed with medication alone.

A decision to prescribe Clozapine for schizophrenia that has proved resistant to other antipsychotics would appear to depend on whether there are any physical contra-indications and whether monitoring of white blood cell count is accessible and affordable. However, clinical experience shows that unless a realistic assessment is made as to whether the cooperation of patient and relative can be ensured, it is futile and possibly dangerous to prescribe the medicine. A prediction of adherence to medicines cannot be made without an indepth knowledge of the families' fears, concerns, expectations and ability to understand and remember instructions.

Suicidal behaviour, heightened anger or apathy and anhedonia caused by the biochemical imbalance underpinning psychiatric disorder in the brain of the suffering individual, also raises guilt, regret, helplessness and frustration in the human beings caring for the patient. These emotional responses in the caregivers, professional or blood relative can influence recovery to a degree greater than is recognized by the average postgraduate student. The skills of supporting the caregiver and maximizing the cooperation of relatives cannot be replaced by medicines.

Non-adherence to medicines is a significant determinant of response. The ability to monitor, recognize and manage the impairment of insight, which causes non-compliance, is an essential complement to prescribing skills.

At its very essence psychotherapy is a treatment modality that engages the mind in the pursuit of health. The principles of psychotherapy, when applied to the medical profession, allow the practitioner to understand and work with the human being rather than the purely with the chemical components of the body. Until the world of science arrives at the definitive solution to pathology at the level of molecules, psychiatrists would be well advised to continue to recognize and work with the complex emotions and thoughts that set apart the human mind from that of animals through the medium of Tharyan: PG psychotherapy training 441 psychotherapy.

The psychiatrist who is able to examine a patient, make an accurate diagnosis and prescribe appropriate medicines is an efficient psychiatrist. A successful psychiatrist, on the other hand, will in addition, have the ability to discern the meaning of symptoms within the narrative of the patient's life, identify causation both in the physical as well as in the psychosocial realm, recruit the patient and families' commitment to the process of healing, enable sufferers to hope as well as accept limits to treatment success.

The way forward.

It is time to complement psychotherapy training available in the ivory towers with a more garden-variety practice. The need of the hour is a version of psychotherapy that allows the principles of psychotherapy to be applied to the health issues of the body and the mind within the average ten-minute consultation time of a medical professional while minimizing costs and avoiding esoteric theory.

Objectives and process

At the end of a postgraduate course in psychiatry the student should have the knowledge, skills and attitude sufficient to identify and correct disorders of the mind, integrating biological and psychological therapy in such a way as to alleviate suffering, reverse pathology and promote growth.

The curriculum for psychotherapy training should include both lectures on the theoretical basis of psychotherapy and clinical teaching. The main focus should however be on the latter, especially on fine tuning attitude and inculcating basic clinical skills.

The holistic ten minute consultation is best learned on the field, amidst time constraints, administrative chaos and exhaustion of the daily grind. Weekly, hour long group discussions are an efficient and feasible format for clinical teaching. Students are offered the opportunity to discuss the management of patients under their care and listen to similar presentations by their peers. While considerable flexibility may be allowed in the size of the group, ten to twelve students work well with one supervisor. The need for supervisory expertise is decreased as the group process contributes significantly to learning. The only requirement for selection of cases for discussion should be that they should be drawn from personal experience and not from theory or conjecture. The cases discussed could either be from the student's case load or one for whom the supervisor has been providing therapy. The presentation could focus on particular aspects of the diagnosis or management or on the general approach to therapy. Failures or successes within the therapeutic 442 Psychiatry in India : Training & training centres encounter or bewildering responses from the patient or personal reactions within the student can become learning opportunities when reflected upon.

Discussions such as these allow for teaching and learning opportunities in the area of psychological assessment, diagnosis, management and above all increasing the clinician's capacity for self awareness. The interactions provide the supervisor with unique opportunities to study each student's strengths and weaknesses as also the chance to monitor the therapy of as many cases as are discussed.

Students learn at their own pace, from a wider range of experience than their own and the focus of teaching and learning remains firmly rooted in the most common and therefore important problems presenting to a clinician. This format causes less performance anxiety in the student than is experienced in individual supervision and allows for inevitable interruptions from calls from acute care, on call duties or absence due to examinations or ill health.

Students benefit from hearing about their teacher's successes and failures within psychotherapy. It is not uncommon for students to make observations and give suggestions that correct or improve the teacher's work!

This format is not, however, conducive to an exhaustive or in depth coverage of psychotherapeutic theory or practice. It cannot replace formal psychotherapy training. It is merely one way of bringing the psychological dimension back into clinical psychiatry and laying the foundation for more in depth teaching in psychotherapy separate from the post graduate course.

Conclusion

Group supervision is an effective method of teaching the basic principles of the psychotherapeutic approach as it applies to common clinical problems.

.

Anna Tharyan Dept. Of Psychiatry Christian Medical College and Hospital, Bagayam, Vellore – 632002. [email protected] 46 Psychodynamic Psychotherapies – Where are they today?

Anurag Srivastava

ABSTRACT

While there is near consensus that the best treatment modality for most if not all psychiatric conditions may be a combination of psychopharmacology and psychotherapy, there is very little of it to be seen in actual practice. This article reviews the situation in India, exploring the various reasons for the low frequency of the practice of psycho- dynamic therapy. The salient features of the techniques as well as the pros and cons are briefly discussed, along with a review of the basic concepts of transference and counter-transference.

In these times of rapidly expanding knowledge and treatment options offered by biological psychiatry, it is perhaps necessary to review the role of psychotherapies in general, and psychodynamic therapies in particular, in the treatment of psychiatric disorders.

There are many who believe that psychodynamic psychotherapy has had its day, that there are significant doubts as to the validity of the theory, that the results are not very encouraging, and that the future of such therapies is in doubt. In fact, especially in our country, the vast majority of psychiatrists will hold this viewpoint. In the present times, to talk about psychodynamic therapy as a valid treatment option in many disorders invites open skepticism and even ridicule. This even as the majority of us continue to use the concepts and terminology of psychoanalysis in our professional and even day-to-day life. Thus clinicians who have grave doubts about psychoanalytic therapy will nevertheless use the concept of the unconscious while carrying out a narcoanalysis, will talk of the ego and superego; defence mechanisms remain a favorite with clinicians, academicians, and examiners alike.

Before going on to examination of the role of psychodynamic psychotherapy in current practice, it would probably be fruitful to try to understand why so 444 Psychiatry in India : Training & training centres many people turn away from this school of thought. One reason that stands out is the lack of trained psychoanalysts in the country, so that most of us have little exposure to the psychodynamic school during our training in psychiatry. This is a vicious circle, where the number of psychoanalysts in India is stagnant or even dropping even as the number of psychiatrists is rising.

Psychoanalytic theory is notoriously hard to grasp, and there are many interpretations of it. If we take just Freud's work, which is in German in the original, the content as well as the language (though elegant and fascinating) makes it very difficult for us to come to grips with what is being said. It seems that this is a major impediment to the expansion of the theory. The difficulty is compounded by the paucity of psychoanalytic teachers who can guide newcomers through the basic tenets. Anyone traveling this path is bound to flounder at some point of time, and it is very helpful to be able to discuss our way through our difficulties. Many of us, therefore, are unable to see our way clearly through the theory, and thus may reject the theory prematurely, with a superficial understanding of it.

A further objection raised is that dynamic therapies take too long. That is a very valid objection, especially in these days of quick relief offered by pharmacological therapies, but there is one small caveat. All of us will agree that there are some disorders, like personality disorders, somatoform disorders, gender identity disorders (to name only a few), which do not respond very satisfactorily to the present armamentarium of medications. Thus the course of many disorders like these will run into years, if not for the entire life span. Are we not justified, then, in taking the time out to offer a therapy that offers hope, even though it may take a relatively longer time?

This brings us to another major point of contention, is psychodynamic therapy effective? The nature of the therapy makes it difficult to run, say, a randomized double blind placebo-controlled trial. So the validity is always in question. But there is abundant data, in a different format, regarding the effectiveness of therapy. The patients include those with personality disorders (OCPD, Borderline, & Narcissistic), sexual perversion, gender identity disorder, specific phobia, PTSD, adjustment disorder, Major depression, Panic disorder, and marital conflict.

Freud, true to style, pointed to a deeper reason for the resistance to acceptance of psychoanalysis. He points out that narcissistic injuries are not very well accepted by man, quoting the resistance to the theories about the solar system (which removes earth from the center of the universe), about Darwin's theory of evolution, fiercely resisted when propounded (which takes away from man his divine descent), and goes on to point that psychodynamic therapies are the third injury, suggesting that man's conscious mind, his Srivastava: Psychodynamic Psychotherapies 445 control over his own life, is limited, that the unconscious mind has a larger role to play.

So perhaps it is time to examine whether the rejection of psychodynamic theory is really due to our being convinced that it is ineffective, and whether the problems in understanding the theory & practice, and our biases, come in the way of acceptance.

Psychoanalytic Psychotherapy – from theory to practice

The use of psychotherapy in the clinical practice of psychiatrists has shrunk in this age of increasing options offered by psychopharmacology. But probably everyone will agree that there is a significant population of patients who do not respond optimally to medication; quite often the clinician will feel that therapy is needed.

The first issue that comes up is to decide which patients need therapy. In this age of rapid advances in psychopharmacology, any condition or illness that is likely to respond to medication should be treated with medication, unless there are special circumstances (e.g. a non-psychotic patient refusing medication). The question that rises is whether addition of psychotherapy will make the treatment better. This may be the case for a majority of conditions commonly treated with medicines, like depressive disorders and anxiety disorders. Though traditionally these disorders respond well to drugs, the clinician should judge whether there are issues where therapy would be of help.

There will be some disorders, on the other hand, where psychotherapy may be considered to be the primary modality of treatment. Personality disorders (PDs) are the first to come to mind. Nearly all PDs will need therapy for optimal improvement. Other disorders like somatoform disorders, eating disorders, sexual disorders etc. probably also often don't respond optimally to medications. Some disorders, which respond well to medications traditionally, will have instances in which therapy may be needed to achieve satisfactory results (e.g. major depression, anxiety disorders, including OCD & PTSD). So there is a wide range of disorders that may benefit from therapy, and one has to judge whether the disorder will respond better to medications or therapy or a combination. Probably PDs, somatoform disorders, anxiety disorders, depression, adjustment disorders and sexual disorders are the ones most commonly seen in therapy.

Psychoanalytic therapy can usually be described as having an initial, middle and termination phase. Each has slightly different course and events, and there may be some merit in taking up these phases individually. In this article we shall look at the initial phase, and will consider the next phases later. 446 Psychiatry in India : Training & training centres The initial few sessions are crucial in determining whether the therapist and patient can work together meaningfully, whether the patient will continue therapy. After the initial history has been taken, and the decision is made that the patient would benefit from therapy, this option is given to the patient. Initial questions about the goals and expectations from therapy have to be dealt with here. Most often asked questions include those pertaining to duration and effectiveness of therapy. The answers have to be customized for each patient. For most cases, and specially so for PDs, the duration of therapy should be estimated to be a few weeks to months rather than a few days. The latter may the case when the therapist is planning brief dynamic therapy, but as I am not very familiar with those, I will skip that modality. In my experience, I have found that the shortest reasonably effective therapy lasted 25-30 sessions, and the longest about 180 sessions. At 2-3 sessions per week, that means 2-3 months to 1½ years. Probably, in estimating the duration, one can expect adjustment disorders and depressions and anxiety disorders to respond faster than PDs, but it is really impossible to give a precise estimate. Only a probable guideline can be given at the beginning. “Our answer is like the answer given by the Philosopher to the Wayfarer in Aesop's fable. When the Wayfarer asked how long a journey lay ahead, the Philosopher merely answered 'Walk!' and afterwards explained his apparently unhelpful reply on the ground that he must know the length of the Wayfarer's stride before he could tell how long his journey would take … To speak more plainly, psycho- analysis is always a matter of long periods of time, of half a year or whole years - of longer periods than the patient expects. It is therefore our duty to tell the patient about these issues before he finally decides upon the treatment.”. Freud, 'On the beginning of treatment', 1913c.

Therapy sessions usually begin with a discussion about the ground rules of sessions. Sessions times are usually prefixed, and as far as possible, schedules are adhered to. A typical session would last 50 minutes and two or three sessions a week are usual. It is made clear that usually the session time will not be extended if the patient is late; this does not carry if the therapist is late. An arrangement must be made to deal with emergencies, and out of therapy contact and discussions ought to be avoided. The payment is also discussed and will be fixed. Concessions may be made at the therapist's discretion, but no-payment situations may have the danger of contaminating transference and artificially introducing counter-transferential elements. The atmosphere is kept as constant as possible, and the therapist fades into the background. Silence is very important, and while care is taken to avoid the patient to use silence as a defence, the periods of silence will get longer with time to allow the patient to free-associate. It is important to be as unintrusive as possible so as to allow the transference to deepen, and censorship to be lessened.

The question about the effectiveness needs more evaluation. The Srivastava: Psychodynamic Psychotherapies 447 effectiveness will be determined by the nature of the disorder, the characteristics of the patient, and the skill of the therapist. Probably the latter is the most important factor. Therefore, it is difficult to provide a general guideline for answering this question, but if the therapist feels that there is a reasonable chance of betterment, he should convey this. In fact, if the therapist does not feel so, probably therapy should not be undertaken at all. One's own experience can be drawn upon to offer an estimate (without the need to cite personal examples and statistics).

Once it has been mutually agreed to start therapy, certain issues should be pre-fixed. The timing, place, and length of sessions should be decided upon, and, as far as possible, should remain constant. 2 or 3 sessions a week is usual. The sessions may last 40 – 60 minutes; I personally use 50-minute sessions.

“In regard to time, I adhere strictly to the principle of leasing a definite hour. Each patient is allotted a particular hour of my available working day; it belongs to him and he is liable for it, even if he does not make use of it.” Freud, 'On the beginning of treatment', 1913c.

The environment of the therapy room should be kept as constant as possible. Patients with good ego strength and better functioning may be able to tolerate more regression; the couch may be used in such cases. But if the therapist is unfamiliar or uncomfortable with the patient on the couch, face- to-face sessions will suffice. If possible, the therapist and the patient should not be across a desk; side-on seating arrangement may be used. There should be no interruptions during the sessions. The length of the sessions should not be varied except in the rarest of circumstances. If the therapist is late for a session, it should be extended so as to give the patient the full time. But if the patient is late, it must be explained before hand that the session will stop at the scheduled time. If the therapist can go on for 5-10 minutes more, he may do so; but that is at the therapist's discretion. Out-of-session interactions must be discouraged; the patient must be invited to bring every issue into the therapy sessions.

“Both lay public and doctors - still ready to confuse psycho-analysis with treatment by suggestion - are inclined to attribute great importance to the expectations which the patient brings to the new treatment. They often believe in the case of one patient that he will not give much trouble, because he has great confidence in psycho-analysis and is fully convinced of its truth and efficacy; whereas in the case of another, they think that he will undoubtedly prove more difficult, because he has a skeptical outlook and will not believe anything until he has experienced its successful results on his own person. Actually, however, this attitude on the part of the patient has very little importance. His initial trust or distrust is almost negligible compared 448 Psychiatry in India : Training & training centres with the internal resistances which hold the neurosis firmly in place. It is true that the patient's happy trustfulness makes our earliest relationship with him a very pleasant one; we are grateful to him for that, but we warn him that his favourable prepossession will be shattered by the first difficulty that arises in the analysis. To the skeptic we say that the analysis requires no faith, that he may be as critical and suspicious as he pleases and that we do not regard his attitude as the effect of his judgement at all, for he is not in a position to form a reliable judgement on these matters; his distrust is only a symptom like his other symptoms and it will not be an interference, provided he conscientiously carries out what the rule of the treatment requires of him.”

Freud, 'On the beginning of treatment', 1913c

It is common for therapy to begin hesitantly, as the patient and therapist get comfortable with one another. Initially, more encouragement from the therapist may be needed to get the patient to start talking about issues important to him. The patient should be encouraged to talk about whatever is there in his mind, regardless of whether it appears trivial, embarrassing, shameful, out-of-context; conscious censorship should be suspended as far as possible. This invitation to free-associate is crucial, especially in the initial stages, while the patient is familiarizing himself with the procedure. It will never lose its importance, however. As far as possible, the therapist should allow the patient to open the session conversation, and allow the patient to go wherever he wants with his thoughts. Slowly, as things begin to fall in place, interventions may be directed to specific points. Silence is very important in allowing free-association to develop, and for transference to deepen. But prolonged silences should probably not be allowed early on in the sessions. If there is an impression that the silence is whiling away the time, it can be gently broken with a general question or observation like “you are very quiet today” or “what are you thinking?” As the sessions progress, greater periods of silence may be tolerated, but one must always be cautious about silence being used as a defence.

The way the initial sessions go will vary a lot. A patient who adjusts well with the therapy requirements, and starts to talk about issues uppermost in his mind, with little urging or interventions, comes regularly to sessions (and pays fees on time) is every starting analyst's dream. Some patients will be like that, too. But we shall try to focus on the difficult issues that may crop up early in therapy.

I think that the most difficult patient is the one who does not talk much; getting information is like extracting teeth. Prolonged periods of silences are followed by single line answers to interventions. There was for example a patient who characteristically would not speak for the first 20 minutes or so Srivastava: Psychodynamic Psychotherapies 449 unless there is a question or observation from the therapist. She will usually claim that she has said all that was there in her mind and she cannot think of what to say next. The next 30 minutes, however, are full of information; the initial lack of material gives way to many issues that are to be discussed, so much so that she is dismayed when she is told that the time is up. When this initial silence as a pattern was pointed out, she said that it was not true, she was merely trying to think about the topic she should talk on. But an observation that she was silent so as not to talk about issues that were painful to her helped her to talk of several such issues. She said that she often became silent when confronted with hurt or when she was angry. Though she resented parental control in her life, she actually had allowed her parents to take all significant decisions in her life, even if they were contrary to her wishes. She had never protested or resisted the decisions, and she always waited to let someone take the lead in deciding which path she would follow. I pointed out that she was doing this in therapy, waiting for me to take the lead in guiding the session. Again after the intervention she came up with many instances in which she had agreed to a decision made by family members which had gone against what she wanted, which had angered and saddened her. But she had never insisted on what she wanted.

Thus it may be that the initial silences are the way a person responds to a particular situation in life, not just in therapy, and an interpretation can open up gates through which a lot of information may flow, and allow the analyst and to see himself in a new light. This may eventually pave the way to a mutative change in traits that bother the patient.

Another problem that may confront the therapist in the initial phases is the patient that goes the other way. These patients may either have very intense feelings and extreme behaviors that may make the therapist feel he is on a roller-coaster with the patient. Many borderline PD patients may bring in very intense emotions and acting-out fairly early in therapy. In such cases rigid control of counter-transference and early interpretations may be very important in reducing disruption to manageable levels. A non-judgmental therapist who does not respond angrily to provocation may be a new experience in the patient's life, and it may change the way he reacts to situations. At all times an effort must be made to be able to get the patient to examine the reasons for his intense emotions. Emotions that are expressed as actions rather than experienced as feelings should be brought to the notice of the patient. Usually the feeling that the therapist is trying to help him in understanding why he is the way he is, and the willingness to listen to any view-point or emotion without criticism decreases the need to act out. This lays the foundation for the interpretations which will bring change.

In one such case, the patient (with a narcissistic PD) was very irregular with his 450 Psychiatry in India : Training & training centres sessions. He often would not turn up, or turn up very late, and would give reality reasons for his being late (e.g. being caught in traffic). He used to deny that there was any other reason for his being late. Now it turned out that this patient had requested that the sessions be held in the morning, when he was “the most relaxed”. I was unable to comply due to other commitments in the morning. When his missing sessions or being late happened a few times, I asked him whether he was late because he was angry. He initially denied this, but then said that he was missing sessions so as to make me wait for him, revenge for not granting morning sessions. He went on to say, in subsequent sessions, that if he was angry about something he always did something to “get back”. He said that his family's efforts to push him towards a job or marriage had been met with actions directly opposite to their wishes – he would not work and had refused to marry for the past 7 years. This interpretation about his present behavior helped him talk about how he responded to situations in the past, which he reproduced in therapy.

“So long as the patient's communications and ideas run on without any obstruction, the theme of transference should be left untouched. One must wait until the transference, which is the most delicate of all procedures, has become a resistance.

The next question with which we are faced raises a matter of principle. It is this: When are we to begin making our communications to the patient? When is the moment for disclosing to him the hidden meaning of the ideas that occur to him, and for initiating him into the postulates and technical procedures of analysis?

The answer to this can only be: Not until an effective transference has been established in the patient, a proper rapport with him. It remains the first aim of the treatment to attach him to it and to the person of the doctor. To ensure this, nothing need be done but to give him time. If one exhibits a serious interest in him, carefully clears away the resistances that crop up at the beginning and avoids making certain mistakes, he will of himself form such an attachment and link the doctor up with one of the images of the people by whom he was accustomed to be treated with affection.” Freud, 'On the beginning of treatment', 1913c

“…a condemnation of any line of behaviour which would lead us to give the patient a translation of his symptoms as soon as we have guessed it ourselves, or would even lead us to regard it as a special triumph to fling these 'solutions' in his face at the first interview. It is not difficult for a skilled analyst to read the patient's secret wishes plainly between the lines of his complaints and the story of his illness; but what a measure of self-complacency and thoughtlessness must be possessed by anyone who can, on the shortest Srivastava: Psychodynamic Psychotherapies 451 acquaintance, inform a stranger who is entirely ignorant of all the tenets of analysis that he is attached to his mother by incestuous ties, that he harbours wishes for the death of his wife whom he appears to love, that he conceals an intention of betraying his superior, and so on! I have heard that there are analysts who plume themselves upon these kinds of lightning diagnoses and 'express' treatments, but I must warn everyone against following such examples. Behaviour of this sort will completely discredit oneself and the treatment in the patient's eyes and will arouse the most violent opposition in him, whether one's guess has been true or not; indeed, the truer the guess the more violent will be the resistance. As a rule the therapeutic effect will be nil; but the deterring of the patient from analysis will be final. Even in the later stages of analysis one must be careful not to give a patient the solution of a symptom or the translation of a wish until he is already so close to it that he has only one short step more to make in order to get hold of the explanation for himself. In former years I often had occasion to find that the premature communication of a solution brought the treatment to an untimely end, on account not only of the resistances which it thus suddenly awakened but also of the relief which the solution brought with it.” Freud, 'On the beginning of treatment', 1913c

In the initial phases of therapy, thus, a lot of things must be accomplished. Rapport has to be established, information elicited and documented, feasibility of therapy continuation established, time, place and fees issues settled, and initial dynamic framework put in place. Only after a successful initial phase can therapy proceed to serious therapeutic work, and on to the middle phase of therapy.

Transference and its uses

For most of us, transference is a phenomenon that is so near, and yet so far. We all have been familiar with it, but have heard varying things about it. All too often, we are ready to discard it as yet another, at best, useless, and at worst, troublesome, theoretical concept from the “outdated” analytical school of thought. But the fact is that we encounter transference phenomena every day in our clinical practice, and outside it in our daily life. We may choose to ignore it, and not deal with it, but we cannot just wish it away.

Maybe the first step towards understanding the concept is to de-mystify it. Transference is such a natural concept that we do not need to be analytically oriented to recognize its presence in our life. It is based on the observation that every one will respond to a new situation, a new relationship, in a particular way, depending on their past experiences and relationships. That is to say, the kind of relationships that we have had in the past will influence the relationships that we develop in the present and in the future. Thus every new 452 Psychiatry in India : Training & training centres relationship or interaction will allow us to have a glimpse about past relations, if we look for those signs. So people who have had warm, trustworthy, satisfying relations will tend to respond in similar fashion in their forthcoming relations, and will apply their expectations and perceptions from their past to the new interaction. Similarly, if someone has had an unfortunate relationship that has been significant in his life, he may approach future relations with a great deal more caution and skepticism. These characteristics will show themselves in a developing relation, and can be magnified if we follow certain principles while the relation is developing.

Thus in the analytic situation, we see a new relationship developing, that between the patient and the therapist, which is open to scrutiny and intervention even if the patient does not realize this when therapy begins. Because of the way the analysis is carried out, because we have agreed to certain guidelines, we can see the characteristics of the patient (when in a relationship with a stranger) in a manner that is impossible to see otherwise. One of the reasons why this can happen in the analytic setting is that the patient is invited to talk about whatever he wishes to, without any direction given by the therapist. Moreover, emotions, feelings and relationships are given utmost importance, and expression of inner feelings is encouraged. The therapist gives equal attention to whatever is being said, and there is no criticism or disapproval. Slowly the patient is able to talk about his true feelings without fear of retribution. The other very important aspect of the therapeutic relationship is that the therapist does not bring his own thoughts, feelings or viewpoints into the relationship. Thus the relationship becomes unique because the feelings and emotions that are displayed in the therapy, if not exclusively, predominantly originate from the patient. Thus the emotions and patterns of behavior that are seen in therapy come from the past experiences and personality traits of the patient, with little contribution from the present analytic situation. So we are in the unique situation of seeing the relationship develop, which is a reproduction of the past relations of the patient and which is now open to intervention.

For example, a person who feels that enough care was not taken about his feelings at some point in the past may display anger in the present analytic situation when care is taken about how he feels. He may paradoxically get angry when empathy and interest are shown in his feelings and reactions. When this is pointed out, in the face of abstinence on part of the therapist, the patient may realize that there is nothing in the present situation that makes him angry. He is unable to point out anything in the therapists' behavior that makes him angry. That may help him to focus attention on past figures against whom this anger, this feeling of not being cared for, is directed, and about which he was not very aware. This may help him to bring to his awareness feelings which were till now not being dwelled upon, and which might have Srivastava: Psychodynamic Psychotherapies 453 contributed to his feeling bad. Thus we can use an aspect of the present situation to bring to light emotions from the past. For this, it's crucial that the therapist be neutral, uncritical, non-judgmental and understanding. If there is something in our behavior that can give rise to reasonable anger in the patient, we will never be able to show that the anger that he feels towards us is actually coming from his past and is directed towards another person. He will counter this interpretation by taking refuge behind the reality situation that has angered him, and the past will remain obscure.

Transference is of great help in revealing whole aspects of the patient's life, not just the feelings associated with certain people in the past, but also the way they coped with the situation. But this can be of use only when we interpret the situation, and can show the patient how he has been feeling and behaving. Only then can we help in uncovering the feelings and emotions that had been covered up in so many layers, and which had been a source of distress and, perhaps, dysfunction.

Transference is one of the cornerstones of analytic therapy, and interpretation of the transference one of the major tools for change. It is the transference that lets us peek into the feelings that may be otherwise hidden, and interpretations allow us to bring them to the patients' awareness. It is perhaps the most powerful tool in any kind of therapy, and has the potential of bringing about marked changes in the way a person feels of behaves, and copes with situations. Used correctly, it can make enormous differences in the patients' lives, and, in many situations, can do what probably no other modality of treatment can do.

COUNTER-TRANSFERENCE

In the preceding articles in this series, attention has been focused on some aspects of psychoanalytic therapy, including the themes of transference, silence, practical aspects of implementation, and some case-reports. However, an important aspect of therapy, (and not only therapy, but all clinical situations), is the way we feel about our patients and react to them.

Throughout our medical training, and specially at the under-graduate level, little attention is paid to the way we feel about our patients, apart from the general instructions to dress appropriately, to be on time, to have compassion for suffering and spare time for the patient. The importance of dealing with the feelings that patients generate in us is rarely stressed, and even, by and large, ignored.

These feelings play a very important role in how we deal with patients, whatever our specialty, and are especially relevant in psychiatry. Though it is tempting to say the politically correct thing, that we feel the same way about 454 Psychiatry in India : Training & training centres all our patients and that we treat every patient in the same way, in reality probably all of us can identify patients that we like and dislike. We all may remember some “favorite” patient, and another patient who “annoyed and frustrated” us.

It is probably impractical to lay down a rigid doctrine that we are not supposed to have any feelings towards our patients. Perhaps a more reasonable line is to insist on a rigid control of such feelings as we may have, and not to act on them, whether the feelings are positive or negative. That is so because it is impossible not to have feelings, but it is possible to modulate the way we express them, act on them.

Even though we may feel that the way patients affect us has little clinical significance, it may influence treatment in profound ways. This is specially so when the patient is in contact with the doctor for prolonged periods of time, which is often the case in psychiatry. We may be impatient and quickly abandon therapeutic possibilities if the patient is a trying one, and may be eager to get him “off our hands” without exploring all the possible alternatives that may exist. Sometimes our irritation with a particular patient can have devastating consequences. Even if the patient has attitudes or behaviors we find annoying, the fact is that he has approached us because he is in distress. The last thing that a patient needs is a doctor who is impatient and easily annoyed. Even if we make the correct diagnosis and institute the appropriate treatment, our anger and negative feelings may make it difficult for the treatment to be executed. The patient may become resistant and non- cooperative, and may be non-compliant just to “get back” at the psychiatrist.

On the other end of the spectrum is the situation where the patient becomes a source of gratification for the doctor, and issues other than the betterment of the patient come into play. In extreme cases, advantage may be taken of the patient sexually. But less obvious and subtle gratifications are very common. Of course, all of us will feel gratified if the patient gets better and we get the satisfaction of having made a difference in his life. But sometimes more sinister forces are at play. We may need the narcissistic satisfaction of being in power and control, and relish so much that we are unable to give up an authoritative and dictatorial position. There the feeling of being in command may be more important than the patient getting well. Many times we may not even be aware of such needs and that we are silently gratifying them in the treatment of our patients. Probably the very situation of treating a patient offers probabilities for the gratification of hidden needs. Unless we are aware of these needs and keep a strict vigil, we end up satisfying such needs to some extent. The trick is to raise our awareness of such instincts and be on our guard as much as possible so that we don't satisfy them through our professional life. Srivastava: Psychodynamic Psychotherapies 455 Counter-transference issues will be always important in any treatment situation. It is sometimes believed that they assume importance in analytic situations only, but that is far from the case. True, in analysis, the feelings generated are likely to be more intense, but then analysts are forever being taught to be aware of these feelings and to try and keep them under control. But a look at literature will reveal that over 10% of therapists end up having intimate and non-professional relations with their clients. Such an abuse of the therapeutic situation is appalling, and we must never relax our guard, whether the situation is analytic or pharmacological. To believe that counter- transferential issues don't arise in non-analytic situation is to ask for trouble.

In my short experience of analytic therapy, I think that patients with Borderline Personality Disorder generate the most powerful feelings. Because of their constant fear of abandonment coexisting with fears of being overwhelmed, patients with BPD are constantly testing the boundaries of therapy. They may make the most vicious attacks on the therapists while trying to convince themselves that they will not be abandoned. So they may find fault with the therapist's personality, dress, room, technique, manners, tone of voice…nothing may escape their critical appraisal. Sometimes being told that our handling of the issue is incorrect may be very irksome, and no one will like being told how defective our technique is, and how problematic our personality and attitude. All the self-restraint that one possess will have to be drawn upon in order not to react angrily, and to use the commentary to expose the fears of intimacy and closeness that may underlie such a tirade.

The struggle to contain our feelings about our patients from showing it to others is never-ending. Of all the frontiers of psychiatric treatment, the control of counter-transference will probably remain the most distant and the most difficult to conquer.

Anurag Srivastava Professor & Head. Dept of Psychiatry, Mediciti Institute of Medical Sciences Hyderabad. [email protected]

47 Clinical Viva: What is it after all?

Sujata Sethi

ABSTRACT

Clinical viva voce is one of the oldest methods of assessment in medical education. Traditionally the viva is based on clinical cases and is ideally held in the clinical setting. In India, there is no uniform standard for the clinical viva in psychiatry. The type of competencies assessed, nature of cases given for assessment, time duration and areas covered can vary from one institute to another. However most of the institutes follow more or less similar format consisting of long case, short cases and 'oral' (grand viva). This part of the examination is the most feared segment. This article tries to demystify the clinical viva and explains the procedure and what to expect in clinical viva.

Key words: Viva, grand viva, clinical examination

Clinical viva voce is one of the oldest methods of assessment in medical education. Traditionally these vivas are based on clinical cases and are ideally held in the clinical setting.

What is the purpose?

The purpose of clinical viva is two-fold:

1. To assess the knowledge, and 2. To assess the clinical abilities of the future psychiatrists.

So this examination is as much about performance as it is about knowledge. It tries to assess the knowledge which is more than knowing facts. i.e. the ability of the candidate to apply the knowledge to a particular patient and situation and to formulate the best applicable treatment plan.

Format of Clinical viva

In India, there is no uniform standard for the clinical viva in psychiatry. The 458 Psychiatry in India : Training & training centres type of competencies assessed, nature of cases given for assessment, time duration and areas covered can vary from one institute to another. However most of the institutes follow more or less similar format consisting of long case, short cases and ‘oral’ (grand viva).

As there is no written format available whatever is transcribed here comes from personal experience as an examiner in various universities across the country. Students may find minor variations in the format but the essence would remain the same.

How to prepare and present the long and short cases is discussed elsewhere. The focus here is on the procedure and what to expect in clinical viva. Let us start with the long case.

Long Case: Generally students are allotted long cases by a draw of chits/slips. Each student is given 40-45 minutes to work up the case. This involves eliciting the history, mental state examination, summary, diagnostic formulation, possible differential diagnoses and formulation of management plan. Do Not Forget To Do The Physical Examination. The student will be asked to present the case and will be perused by the examiners. Now what is expected of a student? What are the likely questions?

1. Ability to gather adequate information to reach a diagnosis and this includes the ability to rule out relevant negative history.

2. Assimilation of various bio-psychosocial factors in reference to etiology, prognosis and management.

3. Use of multi-axial classification for presenting the diagnosis. Always specify which system (ICD or DSM) you are using to make the diagnosis. Focus on all the axes; do not limit yourself only to Axes I and II. List out the points favoring your diagnosis and points against the diagnosis.

4. Weigh your provisional diagnosis against various alternative (differential) diagnoses.

5. Charting a management plan: The most common omission error is to forget about the investigations or to mention all the investigations one knows in rhetoric manner. So be very specific about which investigations would you ask for and why. Further while mentioning the treatment plan do not get lost. Very often students present a plan that lacks clarity and completeness. Focus not only on current problems but also think of future ones. Similarly do not limit yourself with somatic treatments but do include non-pharmacological Sethi: Clinical Viva 459 (psychosocial) modalities. A rough outline of a comprehensive treatment plan is given below.

Treatment Plan â â â ECT Pharmacological Non-pharmacological â â â â â â Acute Maintenance Prophylactic Psychological Social (Specify goals in each phase.)

A number of treatment guidelines and algorithms are available. Do not try to fit your patient into these algorithms. Rather try to individualize the treatment plan according to the needs of the patient. Be realistic.

Be prepared to be questioned about the choice of drugs in each phase, dosage schedules, their likely side effects, duration of treatment and alternative options. Similarly you should know what are the issues in psycho-social management and how to handle them.

6. Keep the likely outcome in mind. Do not be hypothetical; make your opinion based on various good and bad prognostic factors.

Short cases

Generally two short cases are given- one psychiatric and another neurological.

For short cases you would be given a specific ‘problem’ e.g. thought process. Be clear about what has been asked. The time allowed for short case varies from 10 to 20 minutes. Stay focused and do not panic. Always start with socio- demographic details of the patient before moving onto the ‘problem’ area. Follow the same format while presenting the case to the examiner. Substantiate your findings with test questions, answers given by the patient and your inference. While describing the thought and perceptual disorders, give speech samples before arriving at your inference.

Once the presentation is over, expect to be asked about the definition (e.g. hallucination), types (e.g. types of hallucinations), different possible causative mechanisms, differentials (e.g. pseudo-hallucinations, illusions) and their clinical relevance.

Same rules apply to other short case except that most examiners would like to observe you while you perform the neurological examination.

Keep your calm and follow the standard routine steps. Always first tell the examiners what you are going to demonstrate and then do the examination 460 Psychiatry in India : Training & training centres (e.g. “now I am going to test for power of biceps”) and finally give your inference (e.g. “the power of biceps is grade IV.”).

Keep the findings in mind as you proceed further, trying to assimilate and correlate to arrive at a final diagnosis as the moment you finish examining the patient the next question would be, “what do you think is the likely diagnosis?” or “what is the level of lesion?”.

Always base your inference on your own findings even if you know the diagnosis made by the neurologist (patient, his family or your own colleagues often try to help in their own ways). Findings elicited by you might not be sufficient to make a complete diagnosis, e.g. presence of increased muscle tone and brisk deep tendon reflexes may point towards upper motor neuron lesion but to know the level of lesion one needs to do further examination including cranial nerves.

Also follow a standard method of examination and do not device your own method. Many candidates fleet from one group of muscles to another in haphazard manner either because of anxiety or they do not know the method and sequence. Be sure and confident in your approach,

Once you have finished case presentations you are required to face the orals—the grand viva.

The scope and boundary of this part of examination is vast and unpredictable. This would include not only general psychiatry but also various sub- specialties, basic sciences including psychology and psychological testing; various investigative procedures such as reading CT scan, MRI and EEG recordings.

Generally the examiners divide the areas of questioning, number of questions to be asked and/or time spent with each candidate. So this part of examination is relatively structured.

l In most of the institutes, examiners have access to your theory examination sheets. So it would not be waste of your effort to revise your theory questions before coming to ‘orals’, especially the weakest part of your written examination.

l Prepare yourself to be asked about your favorite area. This can give you a chance to lead your viva.

l Be up to date with recent advances, relevant ‘hot topics’ in psychiatry and major psychiatric studies, especially Indian. Be aware of major contributions by Indian researchers and contributions made by your own institute. Sethi: Clinical Viva 461 Let us now focus on issues that enhance the performance in examination.

l As said earlier clinical viva assesses both knowledge and performance. Simply knowing the facts does not help in clinical examination. Preparing for the performance factor is equally important. How do we do that?

l Like everything else, practice is the most effective method but used rarely. Videotape yourself presenting a case or ask your colleagues and seniors to assess your performance in a mock situation and give you an honest feedback. This type of practice and skilled ability to perform a task is very essential for short cases where quickness also matters.

l Carry your own test material (e.g. knee hammer, ophthalmoscope, kit for cranial nerve testing) even if you have been told that all these would be provided for the examination. Most people get used to their own instruments and feel comfortable.

l Do not let your performance anxiety spoil your day. As the exam goes by quickly leaving little chance to recover and make it up on the rest of the examination. If you have problem with one part of the exam I recommend that try to forget about it and move on to the next part with a fresh start.

l Stay focused through the clinical viva. Be an intelligent listener as well as talker.

l If you do not understand the question, ask the examiner to repeat it for you.

l Do not ramble if you do not know the answer. State directly that you do not know.

l Maintain your self-confidence and composure. The examiner might be testing your patience.

l At the end, thank the examiners before leaving the room.

Happy studies.

Sujata Sethi 122/8, Shivaji Colony, Rohtak-124001, Haryana, India. [email protected]

48 Culture and its impact on diagnosis and management of mental disorders: The cultural formulation

K.S. Jacob, Anju Kuruvilla

International psychiatric concepts and criteria suggest that a universal approach to psychiatric diagnosis and treatment is accepted as standard. The widespread use of the Diagnostic and Statistical Manual (DSM) criteria [1] for clinical and research diagnosis supports the contention that variations in culture does not affect the recognition and management of mental and behavioural disorders. The International Classification of Diseases 10 [2] and its routine use in clinical practice across the globe also supports such a point of view. This article briefly discusses the role of culture in the diagnosis and management of mental disorder. It also suggests ways of integrating the local and cultural world of the patient with the international diagnostic and management systems of psychiatry.

Culture and mental disorders

It is universally accepted that cultural beliefs and practices affect nearly all aspects of mental disorders; assessment and diagnosis, illness behaviour and help seeking, expectations of patients and health professionals and the acceptance of appropriate therapies. Culture has its influence in the following ways- the conception of personal identity (group identity vs individual autonomy), mind body relationship (separate vs whole) are important issues. Many other differences which can influence the onset, course and outcome of mental disorders have been established between cultures - e.g. communication styles (e.g. language, gestures, rituals), eating behaviours, family roles (e.g. marital, gender and leadership roles) and in beliefs and rituals (e.g. child rearing practices). Thus, culture can be conceived as a complex construct of socially transmitted ideas, feelings and attitudes that shape behaviour, organise perceptions and label experiences.

Concepts of illness vary between cultures and different cultures express their symptoms differently.[3,4] The ways in which subjects of a particular culture 464 Psychiatry in India : Training & training centres 'express, experience and cope with feelings of distress' are called 'idioms of distress'. They may initiate particular types of interaction and are associated with cultural norms. For example, a common idiom of distress seen among Asian cultures is somatization. In these cultures, many difficulties are conceptualised as somatic and patients less commonly present to physicians with psychological problems. Culture also has an important role in defining norms and influences how particular behaviours are judged. What may be abnormal and psychopathological in Western culture may be considered culturally acceptable in a non-western society and vice versa. For example, brief episodes of trance and possession disorders occurring within a religious or culturally accepted situation are commonly regarded as normal in the Indian culture. Thus, an understanding of the patient's culture is important in assessing the clinical significance of specific symptoms and behaviours.

Over the past 2 decades there has been an increased impact of concepts from anthropology upon psychiatric thinking. These newer concepts have emphasised the need for individual contextualization of illness. Medical anthropologists draw a distinction between disease and illness, disease being the underlying biological reality and illness the result of the social construction of the disease.[5,6] Although these terms are used interchangeably in many medical settings, health care professionals should recognise the validity of the distinction. Abnormality in structure and function of organ/ systems are termed as disease. Illness on the other hand, describes the human experience of sickness. It represents the personal response, which is rooted in the subject's culture. Illness involves a series of intersecting or nested models of illness held by the patient, the family, the physician, other health care professionals, and the larger culture (e.g. as represented by law or religious authority).

Explanatory models of illness

Explanatory models (EMs), a term coined by Kleinman, denote the “notions about an episode of sickness and its treatment that are employed by all those engaged in the clinical process”.[3] Explanatory models can be subdivided into etic and emic. Emic models elicit patient perspectives by the way he conceptualises his sickness episode including beliefs and behaviours concerning aetiology, course, timing of symptoms, meaning of sickness, diagnosis, methods of treatment, roles and expectation of sick individuals.[3,7] Etic models are perspectives usually based outside the subject's culture.

EMs influence many aspects of the human behaviour like help seeking, treatment compliance, patient satisfaction and coping. EMs play an important role in patient-physician interaction and health related behaviour. Eliciting patient EMs can improve the physician's understanding of the Jacob & Anju Kuruvilla: Culture and diagnosis of mental disorders 465 patient and the illness.[3,4,7] Systematically eliciting patient and family EMs, comparing patient and physician EMs for conflict is important in management. It is recommended that EMs held by the physician should be discussed in non technical terms. Negotiating a shared treatment plan, if a patient's EM differs from the physician's management perspectives, is necessary. Understanding local perspectives is also crucial for establishing culturally sensitive health care for a community.

The EM is one approach medical anthropologists use to study systems of beliefs, embracing the significance of symptoms, their cause, mode of onset, likely course, severity and most appropriate form of treatment.[3,4,7] The EM provides a framework to examine how illness is conceptualised, the subject's response and from where help is sought. The approach is not without critics who argue that the EM approach assumes people have static mental templates that provide fixed strategies for action whereas in reality there is a dynamic process that can only be understood in a broader social context where most people's actions are shaped more by the practicalities of coping with everyday life than by what doctors tell them. Professional medical ideologies influence popular ideas about illness, either subtly from patient's interaction with medical professionals or overtly as a result of health education. In addition, subjects can simultaneously hold views which can often be contradictory. Explanatory Models are usually a conglomeration of emic and etic approaches involving ethnocultural, personal and idiosyncratic beliefs and components from both within and outside culture and not necessarily easy to classify as emic or etic. These criticisms are acknowledged by workers in the field who accept that such EMs are not fixed and immutable but tend to be idiosyncratic, changeable and heavily influenced by both personality and cultural factors.[8]

Many patients and relatives hold multiple causal explanatory models including medical, non-medical, supernatural and religious and black magic beliefs.[9,10] These beliefs are often contradictory and yet held simultaneously. Many patients and their relatives simultaneously seek bio-medical and non bio-medical interventions from traditional and faith healers and from institutions practicing modern medicine. This situation is not only in low and middle income countries but there is evidence to suggest that patients in the west also simultaneously hold multiple and possibly contradictory beliefs.[9,11] The immediate subculture seems to play a big role in determining explanatory models of illness. Western philosophy and logic suggests the holding of single causal explanations of illness and the seeking of corresponding treatment. The reality on the ground reflects otherwise. The flourishing alternative medicine industry and practice in the west supports such a contention. 466 Psychiatry in India : Training & training centres Impact of culture on diagnosis

Concepts of illness vary between social groups and different cultures express their symptoms differently.[3,4] What is regarded as abnormal in western culture may be considered culturally acceptable in non-western societies and vice versa. Cross-cultural variations in presentation of the many syndromes are documented. For example, patients with the Dhat syndrome present with a variety of “neurotic” symptoms.[12] These patients also offer “loss of semen” as the explanation for these disabling symptoms. Such patients are diagnosed as Dhat syndrome if the physician is aware of the label and the explanation and if he/she focuses on the content.[13] These patients could also receive a label of anxiety, depression, somatisation or neurasthenia if the physician emphasises the form of the presentation. The patient perspective of “loss of semen” as cause of the symptoms is the explanatory model of his illness.

The culture in South Asia tends to highlight sexual beliefs as cause for a variety of neurotic phenomenon. These explanations generate more acceptance and understanding for the patient than if he highlighted symptoms of anxiety, depression or somatic symptoms per se. Such beliefs are reinforced by traditional Indian systems of medicine which subscribe to these concepts and whose physicians and healers are often the first contact in the “pathway to care”. Sexual misconceptions related to Dhat are also seen in patients with schizophrenia, substance dependence, bipolar disorders, delusional disorders and major depression.

Ataque de Nervios is an idiom of distress reported among Latinos and recognised among Latin American and Latin Mediterranean groups.[14] Uncontrollable shouting, crying, trembling, bodily discomfort, aggression, dissociative experiences are symptoms and are precipitated by stressful life events. Amnesia for the attack and a return to normal functioning are common. Psychiatric labels for such presentations include generalised anxiety, panic, post-traumatic stress, major depression, dissociative disorders and sub-syndromal conditions.

Koro, a presentation seen in Asian cultures, is characterised by intense anxiety associated with a feeling that the person's genitalia (penis in men and the vulva and nipples in women) will recede into the body resulting in death.[14] Psychiatric diagnoses include schizophrenia, affective illness, major depression and anxiety disorders.[14,15]

The form-content dichotomy in diagnosis

The focus on form allows the psychiatrists to differentiate the different syndromes.[13,16,17] International classifications have emphasised form over content as the response to the various treatment modalities based on the Jacob & Anju Kuruvilla: Culture and diagnosis of mental disorders 467 recognition and treatment of the clinical syndrome. This does not imply reduced importance being placed on the person's culture and beliefs. It mandates the management of the patient's explanatory model. This is also true for other culture-bound syndromes like Brain fag, Amok, Possession syndrome, etc. [14] Similar forms can be recognised across cultures, while content is culture specific. Clinicians focusing on content make such presentations appear exotic. Physicians emphasising form are able to recognise behavioural syndromes across cultures.

Impact of culture on management

Collective knowledge, shared beliefs, values, language, institutions, symbols and images result in a shared worldview. These systems have a major impact on therapy. Their interactions are complex and therapy will necessarily have to be tailored to the individual and the context. Autonomy and value placed on health play an important role. The western world favours personal autonomy and hence individual rights. In many eastern cultures, people tend to value health over personal autonomy. The doctor/therapist-patient relationship is commonly viewed in the guru-disciple context [18] and often leads to a situation where the therapist can be and is directive.[17]

Many cultures view intimate conversations required for therapy as inappropriate among socially distant individuals. The socio-economic and political realities add to distance and to therapist power. Good therapists review patterns of sharing of information, language, colloquialisms and conversational style and are able to cross cultural barriers. The heterogeneity within cultures and regions mandates the need for an assessment of each individual and involves offering the choice of the more directive versus the more reflective options, packaged in the local culture for greater acceptability.[17]

Form-content division in therapy

The form-content division is also obvious in theory and practice of psychiatric interventions.[17] Diverse theoretical models have been employed to conceptualize psychiatric disorders.[18,19] However, the medical model has increased its hold on psychiatric thought over the past few decades. It views psychiatric disorders as diseases, supposes a brain pathology, documents signs and symptoms and recommends treatments.[19] The identification of possible neurotransmitter mechanisms and the response to specific pharmacological agents in patients with severe mental illness reinforced the belief that severe depression is a disease of the brain. The current international psychiatric diagnostic systems use a check list of symptoms to diagnose depressive disorders. They ignore context, stress, personality, 468 Psychiatry in India : Training & training centres coping and supports. The disease halo reserved for the more severe forms of depressions is also conferred on people with depressive symptoms secondary to stress and poor coping. The focus on form allows for diagnoses across diverse contexts and content.

Behaviour therapy with its focus on learning, classical and operant conditioning, behavioural analysis, identification of maladaptive behaviours, reinforcement schedules and exposure and response prevention highlights form and structure. The consequent structural analysis is applied across content, situations, regions and culture. Similarly, cognitive therapies with their spotlight on cognition identify faulty schemas, dysfunctional thought patterns, cognitive biases and distortions. They employ Socratic questioning, collaborative empiricism and guided discovery to change beliefs, thoughts, attitude and practice and are applied across contexts and cultures to diverse problems related to anxiety and depression and to different stressors and situations.[17]

Psychodynamic psychotherapies argue that intra-psychic and unconscious conflicts are causal while the resolution of such tensions and the use of mature defences are part of treatment. Psychoanalysis has its own structure and detail. Similarly, interpersonal psychotherapies, supportive psychotherapy, client centred approaches and crisis intervention have their different foci, form and structure and are used to manage diverse contents across contexts and cultures. This is also true for non-western psychological interventions like yoga and meditation, which are employed across diverse clinical problems and are popular across cultures. The different schools of psychotherapy have different theories and techniques and yet only provide structures for psychological interventions. These are useful in a management of a range of contents in dissimilar contexts, regions and cultures.[17]

Cultural critique of biomedicine

Anthropology has contributed to the understanding of mental illness by its critique of psychiatric science and clinical practice.[6] Unlike other branches of medicine where diagnosis is based on blood tests, biopsy or radiographs, psychiatric diagnosis is established using only symptoms and signs of mental illness. Such syndrome criteria are based on language and everyday social experience. Cultural bias can enter the process in many ways:[6]

(I) “Category fallacy”- diagnostic criteria developed in one society may lack validity when applied in another culture. The cultural measures of mental disorders and the validity of international diagnostic systems are the major issues facing psychiatry.[3,7,8] For example, normative experiences in normal people like trance and possession Jacob & Anju Kuruvilla: Culture and diagnosis of mental disorders 469 states commonly seen in non-western societies may be diagnosed as psychosis when such diagnostic criteria are applied to such people. Similarly, personality disorders are modelled on processes which are based on Euro-American, middle-class and male behavioural type and life style.

(ii) Institutional racism in psychiatric diagnosis, referral and treatment as highlighted by the over diagnosis of schizophrenia in African- Americans and African-Caribbean Britons. In addition, these people were perceived as more dangerous and less amenable to psychotherapy resulting in differences in which discharge and after care were organised.

(iii) Anthropological research argues that apart from well established brain disorders (e.g. brain tumours, infections, dementias, encephalopathies, substance dependence, sleep disorders) only six psychiatric syndromes affecting adults can be found cross-culturally (schizophrenia, brief reactive psychoses, bipolar disease, severe depression and anxiety disorders such as phobia, panic and obsessive compulsive disorders). Most of the other diagnoses described in DSM IV and ICD 10 are culture bound to Euro-America.

Anthropology has contributed to the development of culturally informed diagnostic criteria, questionnaires, structured interviews and guidelines for working with translators. Many anthropological concepts, methods and findings await systematic trial in psychiatry and include ethnography, ethnographic databases, cross-cultural comparisons and social theory.

Anthropology has emphasised the interpersonal basis of illness experience and has argued that individuals live in local worlds- families, neighbourhoods, networks, and villages. These local worlds are differentiated by class, ethnicity, gender, age cohort, political factions, and religious affiliation. The person's illness experience is also a product of their social worlds which provide meaning and understanding of the illness and also suggest treatment options and influence illness trajectories.

Ethnography has also underscored the fact that psychosomatic processes are also socio-somatic. The local context and world has a major impact on many psychiatric presentations. Similarly, poverty, an example of a sociosomatic process, correlates well with psychiatric morbidity. Depression, anxiety, substance use, violence, trauma and stress in the local contexts produce much greater amounts of morbidity when compared to stable and cohesive worlds. [6]

Anthropology has argued that all knowledge is positioned and that norms 470 Psychiatry in India : Training & training centres (factual, statistical) and values (absolute values, normativity) are difficult to separate. They have emphasized that the illness experience is too complex to be easily boxed into watertight analytical categories and highlight the consequent fallibility in understanding and the limitations within clinical practice.

Cultural pluralism and sensitivity

Cultural competency in psychiatry has become an explicit goal. Cultural pluralism, a worldwide reality, demands cultural competence and mandates a cultural formulation, which examines the identity of the individual, societal explanations of the illness, the psychosocial environment and the differences in backgrounds of the patient and the clinician.[1] Therapists need to be aware and enquire about the patient's self-perceptions and attributions regarding ethnicity, race, social class and religion. While there is evidence that ethnicity per se does not impact on psychotherapy referral and compliance and that culturally sensitive psychotherapy has refuted many cultural stereotypes, [20] there is a need to integrate knowledge of the unique cultural and religious values and beliefs during assessments and planning of therapy. This is not only true for education related to psychotherapy but also for all doctor/therapist-patient interactions where the biomedical model of illness is to be transferred.[17]

Matching and integrating therapies

Anthropological constructs aim to reduce the explanatory gap between patients and their physicians/therapists by improving clinical relationships.[3,6] This can be achieved by:

(i) Elicitation of the patient and family explanatory models of the illness experience and treatment. This is accomplished by asking the following questions: What do you call your problem? What do you think caused it? Why did it start when it did? What course will it take from here on? How does it work in your body? What do you fear most about your illness? What kind of treatment do you desire for this illness? What do you most fear about the treatment?

(ii) Presentation of the clinician's explanatory model of the disease process.

(iii) Negotiation of a mutually acceptable understanding of the clinical problem across patient, family and physician models.

The diversity of beliefs within cultures, regions and populations demand the need to understand the individual patient's perspective and the need to Jacob & Anju Kuruvilla: Culture and diagnosis of mental disorders 471 explore different dimensions of patient experience and is part of all psychotherapy and doctor-patient interaction. Therapists will have to enquire about common explanatory models prevalent in the community and elicit the patient's causal and treatment beliefs. The common factors related to the relationship, expectancy, reorganization, and impact factors are part of most psychological interventions will necessarily have to be employed. The integration of the apparent contradictions between the patient's explanatory model with the school of psychotherapy and to negotiate a treatment plan is cardinal for success. Therapists will have to put forward the specific psychotherapeutic model and structures without dismissing or directly challenging patient’s beliefs. The presentation of the psychotherapeutic framework, the education related to the form and structure of the therapy and negotiating of a shared model is mandatory for proceeding with therapy and for success.

Locally acceptable and available models and therapies are preferred as they are more easily applicable than new frameworks. However, the structures of the standard frameworks can be easily be introduced, elaborated, discussed and employed in diverse settings to treat varied problems, situations and conflicts. These will necessarily have to be introduced in the context of a strong psychotherapeutic relationship and the specific framework gradually explored with explicit permission from the patient to discuss issues from a different perspective.

The form and structure of the psychotherapy can thus be employed across cultures and are content independent processes. However, most therapists match therapies to the patient, their socio-economic and educational background and culture in addition to matching broad psychiatric diagnostic categories (i.e. organic, psychosis, substance use, neurosis and stress related conditions), the personality of the patient and the urgency of the situation (e.g. suicidal risk, harm to others).

Matching of therapist and patient characteristics (e.g. ethnicity) has been suggested to better understand patient reality. However, the heterogeneity with cultural groups and the many differences in social class, educational status, language and dialects suggests that strict matching is not practically possible and that therapists should be aware of the local cultural organization, worldviews and values, etic-emic differences, linguistic concepts and idioms of distress. Psychotherapy is a specialized form of communication where a therapist adopts specific roles such as teacher, redemptive listener, a guide through the healing process, motivational speaker, and persuader and engages in different types of interactions.[21] These complex tasks mandate cultural understanding and sensitivity. While both psychotherapy standards and culture are not value free, all psychotherapy involves a negotiation 472 Psychiatry in India : Training & training centres between therapist and the patient, where they attempt to understand each other's points of view. The structure and form of the approach allows the therapist and the patient to analyze the content and context, consider, and implement solutions.[17]

Cultural sensitivity

Cultural competency in psychotherapy has become an explicit goal. Cultural pluralism, a worldwide reality, demands cultural competence and mandates a cultural formulation which examines the identity of the individual, societal explanations of the illness, the psychosocial environment and the differences in backgrounds of the patient and the clinician.[1] Therapists need to be aware and enquire about the patient's self perceptions and attributions regarding ethnicity, race, social class and religion.

Exploring diversity

These arguments recognise diversity across cultures and suggest the need to adapt psychotherapeutic models to match patients with their contexts. Effective therapists are able to employ and adapt their psychotherapeutic models to provide structure while exploring the patient's issues, stress, personality, coping, context and culture. Psychotherapies are at their weakest when they attempt to provide explanations across cultures and are at their strongest when they are used as vehicles for engagement with patients. The challenge is to find a common psychotherapeutic language, which attempts to bridge the divide between the issues facing the patient and the armamentarium of the therapist. These different belief systems at the onset of the therapy evolve to common insights between patients and their therapists with the progress of therapy. The form-content paradigm at least partly explains the complexity of the issues within psychotherapy. It also allows the therapist to move from the therapy-centric orientation of western approaches to patient-centric orientations required for success in psychological therapies.

The cultural formulation

The DSM IV[1] provided, in its Appendix I, an outline of how psychiatric cases can be culturally formulated. It suggested the need to supplement its multiaxial diagnostic assessment to address difficulties encountered while applying its criteria in a multi-cultural environment. It suggested the use of the cultural formulation to systematically assess the individual's cultural and social reference groups. It included the following heads in assessment:

(i) Cultural identity of the individual, Jacob & Anju Kuruvilla: Culture and diagnosis of mental disorders 473 (ii) Cultural explanations of the individual's illness,

(iii) Cultural factors related to psychosocial environment and levels of functioning,

(iv) Cultural elements of the relationship between the individual and the clinician, and

(v) Overall cultural assessment for diagnosis and care.

These have been recently updated [6,22] and include:

Step 1: The ethnic identity - The ethnic identity is important to the individual. Acknowledging and affirming a person's experience of ethnicity and illness is crucial and enables a respectful inquiry into the person's identity. The recognition that people live their ethnicity differently and, that it bears significance in the health-care setting is useful. It allows the clinician to understand how the patient sees him/herself and their place within family, work, and social networks. Such a strategy prevents assuming knowledge of the patient, which can lead to stereotyping. Simply asking the patient about ethnicity and its salience is the best way to start the process of viewing the patient's local world.

Step 2: What is at stake? The second step is to evaluate what is at stake as patients and their families face an episode of illness. This evaluation should include close relationships, material resources, religious commitments, and different aspects of life. This step will allow the clinician to see the patient's local world and context.

Step 3: The illness narrative. It is important to construct the patient's “illness narrative”. This involves a series of questions the patient's explanatory model and allows for an understanding of the meaning and context of illness. This step can be used to discuss differences in the local worlds of the patient and the clinician and to recognize stereotypes.

Step 4: Psychosocial stressors: It is crucial to examine and identify the ongoing stressors and social supports that characterize people's lives. Family tensions, work problems, financial difficulties, personal anxiety, adverse life events, etc should be examined and their role in predisposing, precipitating and perpetuating the illness recognized. Similarly, the personal resources, family and social supports available should be identified.

Step 5: Influence of culture on clinical relationships: The next step is to examine culture in terms of its influence on clinical relationships. The 474 Psychiatry in India : Training & training centres recognition of cultural stereotypes is crucial in providing culturally sensitive care to immigrants, refugees, and ethnic-minority populations. The many differences between the local worlds of patients and clinicians need to be acknowledged to better understand the contrasting worlds. Issues related to therapist power and social distance need comprehension as do personal autonomy, and the influence and role of families and society.

Step 6: The problems of a cultural competency approach: Finally, step 6 is to take into account the question of efficacy of interventions. “Does this intervention actually work in particular cases?” “What are its potential side- effects?”. Every intervention, including culturalist approaches, has potential unwanted effects. These include the following:

(i) The most serious side-effect of cultural competency is that attention to cultural difference can be interpreted by patients and families as intrusive. It can even contribute to a sense of being singled out and stigmatized.

(ii) A common danger is the overemphasis on cultural difference and the need to identify the cultural roots of the problem for resolution. This may not be necessary for resolution or can also result in further complication of the issues.

Such an approach makes the psychiatric care culturally informed and culturally sensitive. It allows for genuine respect for the patients, their families and background and for their cultures and practices.

Conclusion

The diversity of patients, problems, beliefs and cultures mandates the need to educate, match, negotiate and integrate psychological interventions in all cultures and every setting. Psychiatric interventions based on medical models and many schools of psychotherapy offer specific theory and particular techniques and yet share many common approaches. Their individual techniques allow therapists form and structure to treat different clinical problems, discuss diverse content, and use it in varied settings and among people with assorted cultural backgrounds. The heterogeneity within cultures, regions and populations demands that therapists understand the local and individual reality. The apparent contradictions between standard psychological therapies and their use in cross cultures, when viewed through a form-content framework allows for matching strategies for specific individuals and their distress and for choosing the best treatment options from a diverse therapeutic armamentarium. Jacob & Anju Kuruvilla: Culture and diagnosis of mental disorders 475 References

1. American Psychiatric Association. Diagnostic and Statistical Manual IVth edition.. Washington, DC: APA.1994. 2. World Health Organisation. International Classification of Diseases 10: Clinical descriptions and diagnostic guidelines. Geneva: WHO. 1992. 3. Kleinman A. Patients and healers in the context of culture. Berkeley: University of California Press.1980. 4. Kleinman A. Anthropology and psychiatry: the role of culture in cross-cultural research on illness. Br J Psychiatry, 1987: 151: 447-454. 5. Konner M. Anthropology and Psychiatry. In Comprehensive Textbook of Psychiatry 6th edition (eds H.I. Kaplan & B.J. Saddock) volume 1, p337-356. Williams & Wilkins, Baltimore. 1995. 6. Kleinman A. Social and cultural anthropology: salience for psychiatry. In New Oxford Textbook of Psychiatry 2nd edition, (Eds MG Gelder, NC Andreasen, JJ Lopez-Ibor, JR Geddes) Oxford University Press: Oxford. 2009. pp 275-279. 7. Littlewood R. From categories to contexts: A decade of the 'new cross-cultural psychiatry'. Br J Psychiatry 1990; 156: 308-327. 8. Weiss M. Explanatory model interview catalogue (EMIC): Framework for comparative study of illness. Transcultural Psychiatry, 1997; 34: 235-263. 9. Lloyd KR, Jacob KS, Patel V, St Louis L, Bhugra D, Mann AH. The development and use of the Short Explanatory Model Interview (SEMI) and its use among primary care attenders with common mental disorders: A preliminary report. Psychol Med, 1998; 28: 1231–1237. 10. Saravanan B, David A, Bhugra D, Prince M, Jacob KS. Insight in people with psychosis: the influence of culture. Int Rev Psychiatry, 2005; 17:83-87. 11. McCabe R, Priebe S. Explanatory models of illness in schizophrenia: Comparison of four ethnic groups. Br J Psychiatry, 2004; 185: 25–30. 12. Sumathipala A, Siribanddana SH, Bhugra D.Culture-bound syndromes: the story of dhat syndrome. Br J Psychiatry, 2004; 184: 200-209. 13. Rajesh G, Jacob KS. The form-content dichotomy in psychopathology. Br J Psychiatry 2004; 185: 520-521. 14. Lewis-Fernandez R, Guarnaccia PJ, Ruiz P. Culture-Bound Syndromes. In: Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 9th edition (Eds B.J. Sadock, V.A. Sadock, P.Ruiz) Lippincott Williams & Wilkins, Philadelphia. 2009. pp 2519-2538. 15. Devon GS, Hong OS. Koro and schizophrenia in Singapore. Br J Psychiatry, 1987; 150: 106-107. 16. Sims A. Symptoms in the mind: an introduction to descriptive psychopathology. pp.12. London: Bailliere Tindall. 1988. 17. Jacob KS, Kuruvilla A. Psychotherapy across cultures: The form-content dichotomy. Clin Psychol Psychotherapy 2011 (in press). 18. Kleinman A. Culture and depression. N Engl J Med, 2004;351: 951–952. 19. Jacob KS. The cultures of depression. Natl Med J India 2006; 19: 218-220. 20. Foulks EF. Cultural issues. In Encyclopaedia of Psychotherapy. Eds Hersen M, Sledge W. Amsterdam: Academic Press. Vol I, 2002. pp 603-614. 21. Walker WR. Language in psychotherapy. In Encyclopaedia of Psychotherapy. Eds Hersen M, Sledge W. Amsterdam: Academic Press. Vol II. 2002. pp83-90. 22. Kleinman A, Benson P. Anthropology in the clinic: The problem of cultural competency and how to fix it. PLoS Medicine, 2006; 3: e294. www.plosmedicine.org 476 Psychiatry in India : Training & training centres K.S. Jacob Department of Psychiatry, Christian Medical College, Vellore 632002 India. [email protected]

Anju Kuruvilla Professor of Psychiatry, Christian Medical College, Vellore 632002 India 49 Role of Continuing Medical Education (CME) Programs in Psychiatric Training

Rajesh Nagpal

A population of over a billion, over 4000 professionals in psychiatry, lack of a focused mental health policy, skewed rural/urban distribution of mental health delivery, non-uniformity in psychiatric training, and the continuing information explosion along supersonic internet highways makes the contemporary uninformed psychiatrist a dinosaur.[1]

Issues in Psychiatric training

Undergraduate medical education mandates two weeks program of clinical postings excluding theory lectures. Several representations by the professional societies have fallen on deaf ears. The staffs teaching the undergraduates are relatively juniors and not fully trained in teaching methodology, curriculum planning and use of teaching aids.[2]

Postgraduate training, especially in areas of de-addiction, child psychiatry, geriatric psychiatry and basic neurosciences, suffers because of the paucity of trainers. However, one of the glaring deficits is the lack of uniformity in the training offered by various institutions, with training in some institutions comparable to the best in the world and training in others being poor [3]. Postgraduate training leading to Diplomate of National Board (D.N.B.), M.D. and Diploma courses (D.P.M.) differs in content, structure and assessment procedures. Further, there is a paucity of supervisors/ consultants with formal training and expertise in various forms of psychotherapy [4].

Senior residency is not mandatory except if one desires to pursue teaching or employment. In the majority of centers, senior residents undertake the bulk of the very large case load, leaving little scope for training. Postgraduate degree credit hours are in the process of becoming mandatory. A comprehensive regulatory apparatus is currently being examined by the policy makers. 478 Psychiatry in India : Training & training centres 70% of the clinical case load is managed in the private sector. The clinician in private practice is usually overloaded with clinical work. It is not uncommon for individual practitioners, to cater to more than one hundred clients, daily! Since the mandatory clause is yet to kick in, the majority of the postgraduate degree training is provided by the professional societies, sponsored drug launches and pharmaceutical sponsored continuing medical education programs in the country and abroad. Usually pharmaceutical industry stays away from non-drug psychiatric training.

The other area of equal concern is the training of the trainers. With little regulation in place, the teachers in a significant number of institutions rely on the same avenues for training as those available for the private sector. Further, premier institutes offering post graduate training comparable to international standards continue to suffer brain drain.

Continuing Medical Education (CME): Can it fill the Gap?

The field of CME is unregulated with a distinct absence of a level playing field. The bulk of the sponsorship is directly by the pharmaceutical industry leading to obvious ethical concerns. The professional societies also provide CMEs with indirect but complete funding support from the pharmaceutical industry. The other new interface is the introduction of dedicated CME companies which serve as the interface between the sponsors and the clients (read clinicians). Another initiative in the recent past is the advent of foreign professional societies and CME institutions conducting mega launches. In 2010, on at least two occasions, offshore CME companies retained ten times the usual attendance of professional society's annual conference for eight hours!

Educational junkets to tourist destinations have led to new restrictions by the regulatory body and endless criticism by the media. Further, direct pharmaceutical sponsorship ensures that drugs remain the content provider of CMEs. Recently, in at least three distinct exceptions, pharmaceutical industry has chosen to sponsor CME content of law, psychotherapy and child psychiatry.

In terms of providing psychiatric care, there is a need for a more coherent and involved policy from the government and national bodies (i.e. The Indian Psychiatric Society) alike .[1]

It is imperative that professional societies examine the design of CMEs, targeting undergraduate, post graduate and post degree training. Further, the sponsorship model necessitates introspection. Professional societies abroad are changing their sponsorship model because of pressure by law makers. A recent and further shake out by the pharmaceutical industry in Rajesh: Role of CME in Psychiatric Training 479 India would lead to tightening of purse strings.

The content of CMEs also needs drastic revision. To cater to different audiences with differing felt needs, out of the box thinking is the need of the hour. Newer areas like rTMS (Repeated Transcranial Magnetic Stimulation) , DBS (Deep Brain Stimulation) and Neuro-radiology need to be addressed. Phenomenology and art of clinical examination needs wider exposure.

Conclusion: CMEs are a time tested, durable option at all stages of psychiatric training. The need of the hour is formal association of professional bodies and setting up of regulatory standards by policy makers.

REFERENCES

1. MRIGENDRA DAS, NITIN GUPTA & KAVITA DUTTA. (2002) Psychiatric Training in India. Psychiatric Bulletin (2002) 26: 70-72. 2. ALEXANDER, P. J. & KUMARASWAMY, N. (1995) Impact of medical school experiences on senior medical students interested in psychiatry. Indian Journal of Psychiatry, 37, 31-34. 3. KURUVILLA, K. (1996) A common minimum programme needed in postgraduate training in psychiatry. Indian Journal of Psychiatry, 38, 118-119. 4. SHARAN, P. (2000) "Do what you must...?" Indian Journal of Social Psychiatry, 16, 10-15.

Rajesh Nagpal Director, Behavioral and Neuroscience Academy of India (BANAI) New Delhi [email protected]

50 The role of mentoring for trainees

T.S. Sathyanarayana Rao

ABSTRACT

Mentoring is a common word used widely worldwide, particularly in management. However, it is a not so common word used in our medical training, in general and in psychiatric training, in particular. The present article looks at the concept, different perspectives concerning mentor & mentee, the future development and meanings, all in the context of our culture and trainees.

Keywords: Mentoring, training in psychiatry, mentee, mentor.

Introduction:

The word 'mentor' has it origin in Greeks1. It is one of the words closely woven with the mythology of the Trojan War when Odysseus, King of Ishaka leaves behind his young son Telemachus under the care of his childhood friend Mentor. 'Mentor brings up Telemachus teaching him the art of statecraft, guile to survive internecine intrigues and techniques to enforce his will over Kingdom'. (Iliad, by Homer). There are many more legends abound of saving Mother Pinelope from the usurpers which added to the legend of Mentor. Ultimately the story is about young and unsure lad growing up to fine youth emphasizes the importance of such a guide in the life of any person. There are many example, quoted in the west as Socrates and Plato, Plato and Aristotle, Haydn and Beethoven, Freud & Jung etc. Coming to India the concept of “Guru & Chela” is as old as our civilization2,3,4. Kings and Chieftains infact encouraged their lads to be brought up by rishis and sages. Other notable examples are Arjuna's relationship with Krishna and the crucial message is immortalized in the Bhagavad Gita (Gautham / Venkoba Rao etc). Other examples are Parashurama and Karna and Shakuni and Duryodhana. They are less commonly discussed as they were on the losing side. Nevertheless they bring out very strongly the varied issues involved. 482 Psychiatry in India : Training & training centres MENTOR'S ROLE

Some of the common names given to mentor are friend, guru, counselor, master, philosopher, teacher, role model, coach, specialist, consultant, Godfather etc. Most common euphemism may be 'friend – philosopher – guide! Friend for the trust, able to reach for a wider horizon and as a guide, able to show the direction and the best way to reach it. All the other terms convey one or the other part of mentoring issue.

It is said that all have 3 major aspects in their lives: the personal, the social and the professional. There is someone sometime who has helped us wade through these mazes. The role of parents in personal life, guardian in an individual's social life and the mentor in professional life are well known. They may be distinct but overlap each other and this may be the cause of quite a few problems in mentorship.

Some of the well recognized roles of the mentor are emphasized by different authors: - Stephen gibbs states that a mentor is an accomplished and experienced performer who takes a special personal interest in helping to guide and to develop a junior or more inexperienced person and is done without taking the fees. - Arizona National Guard emphasizes that a mentor facilitates personal and professional growth in an individual by sharing the knowledge and the insights that have been learned through the years. The desire to share their 'life experiences' is the characteristic of a successful mentor. - Daxid cutterbuck states that a mentor is a more experienced individual willing to share knowledge with someone less experienced in a relationship of mutual trust.

Mentoring process

May begin with a simple contact which may act as a trigger and progresses through various stages of exploration, working arrangement, identification of goals and objectives, methods to reach the goals like strategies, monitoring and review and ultimately termination. Sunil Unny Guptan elaborates that it necessarily covers

1. Values as fundamental issues. 2. Attitudes which are positive and required 3. Personal using – what-is-in-for-me (WIIFM) which guides the relationship. Rao: Mentoring: During Training 483 The positive WIIFMs recognized are learning, helping, sharing, feeling energetic, belonging, teaching, giving back to society, helping the underprivileged, way of life etc.

The not - so - positive WIIFMs are power, control, information, sponsoring, reliving youth and appreciation and a few which are both are networking, recognition and relationship.

4. Maturity and Wisdom 5. Cultural issues

INDIAN CULTURE & MENTORING ISSUES 1. Paternalism It possibly has its basis in joint family system where the head has to shoulder responsibilities and guide others.

2. Patronage is a very commonly encountered behavior 3. Familial identity which creeps in all encounters and relationships.

MENTORING COMPETENCIES & SKILLS

It is necessarily for the mentor & mentee to get together, hence the 'chemistry' between them. It can also be expressed as 'perfect fit' which explains being acceptable and positive.

The success of this fit can be assessed on various parameters and they are listed by Guptan as follows:

1. Investment in learning & development 2. Success orientation 3. Altruism 4. Heightened self awareness 5. Technical expertise in the chosen field. 6. Focused approach and goal clarity 7. Communication skills 8. Empathy and sensitivity 9. Relationship skills 10. Conceptualization skills

There are whole gamut of ethical issues involved in the mentoring process which are again summarized by Guptan1. 484 Psychiatry in India : Training & training centres l The mentee's developmental needs and growth are the primary focus of the mentoring process, and the mentor's role is to address these. l The relationship between the mentor and the mentee is mutual and all decisions and actions will be taken by mutual consent. l The mentor and the mentee must work within the agreed terms of confidentiality and within the context of the relationship. l Any decision to involve or refer to an external person must be taken following a discussion and mutual consent. l The mentor and the mentee must strive to be open and truthful with each other not only in the context of the relationship but also in the relationship itself. l No exploitative expectations should be overtly or implicitly carried into the relationship, either by the mentor or the mentee. l The mentor and the mentee must strive to guard the relationship and its context against misinterpretation from within and outside. l The mentor must not intrude into the areas that the mentee does not wish to share in the relationship. The mentee must respect this reciprocally too. l The mentor must recognize and respect the individuality of the mentee and must encourage the autonomy of the mentee. l The mentor must recognize the limits of her / his own competency and capacity and operate within them. l The mentor must accept the responsibility and work on developing her / his own competencies and capabilities in the practice of mentoring. l The mentor and the mentee must respect each other's time, other commitments and responsibilities to other relationships. They must be careful not to impose on each other unduly. l The mentee must work towards accepting increasing responsibility in managing and working with the relationship as the process progresses. l The mentor and the mentee have a mutual responsibility to discuss any move towards the dissolution of the relationship and the mentoring association with each other. l The mentor and the mentee share equal responsibility in the smooth and graceful denouement of the process when the set purpose has been achieved. Rao: Mentoring: During Training 485 l The mentor and mentee have an equal responsibility in avoiding the creation of dependencies. l The mentee should be aware of her / his rights and the mentor must help the mentee understand them. l The mentor must work within the realms of any rule or law that may be in force.

Future of Mentoring:

Mentoring process is evolving and bound to grow as more and more organizations realize the importance. Though there are some downsides to mentoring, the advantages for mentor, mentee and organization are profound and they outweigh the former. The organization sponsored mentoring have additional benefits as it brings organizational initiatives. The choice of Internal Vs External mentors have been debated. The implementation of mentoring scheme involves designing, defining expectations, parameters and goals, establishing implementation team, seeking management support so also wider public support, training mentors and mentees and subsequent support and back-up. It is also necessary to have in place mechanisms for monitoring and evaluation.

REFERENCES

1. Sunil Unny Guptan, Mentoring A practitioner's guide to touching lives, response books, A division of sage publication, New Delhi; 2006 2. Gautam S, Jain N. Indian culture and psychiatry. Indian J Psychiatry 2010; 52:309-13 3. Murthy SR. From local to global - Contributions of Indian psychiatry to international psychiatry. Indian J Psychiatry 2010;52:30-7 4. Manickam L. Psychotherapy in India. Indian J Psychiatry 2010;52:366-70

T.S. Sathyanarayana Rao Prof. & Formerly Head, Department of Psychiatry, JSS University, JSS Medical College Hospital M.G. Road, Mysuru - 570004. [email protected],

51 Psychiatry Unbound

Raghuram

Bridging The Gap Between The Personal & Professional In Residency Training “If you have a gift for critical, conceptual learning, then you are certainly likely to be suited to psychiatry, as you will be able to deal with and explore abstract conceptions and notions” Femi Oyebode 2008 Psychiatry is not a popular career choice among medical students world over. Yet, for a person who makes an informed decision to pursue this path, it can be a very rewarding experience, both personally and professionally. The crucial question however is whether current training programs pay sufficient attention to preparing trainees in both these important domains A casual perusal of training programs across the country is quite revealing in many respects. The most glaring omission in many programs is the absence of a well defined curriculum. A clearly delineated curriculum with explicitly stated objectives, expected outcomes and methods of evaluation is an essential requirement of any training program. Without this, the content of training programs is influenced more by the personal predilections of the teachers and the need of the students to learn only those aspects that ensure success in examinations. Hence not surprisingly, training programs across the country are uneven in content and practice. With the salience of biomedical frameworks in psychiatry which ensure pragmatic clinical operations, biological underpinnings of mental health and distress have acquired an overarching influence in training programs. Such an orientation is not too demanding for trainees with a medical background who then very easily slip into prescription based clinician role. With the alluring presence of pharma companies, it is a role that is difficult to shun for many. In the process of prescribing pills for personal problems, the trainees receive inadequate exposure and and even less encouragement to understand and explore the interweaving influences of psychosocial factors in mental health issues. Even if a trainee is interested in exploring these determinants, there is paucity of teaching inputs in these domains during the postgraduate training 488 Psychiatry in India : Training & training centres period. The Medical Council of India has taken a very short sighted view in this regard as it has not made the availability of clinical psychologists and psychiatric social workers as part of the teaching faculty a mandatory requirement in a postgraduate department of psychiatry. Absence of faculties from these disciplines ensures a truncated perspective and approach to psychiatric disorders. With few exceptions, majority of postgraduate training centers in India, do not offer any supervised training in psychotherapy. The scene is even more dismal with regard to inputs in family therapy, behavior therapy etc. The training programs also emphasize quantitative data based learning. Qualitative approaches have made steady inroads into the mental health arena in the past decade. Unraveling an illness experience through the narrative approach widens the clinical gaze of the trainee and sensitizes him to the cascading influences of cultural factors in relation to mental illness. As a consequence, psychiatric training programs in India seem context free in many respects. Trainees' ability to conceptualize and empathize with a patient's problem is grossly limited when the training fails to incorporate the socio-cultural matrix of a problem Likewise when the training inputs are not in tune with the socio-cultural contexts, it prepares the student poorly to face the practice situation, once he completes his formal training. There is a yawning gap between academic psychiatry and psychiatry as it is practiced in real world settings. This has spurned the emergence of professional bodies like the Indian Association of Practicing Psychiatrists which aspire to address the needs of the practicing professional. The lack of a closer liaison between practitioners and academicians ensures that the trainee is caught in the cleft of an indeterminate orientation to psychiatric practice. There is minimal information on training psychiatric residents in practice management. The Canadian Psychiatric Association published an article on “Navigating the Transition to Practice”; however, this focused mainly on the emotional loss of leaving one's training program rather than the skills needed to do well outside of a training program. The true test of all that the trainee learns during his academic exposure is when he starts applying these constructs in practice settings which are markedly different from the one where the training occurred. The issue is parallel to driving on Indian roads:whatever one has learnt in the driving school facilitates his obtaining a license, which nevertheless has to be unlearnt, modified and flexibly employed while actually driving on the roads! This is a singularly striking lacuna in psychiatric residency training programs in the country which also draws attention to the evaluation process in residency training. We in India still cling onto an archaic model of examining students' proficiency through 'long' and 'short' cases. Such approaches focus on circumscribed assessment under single point-in-time exam conditions. Raghuram: Psychiatry Unbound 489 Thus what is actually measured is only a potential for performance under conditions of enhanced anxiety! More alarmingly, a resident's scientific knowledge, which is tested in examinations, often does not provide specific information about how he will actually deal with a patient in a real life situation. Moreover, some residents may score well on one-time exams yet not be effective in clinical situations. An alternative, the Observed Structured Clinical Examination (OSCE), ensures focused evaluation of particular skills like interviewing, eliciting symptoms, diagnostic formulation etc. Perhaps a better alternative would be the Critical Incident Method, which focuses attention on resident's performance with a particular patient in a specific situation and setting. For example, how would he respond to a well informed schizophrenic patient who is refusing medication and is threatening self harm. Mere diagnostic skills or theoretical knowledge is inadequate in responding to such situations. If assessment methods incorporate everyday practice situations, in addition to examining theoretical knowledge, they will contribute significantly to minimize the gulf between the academia and the world outside. The real challenge to the professional emerges only after he finishes his formal training. Continuing inputs are crucial to keep the knowledge base alive. This to an extent is addressed by the Continuing Medical Education programs of the Indian Psychiatric Society. However mere information accrual is insufficient. As the professional evolves over time, he has to hone his skills not just in relation to the clinical arena, but also in the realm of handling personal, emotional issues which may impact the quality of his care. The need is for a Continuing Professional Development which in addition to updating the knowledge base attempts to enhance personal qualities and skills required for optimal professional functioning. The 'competencies' acquired during formal training need to become 'capabilities' in actual clinical practice. Reflecting on experiences at work is of central importance for a meaningful evolution of the professional. But learning can be hard work, especially in the absence of supervision and this void is filled by the Continuing Professional Development programs. Finally, it strikes me that given the importance of training related issues,our professional bodies do not offer a forum for the trainees! While there is a postgraduate education committee, the lack of representation of the trainees in such forums continues to widen the gap between the personal and the professional!

R. Raghuram Professor & Head Department of Psychiatry, KIMS Bangalore [email protected]

52 Management of Uncooperative Patient

H. Chandrashekar, N.R. Prashanth

INTRODUCTION

In India, mental morbidity is set to overtake that of cardiovascular diseases by 2010. There are over two crore people with serious mental disorders and about five crore people with common mental disorders. About 30 to 35 lakh need hospitalization at any time. But, a huge treatment gap exists, with around 50 to 90% of the people not being able to access the required services.

With the current advances the focus of care has shifted towards community participation and short duration of hospitalization have become a norm. This has led to a revolving door policy where in patients get admitted at the time of crisis and discharged soon after the crisis gets resolved.2

Many consultations with psychiatrists will be in the context of uncooperative behavior of the patient. Uncooperativeness can be defined as patient not responding to the attempts of his caretakers towards care of his health .

Aggression, agitation, confusion, violence, suicidality, non-adherence and exacerbation of psychotic symptoms are distinct challenges in psychiatry during which interventions are most required. Many a times, patients refuse care due to lack of insight. Family members by themselves find it impossible to convince patients to come to the hospital. Lack of knowledge among general practitioners compounds the whole problem. The consequences of such events may be dangerous and disastrous to both parties2.

Routine care generally involves a cooperative patient and adequate time to perform an assessment and to reach agreement with patient on a course that maximizes benefits and minimizes risks. By contrast, in situations where he is not cooperative it is an emergency; the diagnosis is often unknown or provisional at best; there is a sense of urgency, limited time for decision making, and a need both to intervene immediately despite limited data and to change course rapidly as new information becomes available, including responses to prior interventions. Any course of action or inaction may have 492 Psychiatry in India : Training & training centres serious adverse effects. Even an objectively good response may leave the patient feeling traumatized and angered by the process.3

Causes of uncooperative behavior

The causes of such uncooperative behavior can be multiple 1. Disease related factors- Delusions, hallucinations, abnormalities of affect, impaired attention and concentration, thought disorders, negative symptoms like apathy, avolition may be the primary causes of uncooperative behavior. 2. Individual factors- Personality traits like anti-social personality, schizoid personality, paranoid personality also might contribute. 3. Family and social factors- Stigma of mental illness, discrimination, criticism, ridicule from family and society may contribute. In an attempt to protect one’s self esteem, patient may refuse to cooperate with family.4 4. Situational factors- events in the immediate surroundings, arguments, unmet demands of the patient may induce uncooperative behaviour.

Diagnosis associated with uncooperative behavior.

Wide range of psychiatric illness may render the psychiatric patient uncooperative with others.

Psychiatric diagnosis associated with uncooperative behavior

Diagnosis Possible cause for uncooperative behavior Delirium Altered consciousness, disorientation, poor attention and concentration, agitation Dementia Cognitive deficits like aphasia, agnosia and apraxia Substance abuse Intoxication, craving, withdrawal syndromes, undiagnosed psychiatric and medical co- morbidities Schizophrenia Positive and negative symptoms Mood disorders Abnormal affect, delusion and hallucination, abnormalities of thought Anxiety disorders Severity of phobia, panic attacks, dissociative symptoms Childhood disorders Mental retardation and Attention deficit Chandrashekar & Prashanth: Management of Uncooperative Patient 493 Consequences of uncooperative behavior

1. Relapse: Non-adherence to treatment would cause relapse of psychosis.5

2. Poor prognosis: Longer duration of untreated psychosis is found to predict poor prognosis. By being uncooperative, patient may create difficult situation for himself 6

3. Deliberate self-harm behavior: The uncooperative behavior may slowly escalate into suicidal or homicidal behavior

4. Worsening of stigma: By being uncooperative and worsening family’s anxiety, patient may worsen the stigma that family members and society may have

5. Poor psychosocial outcome: Many patients due to their uncooperativeness may not benefit maximally by the psychosocial interventions which the treatment providers and family may have planned.

Management of uncooperative behavior

Since many psychiatric illnesses are chronic, the initial interaction with treating staff would influence patient’s cooperation during subsequent interactions. So, each contact with treating staff, if handled congenially, may avoid subsequent uncooperative behavior during next contacts

1. Informed consent: The process of involving patient in decision making about his illness and further management is known to improve doctor-patient relationship and subsequent compliance with treatment. 7

2. Making the interaction convenient: By planning time spent in hospital, simplifying the medication regimen, taking care to prevent side-effects may further improve cooperativeness of the patient

3. Maintaining best doctor-patient relationship: Addressing patients concerns during treatment, identifying his/her opinions about treatment and discussing them would help.

4. Educating the family: About the nature of patient’s problem, encouraging them to be sympathetic towards patient and avoiding high expressed emotions, supervising patient’s treatment, medication intake, identification of early signs of relapse would help in preventing further uncooperative behavior of patients. In the 494 Psychiatry in India : Training & training centres current social scenario, most of the families especially in the urban area are nuclear families. When a psychiatric patient becomes uncooperative, the families become helpless in handling them. An innovative model for helping such families is to transport an uncooperative patient to hospital is reported.2

5. Awareness in the society:, There should be general awareness about the nature of mental illnesses, and the support which a family with a mentally individual may require. An empathetic support from society would greatly help such families. Mental health professionals will have to initiate such efforts in the society in the form of associations, self-help groups or NGOs to help families with an uncooperative patient. With effective public education, stigma can be reduced. These measures would generally reduce uncooperativeness of the psychiatric patient.3

Surreptitious administration of medication

The peculiar situation in psychiatric practice is when an incompetent patient refuses treatment and the possibility of treatment improving his competence has led to the practice of surreptitious administration of medication. Though it is convenient, it is not legally permitted. Despite it being discouraged by law, there has been a wide practice of covert treatment.8 A wider discussion about the best way of balancing patient’s autonomy and paternalistic approach of family and doctors would help to resolve our stand on surreptitious medication.

The practical difficulty with surreptitious medication is non-availability of water soluble preparation of all classes of psychotropic medication.

Government has to consider provision of community treatment orders which sets out that affected person needs to take medication, therapy, rehabilitation and other services set out in the treatment plan. 9 This provision will be more meaningful in a country like ours where most of the psychiatric treatment occurs in the community. So, it would help greatly if there are laws pertaining to shifting the uncooperative patient to hospital, administering medication forcibly to a psychiatric patient with impaired competence at his home.

Uncooperative patient and the law

Important laws relating to psychiatry in India are:

1. Mental Health Act 1987 Chandrashekar & Prashanth: Management of Uncooperative Patient 495 2. Persons with Disabilities Act 1995 (PDA)

3. Child Care and Protection Act 2000 (juvenile justice act )

4. Rehabilitation Council of India Act 1992

While following these principles we need to balance between individual and societal interests. By practicing forensic psychiatry, psychiatrist can offer valuable expert service for the welfare of the society at large, safe guard his own interests as well as that of his patients.10

As per Madrid Declaration on ethical standards for psychiatric practice, approved by the general assembly on August 25,1996 and amended by the general assembly in Yakohama, Japan August 2002.11 when psychiatrists are requested to assess the person, it is their duty first to inform and advise the person being assessed about the purpose of the intervention, the use of the findings and the possible repercussions of the assessment. This is particularly important when psychiatrists are involved in third party situations.

Information obtained in the therapeutic relationship should be kept in confidence and used, only and exclusively, for the purpose of improving the mental health of the patient. Psychiatrists are prohibited from making use of such information for personal reasons, or financial or academic benefits. Breach of confidentiality may only be appropriate when serious physical, mental harm to the patient or to a third person would ensue if confidentiality were maintained; as in the case of a child abuse in these circumstances, psychiatrists, should whenever possible, first advise the patient about the action to be taken.11

Involuntary admission is a legal mechanism allowing dangerous psychiatrically ill individuals to be hospitalized against their will. This is based on the concept of ‘Parens patriae’ the doctrine that state has a responsibility to its subjects analogous to the parents duty to his children. In this case by providing for detention and treatment of mentally ill deemed to be in need of such services. We should also remember that state also has responsibility to maintain safe and orderly society. 12

Indian law permits physicians to take over decision making in following situations only- when patient is unconscious or when patient is non- competent. The non-competence is very important in the context of psychiatric practice. But competence is a legal concept and will have to be decided in courts. A clinician will have to work with the assumption that a person who is uncooperative has impaired competence.

If a mentally ill person is unable to express his willingness for admission, he 496 Psychiatry in India : Training & training centres may be admitted on an application made by a relative of such a person in a prescribed format accompanied by two medical certificates by two medical practitioners(Section 19 Mental Health Act 1987). As per sections 20-25 of the said act, Magistrate through the reception order can admit a patient to a hospital against his will through a medical officer. The important question is how a family can bring a patient to a magistrate or a doctor when he is refusing to cooperate. The Indian law permits a police officer (section 23,24) to intervene in this situation.13 But it has been very difficult to use the structure of assistance in situations of uncooperative patient and helpless family.

Draft of Mental Health Care Act 2012

Draft document of Mental Health Care Act 2012 by Ministry of HFW has tried to bring about improvement over archaic Mental Health act 1987.The changes are right based and brings it in harmony with the United Nations’ Convention on Rights of Persons with Disability (UNCRPD) ratified by the Government of India in May, 2008 and in tune with the present requirements. It has a chapter describing the important rights of the mentally ill. Their rights are also supported by Mental Health Review Commission, Advance directives and appointment of nominated representative. It describes about restraint, prohibited treatments.17

Management of Violent patients

Violent patient form a sub-group among uncooperative patients. It is important to note that most violent individuals are not psychiatrically ill. The risk factors for violence include a statement of intent or plan, availability of means of violence, male sex, young age, low socio economic status, poor social support, past history of violence, poor impulse control and recent stressors. Following are guidelines to be followed.14,15

Preferred initial interventions Alternate interventions Verbal intervention Physical restraints Voluntary medication Locked or unlocked(quiet room) seclusion Show of force Emergency medication Offer food, beverages, or other assistance

Do’s 1. Do protect yourself. 2. Un arm the patient. Chandrashekar & Prashanth: Management of Uncooperative Patient 497 3. Keep the door(s) open. 4. Keep others near you. 5. Do restraint if necessary 6. Wear white coat and id card 7. Assert authority 8. Show concern, establish rapport, and assure the patient.

Don’ts

1. Do not keep potential weapon near the patient 2. Do not sit with back to patient 3. Do not wear neck tie or jewellery 4. Do not keep any provocative family member or friend in the room 5. Do not confront 6. Do not sit close to the patient

Methods of physical restraint

1. Use restraint judiciously for the minimum period possible 2. Explain to the patient the reason for restraint 3. It should be done by trained personnel 4. At least five people are usually required for restraint 5. Restraint is done one limb at a time, while the other limbs are held firmly by the others 6. Restraint in arms are placed in such a way that IM or IV injections can be given easily 7. Intoxicated patient should be restrained in the left lateral position 8. Assess periodically about removal of restraint 9. Remove restraint of one limb at a time 10. Vitals should be monitored periodically

Oral medications, particularly concentrates, are clearly preferred if it is possible to use them. Benzodiazepines alone were top rated in 6 of 12 situations. A combination of a Benzodiazepine and an antipsychotic was preferred for patients with suspected schizophrenia, mania, or psychotic depression.3

The doctrine of ‘least restrictive alternative’ (‘least’ in terms of modality, severity, and duration of the action taken) should be used. Positive 498 Psychiatry in India : Training & training centres approaches, such as persuasion, should be the strategies of choice and negative approaches, such as threats should be avoided. One should be explicit about what one is doing and why they are doing so, allow patients to tell their side of the story, and seriously consider this information. The last, and possibly one of the most relevant dictums is discussion among colleagues for the most acceptable approach.

Finally, it is obvious that more research is needed in this area, particularly from India and the other Asian and developing countries. Such research needs to be not only service- and doctor-oriented, but also patient- and society- oriented, so as to enable each side to hear the voice of the other15.

Our experience at our institute has been that 90% of these so called ‘uncooperative patients’ can be convinced by para medical staff to seek medical intervention. A minority of them need stern warning to comply, minimal restraint or sedative medication. A huge majority of the patients were shifted and admitted in psychiatric hospitals without any untoward consequences when their family had failed.

Role of Indian Psychiatric Society

We are of the view that Indian Psychiatric Society needs to improve awareness of both society at large and the government about the uniqueness of uncooperative psychiatric patients. Society should come forward to help families with such uncooperative patients and government should draw legal guidelines and provide infra-structural support like ambulances, trained staff for helping both uncooperative patients and their families.

Conclusions

Many of the psychiatric consultations will be for management of uncooperative patients.

Mental health professionals are frequently asked to make rapid decisions about interventions in situations in which safety of the patients and staff may be at risk. The decisions will have to be highly individualized. The restraint and seclusion ‘work’ in the limited sense that they “can prevent injury and reduce agitation”. However there can be deleterious effects on patients ,who perceive such interventions as coercive and traumatic.16 It is possible to organize help for such patients and their relatives so that the crisis is handled more smoothly. These guidelines provide some direction for addressing common clinical dilemmas in the management of such uncooperative patients. Chandrashekar & Prashanth: Management of Uncooperative Patient 499 REFERENCES

1. Nagaraja D, Murthy P. Mental Health Care and Human Rights. New Delhi: National Human Rights Commission; 2008. 2. Chandrashekar H, Prashanth NR, Naveenkumar C, Kasthuri P. Innovations in Psychiatry: Ambulatory services for the mentally ill. Indian J Psychiatry 2009;51:169-70 3. Allen MH, Currier GW, Hughes GH, Harde MR, Docherty JP. Treatment of behavioral emergencies. Post grad Med special report 2001;(May):1-88 4. Loganathan S, Murthy SR. Experiences of stigma and discrimination endured by people suffering from schizophrenia. Indian J Psychiatry 2008;50:39-46 5. Gilbert PL, Harris MJ, Mcadams LA, et al. Neuroleptic withdrawal in Schizophrenic patients: A review of the literature. Arch Gen Psychiatr1995; 52:173-188. 6. Norman RM, Lewis SW, Marshall M Duration of untreated psychosis and its relationship to clinical outcome Br J Psychiatry Suppl. 2005 Aug;48:s19-23. 7. R B Deber The patient-physician partnership: decision making, problem solving and the desire to participate. CMAJ. 1994 August 15; 151(4): 423–427 8. Singh AR. Covert treatment in psychiatry: Do no harm, but also dare to care. in souvenir ANCIPS 2008. 9. Community treatment orders. Section 131-NSW Mental Health Act 10. Shaw LP. Forensic Psychiatry in India-Current status and future developments, Indian Journal of Psychiatry,1999;41(3):179-185 11. www.wpanet.org/detail.php?section_id=5=48 12. Swallow M, Yutzy SH., Dinwiddie SH. Forensic issues. in Rubin EH, Zorumski CF (ed), Adult psychiatry, 2nd edn. Blackwel’s neurology and psychiatry access series publishing; 2005: 420-1 13. Admission and Detention in Psychiatric Hospitals or Psychiatric Nursing Homes. In Puliani SP(ed). The Mental Health Act 1987,1st edn. Bangalore, Karnataka law journal publications, 2007;19-29 14. Kaplan HI, Sadock BJ. Pocket Handbook of Emergency psychiatric Medicine. New Delhi: BI Publications,1993 15. Shah R, Basu D. Coercion in psychiatric care: Global and Indian perspective. Indian J Psychiatry 2010;52:203-6 16. Fisher WA. Restraint and seclusion: a review of literarture. Am J Psychiatry 1994;151: 1584-91. 17. http://mohfw.nic.in/amendmentsmha/pdf

H. Chandrashekar Bangalore Medical College and Research Institute, Bangalore [email protected]

N.R. Prashanth Bangalore Medical College and Research Institute, Bangalore

53 Alternative and Complementary Health Practices in postgraduate psychiatry training

K.S. Pavitra

ABSTRACT

The new and increasing popularity in India of alternative therapies means that there are a larger range of health-related behaviors now than most practicing psychiatrists learned about in their postgraduate training. It has been preferable to call these behaviors health practices-Alternative and complementary health practices-(ACHP) rather than therapies, as, in many cases, the data are not available to fully determine whether they are truly therapeutic, clinically neutral, or, perhaps, even harmful. A limited evidence base may arise from several specific methodological challenges inherent to research in ACHP. For example, few ACHP treatments have been adequately studied in treatment trials with validated diagnoses as inclusion criteria and with validated assessment tools used to measure outcomes. Though the long ever growing list of ACHPs makes it impossible to study them in depth in postgraduate studies, the need in the area is of acquainting psychiatrists with the complementary medicines routinely encountered in clinical practice, to review the evidence base for their purported effectiveness, to discuss potential adverse effects and interactions and to acquire unbiased knowledge about the non pharmacological therapies which can be used as supplementary to evidence based conventional treatments.

The focus on doctor-patient relationship has been of primary importance in postgraduate psychiatry training. In fact the field of psychiatry is based on this central relationship and despite great advances in psychopharmacology this relationship remains the central theme including issues related to adherence to medications. Hence it has always been important for physicians to ask about and to try to understand the health beliefs and behaviors of their patients. The new and increasing popularity in India of alternative therapies 502 Psychiatry in India : Training & training centres means that there are a larger range of health-related behaviors now than most practicing psychiatrists learned about in their postgraduate training. Its been preferable to call these behaviors health practices-Alternative and complementary health practices-(ACHP) rather than therapies, as, in many cases, the data are not available to fully determine whether they are truly therapeutic, clinically neutral, or, perhaps, even harmful.(1)

ACHPs, medicines in particular are either used as an alternative or in addition to conventional medicine(2). Their use by those with chronic disorders such as cancers, with their associated physical and psychological problems, is well documented(3,4,5) . In psychiatric patients, estimates of their use range from 8 to 57%, with the most frequent use being in depression and anxiety. A population-based study from the USA found that 9% of respondents had anxiety attacks, 57% of whom used complementary medicines; 7% of respondents reported severe depression, with 54% of these using complementary medicines(6). Another survey from the USA reported mental disorders in 14% of respondents, 21% of whom used complementary medicines(7) . Usage was highest (32%) in respondents with panic disorder. In studies restricted to those with psychiatric disorders, usage ranged from 13 to 54%.(8,9,10,11). Complementary medicines are also used by those seen by liaison psychiatrists and a recent study of cancer patients showed that 25% took substances with psychoactive properties(12). In general, women use ACHP treatments more frequently than men and are more likely to have disorders such as MDD and anxiety disorders for which ACHP treatments are commonly sought.(13,14) In addition, when women, use ACHP therapies for psychiatric indications, they may do so in the context of reproductive life events (eg, menstrual cycle, pregnancy, lactation, and menopausal transition.

ACHP refers to treatments that are not considered standard or established practices in Western medicine. Complementary approaches specifically refer to those that are consistent with the Western biomedical concepts, whereas the term alternative applies to those more philosophically separate from traditional Western medical practices.(13) The term integrative medicine is perhaps a more constructive term, as it refers to an approach to medical care that incorporates standard Western medical practices and ACHP. As defined by the National Institutes of Health's National Center for Complementary and Alternative Medicine (NCCAM), ACHP is “a group of diverse medical and health care systems, practices, and products that are not presently considered to be a part of conventional medicine” (NCCAM, 2002)(15,16). Because the NCCAM definition refers to what ACHP treatments are not, rather than what they are, it is essentially impossible for the scientific community to make broad conclusions about ACHP therapies. This term includes a large and heterogeneous collection of health care systems and methods, including folk medicines, healing rituals, and self-care methods from cultures around the Pavitra: Alternative and Complementary Health Practices 503 world. The National Institutes of Health (NIH) Office of Alternative Medicine (OAM) defined the scope of Alternative Medicine to include 12 major health care systems, 26 categories of practice, more than 350 methods, and 10,000 ways of using these methods.(1) The term alternative has been defined in various ways. The World Health Organization defines alternative therapies as usually lying outside of the official health sector. David Eisenberg's definition stipulated, neither taught widely in U.S. medical schools nor generally available in U.S. hospitals. Thus, alternative therapies can be thought of as being alternative in their origin (they all come from somewhere else, somewhere other than the world of hospital-based medical research), rather than as necessarily being alternatives or substitutes for standard therapies Complementary medicines can be grouped into herbal remedies, food supplements, including vitamin preparations, and other organic and inorganic substances, including omega-3 fatty acids. People with mental health problems may take complementary medicines to treat anxiety and depression or to counter side-effects of conventional treatments, for example tardive dyskinesia and weight gain. Some seek a more holistic approach to treatment, others hope that complementary medicines have fewer or no side- effects, and many with chronic anxiety and depression understandably feel disillusioned by the apparent ineffectiveness of conventional treatment. The non pharmacological alternative health practices include another growing list including Diet, nutrition, and lifestyle change, Dance therapy, Art therapy, relaxation techniques, Biofeedback, Counseling and prayer therapies, Manual healing and many more(1)

ACHPs typically use a holistic, health-oriented approach to the patient rather than a disease-oriented diagnostic and treatment model. Holistic health care emphasizes the inclusion of the individual's mind, body, emotions, spirit, and environment in the development.(1)

Differing beliefs about ACHP can create challenges for patients and clinicians alike. Some individuals perceive ACHP treatments as safer because they are deemed natural, even when evidence is lacking or suggests otherwise. Clinicians might not prescribe ACHPs if they lack education about these treatments or perceive these treatments as ineffective. Clinicians may in addition find it difficult to translate research findings into evidence-based practice because of the limited evidence base for some ACHP treatments(13).

Despite the relative lack of high quality research on ACHP treatment outcomes, high rates of ACHP use makes it critical for clinicians to understand what treatments are available—or at least which treatments should be favored if patients are intent on trying them.

There are several limitations to the research literature on ACHP approaches 504 Psychiatry in India : Training & training centres for psychiatric disorders(17, 18). First, there is a wide diversity of practices considered alternative or complementary and various ways in which these methods are applied across cultures. Some authors consider complementary medicines to be only herbal remedies, whereas others include individual therapies such as acupuncture, aromatherapy, herbal therapy, homeopathy, iridology, naturopathy, and reflexology. There are also multiple research design problems, including poorly specified treatments, poorly chosen placebos, and interpreting non significant differences from established treatments as equivalence in underpowered studies. Looking at much sought Yoga therapy which is a popular ACHP in India, few controlled studies have evaluated yoga for anxiety disorders, and all have significant methodological limitations and/or poor methodology reporting. (19) The diagnostic conditions treated and both yoga interventions and control conditions varied. However, these limited results are encouraging, particularly for treatment of anxiety disorders. There is little information regarding safety or contraindications of yoga. Reported attrition rates were high in most studies, which may raise concerns about patient motivation and compliance.

A limited evidence base may arise from several specific methodological challenges inherent to research in ACHP.(13) For example, few ACHP treatments have been adequately studied in treatment trials with validated diagnoses as inclusion criteria and with validated assessment tools used to measure outcomes. The randomized controlled trial (RCT), considered essential for determination of efficacy, is sometimes extremely challenging to create in exercise and acupuncture interventions. When studies are not controlled, the high rate of placebo response in anxiety and depressive disorders makes trial results difficult to interpret. In addition, some alternative medical practices are enmeshed in a broader cultural context and belief system that makes them difficult to evaluate in controlled trials. These challenges must be overcome so that clinicians and patients may discuss the risks and beliefs of ACHP treatment so that safety and efficacy are optimized for each individualized treatment plan.

As many patients will not experience remission from psychiatric disorders with standard treatments, and ACHP use is growing in prevalence, it is important to consider the potential role of ACHP treatments when use is supported by evidence base of efficacy and safety. Pursuing ACHP treatments in lieu of standard evaluation and treatment carries the risk of delaying other possibly efficacious treatment(13). The popularity of many ACHP treatments necessitates that health care providers actively and respectfully inquire about ACHP use and understand their risks and benefits.

However, with appropriate consideration of benefit and harm evidence, some of the better-studied ACHP treatments can expand the list of treatment Pavitra: Alternative and Complementary Health Practices 505 options available to patients. Almost 40% of the adult US population currently uses some form of ACHP treatment, with anxiety, depression, and insomnia among the top 10 health conditions for which ACHP is most frequently used. Given the acceptability of ACHP , inclusion of evidence-based ACHP therapies in clinical practice may help to engage some increase treatment strategies for patients who have not remitted with standard treatments or have had difficulty tolerating them. In the Indian scenario the data on utilization of the ACHP itself is nonexistent but by one's own clinical experience we can see that it is bound to be high. Also the lack of resources, lack of education, poor accessibility in the mental health sector and long term medication compliance issues all can make Indian patients prefer ACHP over conventional treatment.

The ever growing list of ACHP makes it impossible to teach about each and every individuals’ health practices in depth in postgraduate training. However the knowledge of these health practices is essential for a postgraduate student for several important reasons. First, Despite a lack of quality research, some ACHP treatments warrant consideration for patients who don't fully respond to conventional treatment. Second, we need methodologically sound, intervention based studies to provide data on these ACHP and it would be a good idea to motivate students to take up research in this area during postgraduate training. Third, many a time the fresh psychiatrists are posed with a challenging patient who uses ACHP along with his or her psycho tropics, or patient who discontinues adequate psychiatric care for ACHP. These pose difficult clinical situations where the care can become compromised.

Given the complex pattern of potential interactions, clinicians should be taught to handle situations where they should not be afraid to discuss complementary medicines with their patients. Although some patients may choose to use complementary medicines as alternatives to conventional treatment, many may decide to use them in addition to prescribed medications. Complementary medicines have – rightly or wrongly – a very positive 'natural' reputation among significant sections of the population, and therefore can be popular with those from a wide variety of cultural backgrounds. This may lead to higher acceptance and adherence compared with conventional drugs, making it important to be 'willing and prepared to work in partnership with patients' beliefs and preferences – provided their actions are safe(20). Fourth, clinicians need to be aware of side-effects associated with complementary medicines and any interactions with other treatments. They should be able to identify hazards, advising patients accordingly and avoiding uncritical encouragement of potentially harmful use. Ignorance in this area, given the independent usage of complementary medicines, may lead to criticism and possibly litigation(21). Equally, patients 506 Psychiatry in India : Training & training centres should be encouraged to disclose information about complementary medicines to healthcare professionals. These discussions need to be conducted sensitively in order to avoid alienating patients who may feel that they have not been taken seriously or have been criticized for using complementary medicines. Such discussions can be complex and may demand more time than is available in routine clinics. Service models need to be designed to meet this challenge, with consideration being given to specialist clinics providing regular updated advice to both clinicians and patients.

Finally, the postgraduate curriculum should also include a focus on integrating ACHP with conventional therapies wherever feasible and needed. The MANAS intervention study at Goa found that the breathing exercises, and advice about sleep and diet, were felt to be the most useful components of the psychoeducation session(22). The study also utilized yoga, in a course of 5 sessions delivered over consecutive weekdays, as a component of the intervention. As a culturally acceptable mental health promotion activity, yoga could also improve the overall acceptability of the intervention.

Perhaps the need in the area of post graduate training is to acquaint psychiatrists with the complementary medicines routinely encountered in clinical practice, to review the evidence base for their purported effectiveness, to discuss potential adverse effects and interactions and to acquire unbiased knowledge about the non pharmacological therapies which can be used as complementary to the evidence based conventional treatments.

REFERENCES

1. Thomas JK, Alan T. Alternative a8d Complementary Health Practices In; Comprehensive Textbook of Psychiatry ,Editors: Sadock, Benjamin J.; Sadock, Virginia A. 8th Edition ,2005. 2. Zimmerman, R. A. & Thomspon, I. M. Prevalence of complementary medicine in urologic practice. A review of recent studies with emphasis on use among prostate cancer patients, Urology Clinics of North America, 2002; 29:1 –9. 3. Eisenberg, D. M., Kessler, R. C., Foster, C., et al, Unconventional medicine in the United States. Prevalence, costs and pattern of use, New England Journal of Medicine, 1993; 328: 246 –252. 4. Ernst, E. "Flower remedies": a systematic review of the clinical evidence. Wiener Klinische Wochenschrift, 2002; 30: 963 –966. 5. Ernst, E. & Cassileth, B. R., how useful are unconventional cancer treatments? European Journal of Cancer, 1999; 35: 1608 –66. 6. Kessler, R.C., Soukup, J., Davis, R. B., et al The use of complementary and alternative therapies to treat anxiety and depression in the United States. American Journal of Psychiatry, 2001; 158:289 –294. 7. Unutzer, J., Klap, R., Sturm, R., et al Mental disorders and the use of alternative medicine: results from a national survey. American Journal of Psychiatry, 2000; 157: 1851 –1857. Pavitra: Alternative and Complementary Health Practices 507 8. Knaudt, P. R., Connor, K. M., Weisler, R. H., et al Alternative therapy use by psychiatric outpatients. Journal of Nervous and Mental Disease, 2001; 187: 692 –695. 9. Wang, J. L., Patten, S. B. & Russell, M. L. Alternative medicine use by individuals with major depression. Canadian Journal of Psychiatry, 2001; 46: 528 –533. 10. Alderman, C. P. & Kiepfer, B. Complementary medicine use by psychiatry patients of an Australian hospital. Annals of Pharmacotherapy, 2003; 37: 1779 –1784. 11. Matthews, S. C., Camacho, A., Lawson, K., et al Use of herbal medications among 200 psychiatric outpatients: prevalence, patterns of use, and potential dangers. General Hospital Psychiatry, 2003 ; 25: 24 –26. 12. Werneke, U., Earl, J., Seydel, C., et al Potential health risks of complementary alternative medicines in cancer patients. British Journal of Cancer, 2004a; 90: 408 –413 13. Kristina M. Deligiannidis, Marlene P. Freeman, Complementary and alternative medicine for the treatment of depressive disorders in women, psychiatric clinics of north america , june 2010; 33(2) :441-463 14. Elkins G, Rajab MH, Marcus J. Complementary and alternative medicine use by psychiatric inpatients. Psychol Rep ,2005;96(1):163-6. 15. Barnes P, Powell-Griner E, McFann K, et al. CDC advance data report #343. Complementary and alternative medicine use among adults. United States, 2002; 2004. 16. Barnes PM, Bloom B, Nahin R. CDC national health statistics report #12. Complementary and alternative medicine use among adults and children: United States, 2007; 2008. 17. Pilkington K. Searching for CAM evidence: an evaluation of therapy-specific search strategies. J Altern Complement Med. 2007;13(4):451–459. 18. van der Watt G, Laugharne J, Janca A. Complementary and alternative medicine in the treatment of anxiety and depression. Curr Opin Psychiatry. 2008;21(1):37– 42. 19. Diana J. Antonacci, CAM for your anxious patient:What the evidence says? Current Psychiatry online, / 2010;9, . (10):42-52 20. Brugha, T., Rampes, H. & Jenkins, R. Surely you take complementary and alternative medicines? Psychiatric Bulletin,2004;28:36 –39 21. Cohen, M. H. & Eisenberg, D. M. Potential physician malpractice liability associated with complementary and integrative medicinal therapies. Annals of Internal Medicine, 2002; 136: 596 –603 22. Sudipto Chatterjee, Neerja Chowdhary et al, mental disorders in routine primary care feasibility and acceptability of the MANAS intervention in Goa, India ,World Psychiatry, 2008 February; 7(1): 39–46.

Pavitra K.S. Consultant Psychiatrist, Sridhar Neuro psychiatric Centre Shimoga-577204, Karnataka, India Associate Professor, Department of Psychiatry, SDM Medical College, Dharwar, Karnataka, India [email protected]

54 Ayurvedic concepts of mental disorders and their management

Anuradha Nadkarni, Smita N. Deshpande

Introduction

Ayurveda is a Sanskrit term, made up of the words "ayush" and "veda." "Ayush" means life and "Veda" means knowledge or science. The term "ayurveda" thus means 'the knowledge of life' or 'the science of life'. The evolution of the Indian art of healing and living a healthy life comes from the four Vedas namely: Rig veda, Sama veda , Yajur veda and Atharva veda. Ayurveda attained a state of reverence and is classified as one of the Upa- Vedas - a subsection - attached to the Atharva Veda. The Atharva Veda contains not only the magic spells and the occult sciences but also the Ayurveda that deals with the diseases, injuries, fertility, sanity and health.

Ayurveda incorporates all forms of lifestyle in therapy. Thus yoga, aroma, meditation, gems, amulets, herbs, diet, astrology, color and surgery etc. are used in a comprehensive manner in treating patients. Treating important and sensitive spots on the body called Marmas is described in Ayurveda. Ayurveda is a system, which uses the inherent principles of nature, to help maintain health in a person by keeping the individual's body, mind and spirit in perfect equilibrium with nature.

The ancient system of Ayurveda offers a holistic approach to mental health that integrates the mind, body and soul. Sushruta defines health as a state of total biological equilibrium, where the sensory, mental, emotional and spiritual elements are harmoniously balanced. Ayurveda is inherently a psychological as much as it is a physical system of medicine. Its scope of practice includes both physical (sharirika) and mental (manasika) diseases. Therefore, we cannot really understand Ayurveda without considering its viewpoint about mind and consciousness. According to Ayurveda, the human body is composed of four basics-the dosha, dhatu, mala and agni, which are immensely significant. These are also called the Mool Siddhant or the basic fundamentals of Ayurveda. 510 Psychiatry in India : Training & training centres Pancha mahabhuta theory

The concept of Panchamahabhuta (Five elements) is the foundation of Ayurveda to understand its physiology (normal functioning), pathology (disease formation) & pharmacokinetics (movement of drug within the body).

Ayurveda believes that everything in this universe which constitutes living and non-living matters is made up of five basic elements. These five elements are earth (prithvi), water (jala), fire (Agni or tej), air (Vayu) and ether or space (akash) and collectively they are termed as Panchmahabhuta.

Human body is a part of the universe. Space is the various spaces of the body. Air is the subtle and gross movements. Fire is digestion and assimilation. Water maintains fluid balance. Earth helps in shaping the body. Mind represents mental faculties. As part of nature, mind also reflects the same elements but in more subtle form.

Evolution of Matter

Mahabhuta is the smallest part of any matter. Akash Mahabhuta is the space without which matter cannot exist. Its main sense attribute is Sound (Shabda) and Nonresistance (Apratighatatwa) is its main property.

Vayumahabhuta evolved from Akashamahabhuta. Touch (Sparsha) is its chief sense attribute and as it is evolved from Akasha, it also inherits attribute of sound (Shabda). Chalatwa or movability is its chief property.

Agnimahabhuta evolves next from Vayumahabhuta. The main sense attribute of Agni is Vision (Roop) and the chief property is heat (Ushnatwa). It also inherits the sense attributes of sound (Shabda) and touch (Sparsha) from the Akash and Vayu Mahabhuta respectively.

The next Mahabhuta to evolve from Agnimahabhuta is Aapamahabhuta (Jala ). Taste (Rasa) is its main sense attribute and liquidity (Dravatwa) is the chief property, along with other attributes inherited from earlier Mahabhuta. The last to evolve is Prithwimahabhuta. Roughness (Kharatwa) is the chief property and Smell (Gandha) is the main sense of this Mahabhuta besides properties inherited from the earlier once.

These five elements are the basic building blocks of living matter. A single living cell is a unique combination of these five elements- the earth element gives structure to the cell. The water element is present in the cytoplasm or the liquid within the cell membrane. The metabolic processes being carried out in the cell symbolizes the fire element. The gaseous exchange taking place symbolizes the air element. The space occupied by the cell symbolizes Anuradha & Smita: Ayurvedic concepts 511 the Space or ether element. The pores or channels through which nutrition reaches the cell and the waste metabolic products that are formed are excreted out denote the space element.

These elements are represented in humans by three "doshas", or energies: Vata, Pitta and Kapha. Every individual has a distinct balance, and our health and well-being depend on getting a right balance of the three doshas.

The five elements (panchamahabhuta) combine in pairs to constitute the three doshas-vata (ether and air), pitta (water and fire) and kapha (water and earth). The combinations of these doshas inherited at birth indicate an individual's unique constitution. The dynamic balance of tridoshas creates health.

Health as a state of Equilibrium:

Samadosha Samagnischa Samadhathu Mala kriyah Prasanathma indriya manah swastha ithyabhidheeyathe

Sushruta, the ancient exponent of ayurveda, defines Health as svasthya-a state of total biological equilibrium, where the doshas, agni (digestion), dhatu (body tissues), mala kriya (excretion and detoxification), and mental, sensory, emotional and spiritual elements are harmoniously balanced.

Concepts of Mental Health in Ayurveda:

Ayurveda defines mental health as a state of mental, intellectual and spiritual well-being. The concept of health encompasses not only the physical and mental aspects but also the spiritual aspect, which is missing in the modern psychological discourse.

Concept of Mind:

First let us take a look at the Ayurvedic concept of Mind. Manas in Sanskrit, means to think, believe, imagine, suppose. According to Charaka that entity which is responsible for contemplation and thinking is Manas. It is inactive (Achetana) by itself but gets activeness (Chetana) from self or soul (atma). It is substance (dravya). Although it is beyond sensory perception, it is called dravya since it has got both quality (guna) and action (karma) coexistent within itself. It is the internal organ for perception. Manas is responsible to link Atma (Soul) with sense organs and their sensory objects like sound, touch, shape, taste and smell for perception. Atma (Soul) is the basis of all experience, while Manas (mind) is only the instrument of experience. The words Chitt, Chetas, Chetana, Hridaya, Hrit, Svanta, Mana, Sattva are synonyms of Manas. 512 Psychiatry in India : Training & training centres Ayurveda has differentiated our organs into jnanendriya (organs of perception, sense organs) Shabda (auditory), sparsha (tactile), roopa (vision), rasa (taste), gandha (smell)) and karmendriya [organs of action/executive - Vak (speech), Pani (hands), Pada (foot), Payu (excretion), Upastha (sexual)]. Mind has been given the special status as ubhayendriya, meaning organ of both perception & action. Manas have the ability of experiencing Sukha (happiness) and Duhkha (sorrow). Ayurveda also emphasizes the mind to be more important than the body, in the body-mind apparatus. When the mind is in good state, it generates positive feelings like those of love and affection. In the contrary, if the mind is not healthy then the body- mind apparatus gets imbalanced. Due to improper diet and actions, the natural state of the mind is disturbed and the positive feelings are driven out. They then give place to negative feelings like those of anger, jealousy, cruelty, drowsiness which further lead to mental disorders.

Pancha mahabhuta and Mind:

As a part of nature and human being, mind also reflects the five elements. Though panchamahabhutas are more subtle they retain their attributes and actions. In substance, mind is expansive, open and pervading like space. Air element is attributed by the movement of mind which is faster than anything. Fire element gives mind the quality of illumination and capacity to perceive all from the light. Water element shows watery quality of emotion, empathy and feelings. Earth element gives memory, attachment and opinions.

Location of Mind:

The ancient classical Ayurvedic expert Charaka, places the mind in the heart though other texts locate it at the head and the navel. Head is centre for outer mind that works through the senses. Heart is the centre for inner mind or consciousness. Let us not confuse this with heart as the organ, but the one which is deep inside ourselves. These various views are considered complementary rather than contradictory.

Qualities of Mind:

According to Ayurveda, manas has two basic qualities, Anutwa (atomic dimension) and Ekatwa (eternal/unitary). Anutwa denotes subtleness or a state beyond sensory/motor perception. It is different from other entities and is unitary by nature, means it is indivisible unit by itself. However by virtue of its capacity of rapid movements it seems to be engaged in several transactions at a time but the fact is that it can truly apply itself on only one task at a given point of time.

Manas has three operational qualities, the Trigunas which are the super Anuradha & Smita: Ayurvedic concepts 513 qualities of universe responsible for creation of the Universe and Man. Satva – Pure quality, refers to Sat / mind, reality, truth, light, intelligence. Satva is indicated by knowledge acquisition, distribution and reasoning or analyzing, self control.

Rajas –Passion (rosha) refers to Raja / stain, smoke, distraction, turbulence and mind agitated by desire. It is indicated by violence, authoritativeness, self adoration etc. Rajas is the initiator and provides the force essential for initiation of thought. This gets converted to a deed or word after a judicious use of desire, effort and memory.

Tamas – Attachment (moha) refers to Tama/ dullness, darkness and is indicated by inability to perceive, heaviness, lethargy and mind clouded by ignorance and inactivity. Tamas due to its occluding nature provides a calming, soothing effect and in a normal phase becomes the brake which controls the overactive rajas and reasoning satwa. The three gunas (Satva, Rajas and Tamas) are connected to tridosha in Ayurveda through panchamahabhutas. The three gunas together are responsible for the existential, empirical, evaluative and transactional dimensions of mind each of which may serve as a motivational source of stress.

Functions of Mind:

As mentioned earlier, mind is responsible for sensory perception. It has specific functions of its own like, Chintya (Thinking) - Thinking of what to do and what not to do, etc.

Vicharya (Analysis) - Analysis of the subject. Uhya (Speculation) - Speculation and finding out probabilities Dhyeya (Aim/Goal) - Goal setting, Objective. Sankalpa – (Decision) - of doing various activities to achieve a goal- Determination.

Manasa Prakruti (Psychological Constitution):

Prakruti is the intrinsic basic core of an individual, formed at the time of conception. Though it is relatively resistant to change throughout life, it is influenced by various factors like age, food, environment etc. Prakruti is reflected and understood through the individual's behavioral and response pattern in relation to his morphological state and physiological, psychological, social and spiritual dimensions.

Predominance of sattva, rajas, tamas qualities creates psychological constitution of the individual - the pure sattvik, passionate rajasik and the ignorant tamasik. The pure type works at high intellectual level and is considered to be without any blemishes. The passionate type deals at 514 Psychiatry in India : Training & training centres emotional level while the ignorant type leads a vegetative existence. Each of these types of personalities show an indefinite number or variations, on account of the differentiating factors of extent, origin and body built. A particular type of body built goes with a particular type of personality or vice versa. Sixteen different psychological personalities (manasika prakruti) have been explained in Ch.Shar-4/36.They are Brahma, Rishi, Indra, Yama, Varuna, Kubera, Gandharva these seven belong to Satvik type. Asura, Rakshasa, Pishacha, Sarpa, Preta these five belong to Rajasik type. Shakuna, Pashva, Matsya and Vanaspatya- these four belong to Tamasik type. Each of them has specific characteristic features. It is still very well appreciated that there are various degrees of each variety and again an individual personality is usually a mixture of all the three types and it is only the predominance of the quality over others that specifies it to a particular group. (Charaka.Sutrastana-8/6).

Ayurveda considered that personality consisted of intellectual, social, emotional and spiritual attributes, and they gave due importance to moral values. The two broad groups of Satvik and Rajasik personalities who function at intellectual and emotional levels will today be classed as normal individuals while Tamas group would be taken as mentally or intellectually deficient.

The psychological state is a balance of these three, is essential for a healthy state of mind. Mental outlook is healthy when Satva is predominant. Mental and emotional disturbances arise when Rajas is predominant. Mental state is depressed, dull and perverse when Tamas is predominant. Thus the basics of Psychology can be understood seeing which of these qualities is predominant in the personality of a person at any given time.

Tridosha

Tridosha is the most fundamental and characteristic principle of Ayurveda which is basic life energy force, They are - Vatha, Pitta,and Kapha.“Dosha”- Dooshyate iti dosha means, that which vitiates the body when there is flaw in its equilibrium. Vata-Pitta-Kapha are pervasive and subtle entity, inherited at conception and present in every person, differ in permutation and combination and determine physiological constitution of the person known as Prakruti which is unique to every individual.

Constitution of the person has further been elaborated and it has been emphasized that by making a combined study of these factors, it is possible to form a fair estimate of person's potentialities and liabilities. No two people are alike in their physical features or temperament. The reason is that each person occupies a point in space-time different from others. So at the very moment of conception, every person carries with him a tendency towards the development of certain qualities which are specific to him. Space means the geographical and climatic conditions of the person's residence including his Anuradha & Smita: Ayurvedic concepts 515 physical and social environment. While time indicates age of the person, the various seasonal and other influences that molded him till then, including his potentialities and defects which he might have acquired in his previous birth.

The knowledge of prakruti is very essential in designing suitable preventive strategies against various illnesses. It would help in better understanding of the illness and prognosis. In the administration of the treatment also suitable modification may be done in terms of drug selection, dose etc on this basis since manifestation of a disease, severity and prognosis are closely related to both Shareerika and Manasika prakruti.

Tridosha as Functional aspect- Functional aspect of the human body is governed by these biological humors. They govern psycho-biological and physio-pathological changes. The constitutional and temperamental types of body, depending upon the doshas are described. Understanding of these types helps in diagnosis and treatment of any illness.

Vata (ether) - Vata derived from Sanskrit root “Va” meaning motion, represents principle of movement in the physiology and is responsible for functions of nervous system, circulatory and digestive system.

Pitta (fire) - Pitta derived from “Tapa” meaning heat, is the principle of biotransformation which regulates metabolic process in the body.

Kapha (water) - also known as Shleshma means to unite, is the principle of cohesion and is responsible for structure and fluid balance of the body. Three fundamental functions of body, viz. movement, heat production and lubrication are thus carried out respectively. All the modern, scientific understanding of the body's composition and function can be organized according to these principles.

Psychological qualities of doshas:

Psychological quality of Vata is, mental alertness, abundance of creative energy, orderly functioning of systems, light sleep, preference of warm environment, high sociability and enthusiasm. Psychological quality of Pitta predominance is that such people are sharp and determined in thought, speech and action, intelligent, perspective and discriminating. They are self- confident, moderate sleepers and gravitate towards cooler environments. Ambition is usually their second name. Psychological quality of Kapha predominance is happiness, emotional calm, correct retention of knowledge, they are long, heavy sleepers and uncomfortable in damp, clammy environments. Loyalty is usually their second name.

Positive Behavioral qualities: 516 Psychiatry in India : Training & training centres Vata predominant persons are, highly imaginative, creative and filled with ideas, quick in learning and grasping new knowledge. They are excitable, lively personality with tendency for mood swing. They are full of joy and enthusiastic and seek constant action.

Pitta predominant persons have sharp mind and superior memory hence they have good learning and concentrating powers. They are orderly, assertive, and entrepreneurial by nature. They have natural fondness for noble professions leadership skills, good comprehension; focused vision and wisdom. They are capable of sharp, sarcastic, cutting speech. They have deep insight and make good psychologists and law makers.

Kapha predominant persons have exceptionally long-term memory, easygoing, relaxed, slow-paced, stable, reliable, affectionate and loving, forgiving, compassionate, faithful. Have calm, steady mind thus do not lose their temper easily.

Negative behavioral qualities:

Vata predominant people have little will power and little tolerance, and weak in confidence or boldness, and reasoning, they often act on impulse. They are fearful, anxious, and insecure, quick to forget the learned knowledge, restless and often have disjointed thoughts and tendency to change. They get spaced out and may be absent minded.

Pitta predominant person is often stubborn, pushy, prejudiced, and authoritarian. Emotionally, they tend towards hate, anger and jealousy. They are extremely principled, judgmental, critical, perfectionist and are subject to temper tantrums, impatience, and anger.

Kapha predominant people are slow learners. They usually have nonjudgmental nature and slow comprehension. They have much desire, attachment and may be possessive and greedy.

Psychological symptoms produced by vitiated Doshas:

Vata : Insomnia; wake up at night and can't go back to sleep, Nervousness, lack of concentration, anxiety, fearfulness, Impatience, hyperactivity, weight loss, insecure and restless, indecisiveness, Feeling of tiredness, fatigue unable to relax, poor stamina, Agitated movement, generalized aches

Pitta: Disturbing dreams, insomnia, Sensitivity to heat, hot flashes, Weakness, angry, irritable, hostile destructive and impatient, critical of self and others, Argumentative, aggressive, bossy, controlling, Mental confusion

Kapha: Sleepy, drowsy during day weight gain, obesity, Sluggish and dull in Anuradha & Smita: Ayurvedic concepts 517 thinking, lethargic or tired, Depressed, sad, sentimental slow to comprehend, slow to react, dependent , Greedy, possessive, materialistic

Vital Essences:

Vata-Pitta-Kapha have subtle counterparts in the level of vital energy. These are Prana, Tejas and Ojas. These are master forms of Vata, Pitta and Kapha and control ordinary mind body functions. They keep us healthy and free of diseases. While increase in vata, pitta and kapha promotes diseases, increase in vital essences promote positive health, vitality, clarity and endurance.

Prana allows mind to move and respond to challenges of life. Tejas enables it to perceive and judge correctly and Ojas gives patience and endurance that provides psychological stability. These have emotional effect as well. Prana maintains emotional harmony, balance and creativity. Tejas gives courage, fearlessness and vigor to accomplish actions. Ojas provides peace, calmness and contentment.

Emotions:

As per Ayurvedic view thoughts create emotions. They are associated with mood, temperament, personality, disposition and motivation. These are the effect of increase in rajas and tamas qualities of mind.

Concept of Atma:

Concept of Atma occupies important place in Ayurveda. In an embodied state it is Dehatma and in the context of universe it is Paramatma. The embodied Atma is Karta (doer) and Bhokta (experience) is understood by Prana (respiration), Apana (bowel movements), Unmesha-Nimesha (blinking), Sukha (pleasure), Duhkha (pain), Iccha (desires), Dvesha (dislike), Prerana (inspiration), Prayatna (effort), Budhi (decision), Manas (psyche), Sankalpa (resolution), Vichara (thought), Smriti (memory), Vijnana (science), Dhruti (retention of knowledge), Chetana (awareness), Swapna deshantaragati (travelling in dream). These lakshanas are realized only when Manas is in association with Atma and body. Atma is doer or knower but Manas functions represent Atma (Charaka Sharirasthana-1/70, 71-74).

The knowledge of Atma provides a new outlook in the field of treatment. It may be sufficient to treat all diseases with a view to restore physical or mental health. It helps one to develop a sense of equanimity when drug treatment alone cannot give complete relief.

Elements of Ayurvedic Psychology:

Charaka in his treatise Charaka Samhita, describes eight essential 518 Psychiatry in India : Training & training centres psychological factors that are negatively affected in various ways in all psychiatric disorders. The psychopathological condition is a function of these factors. They are Manas-mind, buddhi-cognition, samjna jnana-orientation and responsiveness, bhakti-devotion, sheela-habits, chesta-psychomotor activity and achara-conduct. (Charaka.Nidana sthana-7/5). Compared to other major Ayurvedic texts like Sushruta Samhita, and Ashtanga Hridayam, Charaka Samhita gives more emphasis to the view of life as a self-aware field of pure consciousness and natural intelligence where the knower and the known are one.

Signs of Mental Health as per Ayurveda: (Charaka.Vimana sthana-8/110)

Good memory, taking the right food at the right time, awareness of one's responsibilities, awareness of the self and beyond self, maintaining cleanliness and hygiene, doing things with enthusiasm, cleverness and discrimination, being brave, perseverance, maintaining cheerfulness irrespective of the situation, fearlessness in facing situations, sharp intellectual functioning, self-sufficiency, following a good value system, and ability to proceed steadfastly against all odds are all signs of good mental health.

Evolution of disease (pathogenesis):

Ayurveda describes the evolution of disease in six stages which describe all the processes that happen in the body from exposure to the disease causing factors to disease manifestation.

Ayurveda recognizes three main causes of disease.

1) Doshic imbalances, either by constitution or by external factors. This is caused by Asatmyendriyarth samyoga meaning, wrong use of senses, and too much or too little use of sense perceptionsresulting in doshic imbalances. Mental stress is caused by the imbalance of prana vata while sadhaka pitta imbalance produces emotional stress.

2) Excess of rajas and tamas in the mind. Excess of Rajas and Tamas, results in lack of coordination of three main mental functions dhi (intelligence, learning), dhriti (retention, constancy, resolution) and smriti (memory), ends up in wrong deeds. This is known as Pragyaparadha –mistake of the intellect. Charaka Samhita, defines Pragya-aparadh as the source of all diseases since disease originates when the heart, mind or body loses its connection with natural intelligence if one cannot perceive the reality of life, it is an indication of pragya-aparadh. Anuradha & Smita: Ayurvedic concepts 519 These two factors vitiate the three doshas in the body resulting in disease. The intellect identifies itself with the outer, changing aspect of life and therefore loses the experience of pure consciousness, the inner non-changing aspect of life. This mistake of the intellect is the body/ mind's tendency to forget that it is healthy, in a state of pure consciousness even in the field of diversity in life. Genetic disturbances, poor eating habits, stress, trauma and other sources distort the body's intelligence and pragyaparadha takes over. The memory of health and balance is lost. Body/mind looses equilibrium.

In Bhagvad Gita, Chapter 2/shloka 62-63, the same has been beautifully explained.

“Dhyayato vishayan pumsa sangah teshu upajayate I Sangat sanjayate kama kamat krodho abhijayate II Krodhat bhavati sammoha sammohat smriti vibhrama I Smriti bhramshat buddhi nasho buddhi nashat vinashyate”II

When a person thinks of pleasure (Vishaya), develops attachment of objects (Sanga) with sense organs. Then he becomes a victim of desire for pleasure from sensual objects (Kama). If that pleasure is not fulfilled it results in anger (Krodha). Due to anger his mind gets delusional (Sammoha) and he loses memory (Smruti vibhrama). Due to loss of memory of righteousness, his intelligence gets clouded (buddhinasha) or lost. This deficient intelligence is the cause for destruction, that is to say diseased condition.

3) Karmic factors or results of previous actions (Parinama).

These three factors are generally related to some extent, though one is usually dominant. Doshic imbalances usually rest upon an excess of rajas or tamas, which in turn reflect deeper karmic disharmonies.

Ayurveda has explained pathogenesis of mental disorder in this way. Mental disorder usually affects a person who has a weak will and nervous temperament, a person who is careless of dietetic rules and takes improper food, which is unclean or badly cooked, a person who abuses the general rules of healthy living and indulges in various kind of wrong activities, whose mind is full of lust, greed, excitement, fear, grief, anxiety, regrets and usually remains infatuated with something and is fatigued, whose mind is impaired and unsettled.

When such person's body is exposed to disease causing factors, the equilibrium of three doshas gets disturbed. The disequilibrium of doshas leads to the increase or decrease of their volume which causes the disease. (CharakaNidana sthana-7/14). 520 Psychiatry in India : Training & training centres Over activation of Rajas (action) or Tamas (inertia), causes mind imbalance which in turn affects Tridosha. When this balance is lost totally we have mental disorders, or if it tilts in any one direction we have conditions like anger, anxiety and trepidation, which are normal emotions but exhibited in an intensive manner. The doshas as they accumulate as toxins have negative emotional components like Vata as fear, Pitta as anger and Kapha as attachment. Vata dosha in particular has strong psychological ramification because the mind is part of the sphere of Vata and also composed mainly of the same air and ether elements. Vata problems usually include psychological problems, starting with fear, insecurity and anxiety. Management of Vata must always include psychological intervention as well. The other two doshas have their own important psychological components and considerations as well. Each patient has a particular psychological as well as physical energy level.

The three gunas are mainly psychological factors with rajas as ego-driven impulses and tamas as deeper emotional blockages, insensitivity or addictions. These make the doshas hard to deal with as they may create attitude that resist the treatment. Measures to increase Satva (harmony and pure mind) are necessary to lower action and inertia thus to prevent imbalance. Yet doshas and gunas should always be cross-referenced and treated together. For example, deep-seated doshic imbalances will always involve some degree of tamas, which often referred as deep-seated trauma, pain or debility.

Manifestation of disease is described in six stages.

1. Sanchaya (Accumulation of Dosha) 2. Prakopa (Vitiation of Dosha) 3. Prasara (Spreading of Dosha) 4. Sthansamshraya (Localization of Dosha) 5. Vyakta (stage of clinical manifestation) 6. Bheda (stage of complications of the diseases)

Classification of Psychiatric disorders:

Ayurveda has classified Psychiatric disorders into five types, they are respectively due to Vata, Pitta, Kapha, Sannipata (involvement all three), and Agantu (exogenous) causes.

Conditions from simple anger and greed to complicated psychosis have been classified under Manasa roga. Primary psychiatric conditions are Kama (greed), Krodha (anger), lobha (greed), moha (attachment), irshya (jealousy), Ahamkara (pride), mada ( euphoria, excitement ), shoka (sorrow, grief), chinta (anxiety), udvega (neurosis), bhaya (fear), harsha (happiness). The major psychiatric disorders are unmada (psychosis-vatonmada, pittonmada, Anuradha & Smita: Ayurvedic concepts 521 kaphonmada, tridoshajonmada and agantujonmada), apasmara (convulsive disorder), apatantraka (hysteria), atattvabhinvesha (obsession), bhrama (illusion, vertigo), tandra (drowsiness), klama (neurasthenia), mada-murchha- sanyasa (loss of sensory perception leading to coma), madatyaya (alcoholism), gadodvega (hypochondria)

Other conditions are buddhimandya or mental retardation of varying degrees, jara-janya-manasa vikara (psychiatric problems of the aged or geriatric disorders), and manodaihika vyadhis or psychosomatic diseases where the cause of disease is mental but the manifestation is somatic.

General Principles of treatment:

Ayurveda emphasizes the need of prevention and alleviation of diseases through promotion of healthy habits and suggests various mental and physical health care measures to achieve well being. Management of mental disorders was an area of specialization even during Charaka's time (500 B.C.; Dwivedi, 1966). Charaka suggests treatment for mental illness should be taken from an expert in the field of mental disorders. Chakrapani (11 A.D., Dwivedi 1966) commenting on this statement uses the phrase Manasavyadhibheshajavedi meaning the one who knows about treatment of mental illness. There is no Ayurvedic classic available dealing exclusively on mental health. We have to club the spread material relating to Manas and Manovikara in the available treatises, Charaka Samhita, Sushruta samhita, Ashtanga Hridaya and others. The available information is very useful in understanding Manas and treating mental disorders when they are carefully compiled as per current day needs. Ayurvedic treatment for the alleviation of the disease always adopts a holistic approach. Human body is a mental organ, a vehicle of perception designed to support the functions of the senses and to facilitate experience by the mind. Any breakdown in bodily function has its own root in the perceptional process and results from Asatmyendriartha samyoga. Mental diseases arise mainly from internal factors like wrong use of senses and accumulation of negative emotions. Both physical and psychological diseases are usually mixed and one seldom occurs without the other. Physical disease disturbs the emotion and weakens the senses which give rise to Psychological disturbances. Psychological imbalances have physical consequences. They lead to dietary indiscretion, hurt the heart and nerves thus weaken the body. Ayurveda recommends 3 types of chikitsa for treating mental illness. They are

1) Daiva vyapashraya chikitsa: (Divine therapy)

Ayurvedic treatment methods for mind include Yogic practices for spiritual growth like mantras (incantations), aushadhi (tying of herbs), mani (wearing gems), mangala (worship), meditation etc. These are recommended in mental 522 Psychiatry in India : Training & training centres disorders caused by unrelated factors and administered judiciously after considering the nature, faith, religion, culture and educational level of the patient. These are effective in special ways.

Mantra means instrument of mind which saves it (manam+trayati). This is the main and direct Ayurvedic tool for healing mind from its deepest layers of consciousness (chitta) to surface action. Mantras are specially energized sounds of words, a simple single word like OM or special phrases repeated in regular manner in order to empower them into tools of psychological transformation. A mantra can alter deep seated latencies and impressions. Sattvic mantra aims at dissolving the ego and promoting self awareness. It is not a form of self hypnosis but a way of reconditioning the sick mind by breaking up unconscious sound and thought patterns. It changes energetic structure of the mind in a positive way and dissolves the problem. When mantra is combined with breath as in pranayama, it is a powerful way of charging energy of powerful mind.

2) Yukti vyapashraya: (Rational therapy)

This refers to use of Ahara (diet), Aushadha (drugs) and Vihara (behavioral activities). Drug therapy is advised in mental disorders where Vata-Pitta- Kapha are deranged. Dosha shodhana (purification) has to be done by adopting various purificatory measures. After Shodhana, Samshamana (palliative) drugs and Rasayana (tonic) are given. Later on psycho behavioral measures are adopted in order to increase the sattva bala (mental strength).

Treating the mind is unlikely to be successful if the condition of the body is not considered. This begins with most basic factor, diet. The food we eat not only affects our body but state of mind also. Food that is balanced and full of life force, like whole grains and properly cooked vegetables improves sensory functions and mental clarity. Food, like all things in the universe, consists of three cosmic qualities of sattva, rajas and tamas. These are reflected in both elements and impressions gained through food. This consists the third and core level of nutrition which Ayurveda emphasizes through sattvic diet that was originally devised for practice of Yoga and development of higher consciousness. This helps in treatment of mental disorders by helping to restore harmony and balance of mind. Prime factor in Sattvic diet is vegetarian food like whole grains, seeds, nuts, dairy products, greens, fresh fruits and vegetables. Rajasic and Tamasic food disturbs the mind. Rajasic food is excessively spicy, salty, sour, and too hot and includes stimulating beverages like coffee and alcohol which causes hyperactivity and irritability, increases toxins in the blood, disturbs senses and causes emotions to fluctuate. Tamasic food is stale, old, over cooked, oily, heavy to digest, includes meat, fat, sugar and white flour which causes lethargy, apathy, excess Anuradha & Smita: Ayurvedic concepts 523 sleep, dullness in the senses and keep the emotions heavy and resistant.

Panchakarma is the main Ayurvedic method of physical purification. Owing to subtle nature of its procedures, it penetrates deep into nervous system. This is useful in psychological problems caused by excess of three doshas. The following are some of the treatment procedures of panchakarma which are recommended in treating mental disorders. They are Vamana, Virechana, Basti, Nasya and Shirodhara.

Vamana: Procedure of inducing therapeutic emesis using certain herbs for removing excess kapha. This is good for dealing with depression, grief etc.

Virechana: Procedure of purgation through therapeutic laxative, providing symptomatic relief of mental illness involving excess pitta.

Vasti: Therapeutic enema therapy for removing excess vata with symptoms of anxiety, insomnia, tremors etc. Nirooha Vasti- enema therapy using medicated concoctions+ medicated oil etc. which cleanses toxins from the dhatus and removes naturally accumulated body wastes from the colon. Anuvasana Vasti- enema therapy using medicated oils in prescribed quantity which is to be retained in the body for a longer period for effectiveness.

Nasya-Nasal medication acts as a purificatory aid to the parts above the neck where major sensory faculties are located. The clarity of these faculties (indriyaprasada) leads to clarity of mind.

Snehana and Swedana: For the panchakarma procedures to have proper effect, the doshas must first be brought to the sites from where they can be eliminated from the body. Kapha has to be brought to the stomach, pitta to small intestine and vata to large intestine. This requires a period of minimum 7 days of regular oil massage and steam therapy, known as snehana and swedana. These loosen the toxins in the deeper tissues and allow them to flow back into the gastro intestinal tract. This has to be done before any panchakarma procedure.

Special Ayurvedic treatment techniques include:-

Shirodhara-medicated concoctions, herbal oils, medicated buttermilk and medicated milk are poured on the forehead through a special method for 30 to 45 minutes. It reduces anxiety, depression and mental stress and rejuvenates the central nervous system. The method of Shiro Vasti is the keeping herbal oil in a cap fitted on head.

Shamana chikitsa- Panchakarma therapy is followed by Shamana or palliative treatment and Rasayana or tonics with oral medicines including herbal 524 Psychiatry in India : Training & training centres powders and combinations in different forms like 'medhya rasayanas'. These herbs promote the intellect and deeply nourish the neurological tissues as they are nerve tonics. Ayurveda favors the use of combinations of herbs that meet the specific needs of each patient as no two patients present with exactly the same condition. These medicines act as specific molecular nutrients for the brain, promoting better mental health that leads to the alleviation of behavioral disorders. The medhya rasayanas enhance biological nourishment of the brain, producing tranquility of mind, concentration and improved memory.

Ashwagandha, Brahmi, Jatamaamsi, Sarpagandha, and shankhapushpi have a secondary mild sedative effect. Others like Vacha have a mild stimulating action. Some of the classical combinations are Ashwagandha rasayan, Kushmanda rasayan, Brahmi rasayan, Brahmi ghrita, Panchagavya ghrita, Mahakalyanaka ghrita, Smritisagar rasa, Yogendra rasa, Ashwagandharishta.

3) Satwavajaya chikitsa: (Psychobehavioral therapy)

The aim of this therapy is to restrain mind from desires of unwholesome things. This is achieved by increasing sattva i.e. mental endurance to subdue exaggerated Rajas and Tamas. This permits considering occupational, behavioral and like therapies since ultimate aim of these therapy would be to restrain mind. Emphasizing on the need of compassion and a positive attitude towards the patient in administering Sattvavajaya measures is very important. It is said that the patient should be calmed down with words of religious and moral impact by his well wishers to know him well. According to Charaka, the best approach to achieve the goal of treatment is through Jnana (knowledge of self), Vijnana (professional /analytical knowledge), Dhairya (confidence), Smriti (scriptural wisdom) and Samadhi (concentration).

Trigunas and Therapy:

To benefit from different medical and healing therapy we must understand their approach and how these relate to trigunas. Satvic therapy works through sattvic qualities of love, peace and non-violence. This uses nature, the life force through herbs, diet, mantra and meditation. Rajasic therapy works through rajasic quality of stimulation, energization and agitation. Rajas helps break up Tamas. Tamasic therapy works through tamasic quality of sedation, sleep and grounding which helps to calm Rajas. Ayurvedic therapies are primarily Sattvic and employ rajasic and tamasic modalities only under some circumstances. Ayurveda aims at moving the mind from tamas to rajas and eventually to satva. This means moving from ignorant and physically oriented life (tamas), to one of vitality and self expression (rajas) and finally to one of peace and enlightenment (sattva). Anuradha & Smita: Ayurvedic concepts 525 Preventive measures:

Health is a continual ongoing process; it cannot be permanently achieved once and for all. Disease prevention is higher level of healing to eliminate diseases before they manifest. In support of its concept of preservation and promotion of health and prevention of illness, Ayurveda gives due importance to various measures to be adopted in order to promote mental health and prevent mental disorders. These measures find description in the context of Dinacharya (daily regimen), Ritucharya (seasonal regimen), sadvritta (code of virtues), Roga-anutpadana (prevention of diseases), Annapana vidhi (rules pertaining to food and drinks) in the classics of Ayurveda. This aims at improving our vital essences and enables us to live longer.

In order to be free from mental disorders, Ayurveda advices developing awareness to increase a spiritual approach to life. This includes meditation. It says that one should not allow oneself to become a victim of impulses like greed, grief, fear, anger, jealousy, vanity etc. Further it declares that one who speaks truth, refrains from over indulgence in alcohol and meat, hurts none, fair spoken, always compassionate and given to wholesome eating would enjoy sound mental health. In fact, it would be appropriate to consider the Ayurvedic view points in this regard as a socio-moral value system. If adopted to suit our needs without digressing from the core of this concept, it would prevent mental disorders and promote mental potentialities of mankind.

All these measures are aimed at bestowing relaxation and mental equilibrium which are the basic necessity of sound mind. They are very relevant to our times when we are forced to battle continuously against stress and strain for our survival. Summing up Vagbhata states that one who regularly introspects one's dawn to dusk interactions with fellow beings and surroundings will never become sorrowful and enjoys perennial happiness.

References;

1. David Frawley, Ayurveda and Mind, Motilal Banarasidas Publications. March 1997 2. A.R.V Murthy. Rationale of Ayurvedic Psychiatry, Chaukamba Orientalia. Varanasi. 3. Subhash Ranade ,Bhaskar Patil.Manasa Roga Chikitsa. Ayurvedic Psychotherapy. 4. Vaidya Bhagavan Das.Charaka Samhita, Anvaya, with English translation and commentary in English based on Chakrapani Ayurveda Dipika, (1999), also Translation by Pt. P.V. Sharma. Chaukamba Orientalia Publications. 5. K.R. Shrikanta Murty Sushruta Samhita, Illustrated Sushruta samhita, English Translation Chaukamba Orientalia Publications. 6. K. R. Shrikanta Murthy, Ashtanga Hridaya and Ashtanga Sangraha Chaukamba Orientalia Publications. 7. K.R. Shrikanta Murty Madhava Nidana,, Chaukamba Orientalia Publications. 8. A. Venkoba Rao Mind in Ayurveda, Indian Journal of Psychiatry. 2002,44(3) 201-211. 526 Psychiatry in India : Training & training centres 9. Central Council for Research in Ayurveda and Siddha, New Delhi. Monograph: Ayurvedic Management of Unmada (Schizophrenia) 10. AYUSH portal, Dept. of AYUSH, Govt. of India.

Anuradha Nadkarni Research Officer CCRAS, Dept. of Psychiatry PGIMER-Dr RML Hospital New Delhi.

Smita N. Deshpande DPM, Professor and Head, Dept. of Psychiatry PGIMER-Dr. RML Hospital New Delhi [email protected] 55 Understanding of Human Emotions

Dushad Ram, Abhinav Tandon, M.S. Darshan, Payel Roy

ABSTRACT

Different approaches such as cognitive, behavioral etc have been proposed and these have conceptualized emotion differently. Emotion influences cognition and behavior and is determined by number of factors such as age, gender, socio-cultural, genetic and neurobiological etc. Emotion can be assessed clinically and can be measured using different measurement tools. Understanding emotion may help to understand an individual, and has diagnostic, therapeutic and preventive implications in mental illness

Concept and definition

Emotion is described as a stirred up state due to psycho-physiological changes, which occurs as a response to some event and which tends to maintain or abolish the causative event [1]. World health organization has described emotion as a complex state of arousal compounded of wide spread physiological changes, heightened perception, and subjective experiences tending towards action. Affect is a wave of emotion in which there is a sudden exacerbation of emotion usually as a response to some event while mood is the predominant emotional state (happiness or sadness) prevailing at any given time [1].

Different views have been proposed about emotion. James Lange [2] believed that felt emotion is the perception of body changes. Canon Bart [3] proposed that felt emotion and bodily changes occurs simultaneously but are independent of each other. Cognitive theory [4] proposed that emotion we feel is an interpretation of a given situation. However emotion and motivation have a different construct. Emotion relates more towards feeling while motivation towards goal. Emotion is mostly due to external stimulus with associated bodily changes while motivation does not.

In India emotion has been explained and classified in different schools of thought such as the Gita, Patanjali, and Buddhist and Jaina views [5]. Indian 528 Psychiatry in India : Training & training centres norms of almost all emotional experiences and expressions have been described by various schools. Detailed account of need for emotional regulation and traditional ways in which it can be achieved has been described. Natyasastra by Bharata [6] details the theory of emotion and provides at least 9 different emotions and lajya which was added as the tenth. It can be compared with western theories [7].

Emotional functioning is one of the important specific mental functions described by World Health Organization (WHO). Three main normal aspects of emotion mentioned in International Classification of Functioning, Disability and Health (ICF) [8] are- 1 Appropriateness of emotion- congruence of feeling or affect with the situation. 2 Regulation of emotion-control of experience and display of affect. 3 Range of emotion- spectrum of experience, of arousal, of affect or feeling.

Classification of emotions

1 Basic emotions- There is no agreement about what are the basic emotions. Different authors such as Plutchik, Arnold, Ekman, Gray, James, Mc Doughall, Mowrer, Oatley, Pantley, Panksepp, Tomkins, Watson and Weiner etc have described about it. Izard's [9] basic emotions are anger, contempt, disgust, distress, fear, guilt, interest, joy, shame and surprise. 2 Primary, secondary and tertiary emotions - Sloman [10] proposed primary emotions (generated by the primitive reactive brain), secondary emotions (that result from the cognitive evaluation of the state of current planning activity) and tertiary emotions that result in constant interruption of the agent's/person's current cognitive task. Primary emotions with their corresponding secondary emotions are: 1) Love- affection, lust, longing. 2) Joy- cheerfulness, zest, contentment, pride, optimism, enthrallment, relief. 3) Surprise- surprise, irritation, exasperation, rage, disgust, envy, torment. 4) Sadness- suffering, sadness, disappointment, shame, neglect, sympathy. 5) Fear -horror, nervousness. 3 Positive and negative emotions – Negative emotion serves as a call for mental or behavioral adjustment while positive emotion serves as a cue to stay on the course or as a cue to explore the environment. Positive emotion includes well-being, happiness, gaiety, strength, company, interest, enthusiasm, laughter, empathy, action, curiosity. Negative emotions are discomfort, unfortune, sickness, sadness, weakness, loneliness, apathy, grief, fear, hatred, shame, blame, regret, resentment, Ram & Tandon et al : Understanding of Human Emotions 529 anger, hostility, boredom.

Anatomy of emotions

The amygdala is implicated for the detection of emotions and the generation of physiological responses; it optimizes perception and memory of emotional events through its dense connections with cortical & sub-cortical areas. Medial PFC, including nearby anterior cingulate cortex, coordinates the generation and regulation of affect [11].Anterior medial PFC region is also associated with self-referential processes and is implicated in emotionally meaningful events [12]. Lateral PFC regions control the processes related to emotional regulation.

Initially single-system model of emotion was proposed which assume that single structure is responsible for emotion. In limbic system theory of emotion “every variety of affect” was thought to be mediated by Papez circuit [13]. Right -hemisphere (RH) hypothesis was also proposed that it is the structure of processing for all aspects of emotion including both positive and negative emotions [14].

Dual-system model of emotion was given and left and right cortical regions were thought to involve positive and negative emotions, respectively (The Valence Asymmetry model), with particular involvement of anterior or frontal brain regions. RH (Right Hemisphere) is believed to be critical in the perception and expression of emotion[15] .There was another belief that there is differential involvement of left and right sided anterior neural activity in approach and withdrawal [16,17] related emotions, respectively.

The more recent model given was the multisystem model of emotions. A small set of discrete emotions mediated by central affect programs and lesion of these regions of brain is often associated with selective emotion deficits such as : fear- the amygdala; disgust- the insula/operculum and the globus pallidus; and anger- the lateral OFC (Orbito-frontal Cortex) The distributions for happiness and sadness did not differ, with activations clustered around the supracallosal ACC (and the dorsomedial PFC), an area possibly involved in processing emotion more generally.

Neurochemistry of emotions

Neurotransmitter implicated in experience and expressions of emotions are dopamine (emotion and cognition), serotonin (aggression and social behavior) and opioids (positive affective state and attachment behavior), nor- epinephrine etc. Most of the psychoactive substances and psychotropic drugs given for abnormal mood state are known to act through these neurotransmitters. 530 Psychiatry in India : Training & training centres Function of emotions

Emotions help in communication, adaptation and shaping future behavior. It prepares for an action (physiological changes), alters cognitive function (attention, memory, perception etc) for a given situation and emotional health being associated with success & quality of life.

Basic approaches of assessment

1. Biological–On the brain structures, neural pathways, and physiological underpinnings.

2. Cognitive– On understanding how an individual's goals and their interpretations or appraisals of a situation or event influence the way they feel.

3. Phenomenological– On describing and understanding the emotional experiences and feelings of the individual.

4. Behavioural– On how emotions are reflected in behaviour, and on how reinforcement histories influence emotional responding.

5. Social– On understanding how emotions, particularly emotional expression and recognition, are influenced by the individual's culture, learned 'rules', and the situation.

Measurement of emotions

1 Subjective experience – Self report, decision -making in choice or action.

2 Autonomic nervous system- Autonomic nervous system measures.

3 Affect-modulated startle- Startle response magnitude.

4 Central physiology (CNS) – Electroencephalogram, Positron Emission Tomography, functional Magnatic Rasonanace Imaging etc.

5 Behaviour-Vocal characteristics, amplitude & pitch, facial behaviour- observed & EMG, whole body behaviour.

6 Peripheral measures- Affectometer, Actimeter, and Skin Conductance Response (SCR).

7 Test and Batteries- Perception of emotion test, Victoria emotion perception test, Florida affect battery, Aprosodia battery, Battery of emotional expression and comprehension, New York emotion battery etc. Ram & Tandon et al : Understanding of Human Emotions 531 Assessment of emotions [16]

Current emotional state helps us to determine appropriate strategy for interview or conversation with others and clue to mood state. Before assessment like any psychological assessment examiner should introduce him first, then purpose of assessment should be explained. Rapport is important to get the real status of emotions. People usually experience mixed emotions at a time rather than a single emotion. What we assess is often the predominant emotion among them. While assessing emotion both verbal (tone, loudness, melody etc.) and non-verbal component (Facial expression, Eye behavior, Gesture and body movement, Speech and pause, Posture, Proximities) should be elicited or observed.

Some of the dimensions for assessment are- 1) Appropriateness – Normally appropriate to situation and congruent to thought. Examine for inappropriateness and incongruence. 2) Intensity – Examine for intensity of emotion. Compare with a normal subject of same socio-cultural background. Note for heightened, shallow, blunted or flat affect. 3) Mobility – Usually emotion is mobile, changes with theme of thought. Examine for labile or fixed affect. 4) Range – Normally subject should be able to experience /express all categories of emotion. Look for limited experiencing of certain emotions only. 5) Reactivity- Emotional reaction to a given stimuli. Subject may be asked to display expression (e.g. facial) for different emotions or given a stimulus to elicit an emotion and observed.

Assessment of mood [16]

Information about different dimensions of mood status (over a given period of time) has diagnostic and therapeutic implication. Common aspects for mood assessment include -1) Quality- How did subject feel over a given time? What is the mood like? 2) Stability- Whether mood was same for given time or it changes? 3) Reactivity – Whether mood changed in response to events? 4) Intensity – How they rate the intensity of feeling state e.g. Out of 100 how much they score for intensity of mood? 5) Duration – What is/was the duration of the given mood state? 6) Congruent – What were the thoughts during the given duration of mood? Whether thought can be explained on the basis of mood?

Some aspects of emotion

Experience or expression of emotion is shaped by multiple factors such as age of the subject, gender, socio-cultural background, personality attributes, contextual factors, familiarity with person, past life experience etc. Some aspects to be discussed are age and emotion, cognition and emotion, socio- cultural aspects of emotion and emotional regulation. 532 Psychiatry in India : Training & training centres 1-Age and emotions

Fetus experiences the emotional state of mother through physiological changes of emotion translated through placenta. Fetal crying is reported in response to membrane rupture, manual displacement of head, attachment of monitoring electrode, and abortion at age of 21-22 week. Infant starts understanding positive and negative emotion in first year and become aware of others' emotions by second year [17]. Though the emotion is innate, child also learn due to conditioning, undifferentiated excitement, life's crisis and transitions, maturation, socialization and cognitive development [18].

Pattern of emotional experience changes with age; older adults are less adept than younger at recognizing at least some basic emotions in each modality, especially anger and sadness. Different theories have been proposed for such observation.

1 The socio-emotional selectivity theory - A disproportionate preference for positive information emerges during aging known as the positivity effect [19].

2 The cognitive aging theory - With aging there is increasing optimization of positive mood states, an increased ability to understand and regulate emotions which deteriorate in advanced age [20].

3 Neural decline theory - The recognition of each basic emotion is directed by a complex interplay of brain structures. Differential aging and degradation of the brain (e.g. Frontal and temporal volume or changes in neurotransmitters) leads to age related changes [21].

4 Personality theory -Extraversion & openness to experience is helpful in recognizing more emotional expressions and it decreases with age [22].

2-Cognition and emotions

a) Judgment- Momentary emotion, influences evaluative judgment about the object/event that elicited the emotion (Integral effects) as well as, an unrelated object/event (Incidental effects) [23]. Emotion influences the processing style, feeds the specific information directly into congnitive process (Informational accounts ), provides rapid signals about objects in the environment, and that these momentary feelings feed into ongoing judgments about issues that are too complex to review and synthesize all the relevant evidence[23]. An emotion determines its core appraisal framework (appraisal tendency Ram & Tandon et al : Understanding of Human Emotions 533 framework) that account for the effects of discrete emotions upon judgment and decision making [24].However limiting attention to emotional stimuli can limit responses in appraisal systems.

b) Reasoning- Emotions may impair [25] or facilitate [26] logical reasoning. There is task-relevant versus task-irrelevant affect in shaping action tendencies. An individual difference in affect also influences the performance of reasoning tasks, revealing emotion-cognition interaction.

c) Selective Attention- Emotions direct attention to select a class of stimuli in the environment. Emotions have a bias effect on selective attention, perception and categorization in an emotion congruent fashion [27].

d) Memory - Emotion influences the quantity of remembered information (remembered more) and enhances the vividness of memory e.g. The September 11th terrorist attacks [28].Emotional arousal enhances memory, increases the durability of memory and memory vividness such as flashbulb memories[29].Intensity of valence has effect on memory of negative and positive events[30].Emotion can have dissociable effects on some forms of implicit memory compared to explicit memory[31].

e) Learning and behavior - Aggressive states tend to attribute hostility to the actions of others [32]; this has been reported in ADHD, conduct disorder and ASPD. Fear restricts the visual field, creates severe perceptual changes and limits the range and flexibility of cognitive processes [33]. Intense emotional set may result into illusion [1].

Emotionality along with temperament and environment can impede or facilitate the Development of Emotional Perception and Levelling (EPL) and other facets of Emotional Knowledge (EK) through a number of processes such as negative social feedback, upbringing in harsh environment (which results in strong negative emotions) and emotional dysregulation [34].

Patterns of emotional expression in toddlers predict their personality traits at pre-school age [35]. Trait emotions (e.g., shyness, fearfulness) predispose to experience these emotions at a higher level of intensity resulting into attentional and behavioral problems [36] .A broad pattern of negative emotions virtually define the trait of neuroticism.

3-Socio-cultural aspect of emotions

Collective emotions (emotions shared by large number of individuals in a 534 Psychiatry in India : Training & training centres society) and group - based emotions (emotions shared by members of a group) are determined by particular societal conditions, common experiences, shared norms, and socialization in a society or group [37]. It arises when members of a group focus their attention (Emotional atmosphere) on a specific short-term event that affects them as a group, and emotional relations are socialized (Emotional culture) in a particular culture. It is also experienced as a result of a society's response to its socio-political conditions (Emotional climate).

Society may also have the characterizing tendency to express (collective emotional orientation) and regulate a particular emotion differently [38], and has important behavioral implications when there are conflicts between groups and societies [39]. There are transitional events that make up the environment in which individuals and collectives function, which may have lasting effects for at least a period of few months and sometimes even for many years; such as intractable conflicts, wars, revolutions, peace processes, regimes of terror, information about major threats.

Cross cultural Patterns exist in experiencing and expressing emotions in social context [40]. Individuals are motivated to differentiate themselves from others in individualistic cultures but still motivated to fit in with others and conform to the expectations of their groups in collectivistic cultures [41]. Members of western cultures express their emotions, maximize their experience and expression of positive emotion and minimize their experience and expression of negative emotion more than do members of East Asian cultures (“stoic” and “inscrutable”) [42] .

Emotions and Sojourner adjustment is known for long. Ideal affect differs from actual affect (Affect Valance theory) and cultural factors shape ideal affect more than actual affect, whereas temperament shapes actual affect more than ideal affect. Emotion as an adaptive process requires appraisal of situations and the readiness to act to preserve one's well-being [43] and is learned through socialization which varies according to culture. Adjustment of sojourners can result into negative consequences such as culture shock, academic challenges, strained relationships with family and co-workers, financial problems, poor health, loneliness, and interpersonal conflicts[44]. To adjust, sojourners have to regulate negative emotions to avoid conflict and consequence of negative emotion on cognitions and motivations.

Sociological theories of emotion

The current theories of emotions focus on a limited set of structural properties as influencing emotional arousal: power, status, and perhaps density of networks. Most theories of emotions are micro-structural in focus, Ram & Tandon et al : Understanding of Human Emotions 535 but surely there are macro-dynamic emotional forces. Emotions are distributed across macro-structures. Some of the important social theories are -

1 Dramaturgical Theories - Individuals make dramatic presentations and engage in strategic actions directed by a cultural script [45].

2 Symbolic Interactionist Theories - Self is more than a dramatic presentation; it is a powerful motive pushing individuals to behave in ways that allow them to verify both trans-situational self-conceptions and situational role identities [45].

3 Interaction Ritual Theories - A common focus of attention, rhythmic movement of bodies, heightened emotions, and an emerging sense of external power or guiding thoughts and actions[46].

4 Power and Status Theories - Expectations (for gains or losses of power and status) are central to making predictions about particular emotions that will be experienced by individuals [47].

5 Exchange Theories -Productive exchanges that occur when individuals must cooperate and cannot fully separate their respective contributions and generate more intense emotions, whether positive or negative, than the other forms of exchange [148].

Emotional Regulation-

Two processes have been described in emotional regulation – a) Automatic (non-conscious, implicit or impulsive) processes- Simple registration of sensory inputs activates knowledge structures (schemas, scripts or concepts) that then shapes other psychological functions. Automatic regulation can be divided into two types: 1) Implicit ideas or goals a person has about emotional regulation and 2) Regulation behaviors that people use during emotional situations [49]. b) Deliberate (controlled, conscious, explicit, or reflective) processes - Attentional resources are volitional, and are driven by explicit goals [50].

1-Manipulating Emotion

a) Emotion eliciting Stimuli- Presenting emotionally evocative situations or classes of stimuli (scenes, words and faces with emotional expressions etc) elicits an emotion [51].

b) Mood Induction- it includes present emotional film clips, picture , 536 Psychiatry in India : Training & training centres audio / music, or to ask the subject to focus on emotional situations (real or imagined) that result in either positive or negative affect states, or a more specific state such as sadness or disgust[52] c)Pharmacological Manipulations- Introducing a drug that impacts emotional or social reactions. Drugs used in research are epinephrine [52], Propanolol [54], Oxytocin [55], dopamine agonists or antagonists.

2- Strategies of emotional regulation a) The antecedent-focused emotional regulation (situation selection) strategy - Seeking out or avoiding situations that one knows tends to produce certain emotional reactions [56]. b) Situation modification approach- it is changing the emotional impact of the selected situation [57]. c) Attention deployment strategy - Involves using of distraction, concentration, or rumination; focuses attention on feelings and their consequences [58]. d) Cognitive change strategies- Utilizing works by activating alternative meanings of the critical situation at hand [59] e) Cognitive change strategy of reappraisal [59] - Reappraisal used to reduce negative emotional experience and expression and increase positive emotional experience and expression as well [58, 60]. f) Response modulation strategy- The person attempts to modulate the response tendencies that have been triggered by the emotional experience [58]. g) The response-focused strategy of suppression - Hiding the display of emotions that are actually experienced internally [58, 59]. h) Emotional amplification - 'Faking or exaggerating the display of emotions that are not at all experienced or experienced at low levels internally[61] . i) Emotional Suppression - It is conscious inhibition of emotional expressive behavior while being emotionally aroused [62].

3-Personal and parental factors in emotional regulation

Different factors related to individual, context and environmental factors affect the appropriate and adequate emotional regulation required for the Ram & Tandon et al : Understanding of Human Emotions 537 individual. Two factors often associated are- a) Affective Style - there is inherent motivation to emotionally respond to and approach potentially rewarding situations (Behavioral approach sensitivity) with varied intensity and to avoid or withdraw (Behavioral inhibition sensitivity) from potentially threatening situations [63].

b) Parenting (The Mediating Effect of Emotion Regulation) - Children learn to regulate their emotional arousal and expression through parental response such as acceptance, coaching and problem solving and is positively associated with children's adaptive responses to negative affect. There is channeling effect of emotion-related negative parenting practices on children's social adjustment [64].

Coping with emotion

People cope differently with their bad mood. Common techniques used are self-reward, use of substance, distraction, expressing through behavior such as display, exercise etc. Some important methods used are:

1 Modifying the meaning or significance of the problem- Commonly used techniques are downward comparison (cognitive reappraisal), taking personal credit for success but blaming failure to external circumstances (attributional bias), changes in attitude, devaluating the suffering (just world hypothesis).

2 Problem directed action – Changing behavior to change the mood (inducing circumstances), combining negative feeling with positive expectation.

3 Affiliation- Taking social support to buffer the effect of emotion.

Emotional intelligence (EI)

The ability to perceive & integrate emotion to facilitate thought, understand emotions, and to regulate emotions to promote personal growth [65] .In general emotional intelligence (E.I.) refers to the ability to recognize and regulate emotions in ourselves and others [66].

Some models to explain the EI are:

1 An Ability Model of Emotional Intelligence - Ability to process information of an emotional nature and the ability to relate emotional processing to a wider cognition. They then posit that this ability is seen to manifest itself in certain adaptive behaviours. It includes emotional 538 Psychiatry in India : Training & training centres perception, emotional integration, emotional understanding, and emotional management [65].

2 Mixed intelligence model- It has 5 components of emotional intelligence: intrapersonal, interpersonal, adaptability, stress management, and general mood.

3 Goleman's model [67]. Outlines four constructs - self-awareness, Self- management, social awareness and relationship management [67].

Studies show that EI is a predictor of employee effectiveness, life satisfaction, and healthy psychological adaptation, positive interactions with peers and family, and higher parental warmth. Lower emotional intelligence has also been found to be associated with violent behaviour, illegal use of drugs and alcohol, and participation in delinquent behaviour and related to increased success among those who share similar positions [68]. Gender differences are inconclusive and alexithymia has been found to be inversely related to emotional intelligence.

Emotional Abuse

It is defined as repeated pattern of behavior that conveys to somebody that they are worthless, unloved, unwanted, or only of value in meeting another's needs. Prevalence of emotional abuse by partner is up to 46.7% in females & 30.2% in males [69].

Common types of emotional abuse are: rejecting, degrading/devaluing, terrorizing, isolating, corrupting, exploiting, denying essential stimulation, emotional responsiveness or availability, and unreliable or inconsistent caring [70].

Emotional abuse result into adult depression [71], Suicidality[72], anxiety[73], dissociation [73] and drug and alcohol use among college students[74] and personality disorders[75] .

Disorders of emotion [1]

Classification of emotional disorders includes:

1 Abnormal emotional predisposition- There is a particular tendency of emotional response such as hyperthymia, dysthymia, cyclothymia etc.

2 Abnormal emotional reaction- There is an intense emotional response to emotion evoking stimulus in the form of anxiety, panic, phobia, depression, Verstimmung, euphoria. Ram & Tandon et al : Understanding of Human Emotions 539 3 Abnormal expression of emotion- Emotional expression is very different from average normal reaction but not in type. It includes dissociation of affect, emotional lability, denial of anxiety (belle indifference), derealization, emotional indifference, apathy, perplexity.

4 Morbid disorders of emotion- Origin of heightened emotion is through underlying morbid process (disorder) resulting into depressed mood state, irritability, anxiety, ill-humoured state, euphoria, moria, witzelsucht, ecstasy etc.

5 Morbid disorders of emotional expression- origin of inappropriate expression of emotion is through underlying morbid process (disorder) resulting in to inadequacy and incongruency, parathymia, blunting, compulsive/forced affect, affective incontinence.

Implication of emotional and mood status

1) Diagnostic implication- Abnormal emotional experience involves almost all psychiatric disorders. It has a diagnostic implication in mood disorders, personality disorders, impulse control disorders, neurotic/stress-related and somatoform disorders, organic mental disorders & some childhood psychiatric disorders.

2) Treatment implication- Psychotherapy by definition is based on some correction to emotional components and is important focus when mood problem is focus of attention.

3) Advertisements - Ads use positive affect to make consumers like the ad and then buy the product, and negative affect to evoke an uncomfortable state that makes consumers want the “solution” offered by the advertiser[76] and appeals are usually, claim and fear based. Emotion intended by the advertiser is initially and automatically felt upon exposure to the ads, but subsequently “corrected” as consumers access their persuasion knowledge and “correct” their initial response [77].

4) Physical health- Numerous studies have found that negative emotions are associated with development of morbidity and mortality from a range of chronic illnesses, from cardiovascular disease[78], diabetes[79], asthma[80] to greater body mass. Positive emotions are linked to better immune functioning [81, 82], found experiences and longevity [83].

5) Morality and emotion- Several emotions such as guilt, shame, empathy, happiness & sadness play a fundamental role in morality. Varieties of primary, non-moral emotions such as happiness, sadness, and anger have been examined as predictors or correlates of moral behavior[84]. Empathy 540 Psychiatry in India : Training & training centres and sympathy is another's emotional state related to Pro-social/Antisocial Behavior [85]. Emotions help in moralization, morally relevant action is often emotionally motivated and perceived moral violations often evoke contempt, shame, anger or disgust.

6) Emotions and animals- Anger, frustration, love and joy are usually observed in domestic animals. The most robust evidence comes from the studies of drugs of abuse in animals [86] and the reward mechanism. Most scientifically compelling line of evidence comes from brain stimulation studies. Localized Electrical Stimulation of the Brain (ESB) can evoke several coherent emotional responses [87].

7) Affective forecasting -It is an act of predicting one's future emotions [88]. It has four components: a) Predictions about the valence of one's future feelings, b) The specific emotions that will be experienced, c) The intensity of the emotions, d) Duration of emotion. Accurate prediction may help to know the pattern of emotional experience and to take appropriate strategy on anticipated events. People usually make prediction of valence (good or bad feeling) [88], for events that will happen soon but are overly simplistic for events far in the future. Mispredictions are common and is due to overestimation of the enduring impact (Impact bias), duration (Durability bias), misconstrues , inaccurate theories, motivated distortions, undercorrection , focalism, immune neglect, framing effects, isolation effects, projection bias, expectation effects, hot/cold intrapersonal empathy gaps, emotional evanescence, adaptation level.

8) Gender and emotion - A gender stereotype of emotion is the ways in which males and females navigate the emotional world due to social norms; roles behaviour varies by context [89]. Most studies suggest that women are more emotional [90], show more emotional behaviour [91] and express emotions verbally more than males [92] & with high frequency and intensity [93]. From a developmental perspective male infants are often reported to be angry and female infants' as fearful [94]. A young child holds gender stereotypes by 3 years of age [95] and makes judgments about the emotions of others [96].During the preschool years, parents observed more happiness and sadness with girls & angerness with boys [97].

Different theories have tried to explain the gender difference. Some of them are : a) Normative theory : Male -female differences in feelings and expressive behavior are consistent with gender-specific emotional beliefs [98]. Ram & Tandon et al : Understanding of Human Emotions 541 b) Structural theory- Kemper's structural theory [99] about emotion predicts a pattern of subjective feelings for men and women that departs from cultural beliefs about gender and emotion.

According to Kemper, structural factors such as individuals' social position vis-a`-vis others; rather than culturally derived emotional norms, influence their emotional responses to social situations. c) Functional theory -Parsons's functional theory [100] about gender predicts male-female differences in subjective feelings and expressive behavior that are generally consistent with cultural beliefs about men's and women's emotions.

9 Emotion and genetics- Studies have identified role of gene variation in the 5-HTT (serotonin transporter protein) in the regulation of emotion [101]. Genetically mediated changes in 5-HTT function affect structure and function of key cortico-limbic pathways and may contribute to the emergence of individual differences in affect and temperament that are associated with 5-HTT gene variation.

Conclusion- There is no general agreement in defining emotion but most agree with psyco-physiological change accompanying emotion. Emotion has been classified based on basic processing nature or their adaptive function. There is neuro-anatomical and neuro-chemical evidence for biological basis of emotion. Emotions may be assessed clinically and using a psychological tool. Emotion is shaped by multiple factors such as age of the subject, gender, socio-cultural background etc. EI has been shown to correlate with personal and organizational emotional health. Emotional regulation is an important factor in determining expression of emotion and is mediated by different individual and environmental factors. Emotional abuse has been attributed as an etiological factor of a mental health problem. Further studies are needed to ascertain how psychological factors interact with biological factors in expression, experience and disorder of emotion.

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Trends Cogn Sci. 2006 ;10(4):182-91.

Dushad Ram Asst. Professor of Psychiatry Dept. of Psychiatry JSS University, JSS Hospital (JSS Medical College) M.G. Road Mysuru-570004 Karnataka. [email protected]

Abhinav Tandon Hon. Asst. Editor,Indian Journal of Psychiatry Director & Consultant Psychiatrist, Dr AKT Neuro-Psychiatric Centre, Allahabad,UP & E.SR, MLN Medical College, Allahabad, KGMU, UP

M.S. Darshan Director & Consultant Psychiatrist, Prerana Hospital Mysuru, Karnataka

Payel Roy Consultant Psychiatrist, Psychiatric Hospital, Kolkatta, West Bengal. 56 Importance of networking during psychiatric training

S. Kalyanasundaram

ABSTRACT

Psychiatric training, be it MD, DNB or DPM, needs to take a comprehensive approach. Unlike other fields of medicine, treatment is not restricted to the patient alone. Almost always it involves many significant family members and at times the community around the family also needs to be incorporated in the management plan.

The understanding of causation of psychological problems and their management also has undergone sea changes. From a purely psychological and psycho-dynamic appreciation of the problems, we have moved a long way in our perception and treatment strategies for these psychiatric illnesses. The explosion in the field of Neurochemistry, our improved knowledge in the functioning of the brain, advances in neuroimaging, newer drug discoveries have all contributed to the fact that we are able to offer better solutions to the various psychiatric illnesses.

However, the fact that we understand the brain and the various receptors better should not lull us to believe that all psychological problems can be managed by medication and medication alone. The psychiatrist in training should be offered a comprehensive programme that will equip him / her to deal with the individual as a whole, and also must possess sufficient knowledge and training to help the family that undergoes enormous distress. Networking with other sister disciplines like psychology, psychiatric social work, a sound knowledge in basic neurosciences and the understanding that psycho-social rehabilitation indeed should form a component in the total management plan, especially in certain chronic mental illnesses, will go a long way in making the training comprehensive.

It is said that a good doctor knows the disease well, but a great doctor knows the patient well. This rings true especially of psychiatry. 548 Psychiatry in India : Training & training centres

Traditional psychiatric training in institutions focuses largely on the medical model. The biological basis of the illness is what is most stressed and unfortunately at the expense of other psycho-social contributions to illness and illness behavior. Although this is not true of all training institutes, this pattern prevails at least in some. Mere understanding of the various facets of mental illness in terms of brain substrate, neuroanatomical and neurophysiological parameters, neurotransmitters, and receptors alone is insufficient in understanding the complex nature of these disorders.

With the understanding that the psychiatric illnesses have strong components of biological, psychological and sociological reasons for causation of these illnesses, its stand to reason that the training of a budding psychiatrist should focus on all these aspects with equal measure. Unfortunately, some of the training centres lack the personnel and / or the support departments to offer training in these areas. This in turn will result in churning out some “biologically oriented psychiatrist”, a term some “proudly” wear on their sleeves. It is a pity indeed. These young doctors cannot be blamed for their orientation but the teachers will have to take their share of blame too.

The years of residency training in psychiatry should not be undermined as providing clinical knowledge and skills alone, but also is crucial as it is the formative years of developing the right attitude to patient care. Training should equip the resident in a wide range of clinical and non-clinical competencies and also ensure that the graduate has a network of colleagues in all the fields of psychiatry1. Clinicians will need to broaden their outlook and network with other professionals in non-psychiatric disciplines. It is for this reason that the training scheme must offer the benefits of a wide range of clinical and non-clinical opportunities.

Some institutes have full complement of teachers in these major disciplines, viz., Psychiatry, Psychology and Psychiatric Social Work. However, not all of them are able to provide the correct interdisciplinary approach in managing those with psychiatric illnesses. One of the reasons is because there is no unity amongst the faculty of these disciplines, at times resulting in inter- departmental rivalry. This inevitably results in poor co-ordination in training, and the obvious casualties are the students who, in turn, tend to follow the trend set by the seniors in taking sides with one particular discipline and in some instances this continues through their lives. It is saddening to note that the ultimate sufferer is the patient. This is because, depending on whom they choose to see for their problem, they get the method of treatment offered by the person's orientation. A well-rounded training for a psychiatrist should include a sound knowledge in psychiatry, psychology and psychiatric social work with sufficient grounding in neuroanatomy, neurophysiology and a Kalyanasundaram: Networking in psychiatric training 549 sound knowledge of neurology and basics in general medicines. One should not forget that our beneficiaries are the patients and they deserve the best that we can offer and not to get one's favourite method of management with no biases for or against. It is therefore imperative that proper networking amongst various disciplines in the mental health sector is mandatory in the imparting of comprehensive training modules in psychiatry.

One of the goals of adult psychiatric training2 at the Department of Psychiatry at Harvard Medical School is to get psychiatric residents to understand the psychological, social, economic, ethnic, family and biological factors that influence development as well as psychiatric illnesses and treatments. Ragins3 opines that a medical model role is simply unsuited to building a reasonable relationship with many people with serious mental illnesses, and that learning how to treat neurochemical imbalances is in no way adequate to meeting the daily challenges of a psychiatrist's work.

In psychiatry, recovery is not characterized by symptom control alone. There are complex psycho-social intermediating variables that influence clinical outcome. Training in the basic sciences – neuroscience and psychopharmacology – alone does not give a holistic picture of the patient. At the most, it yields an incomplete and often misleading picture of 'improvement'. Let the psychiatrist not be mistaken like the Emperor and his new clothes, and rest on false laurels.

Another area which is often lacking in training is that of Liaison psychiatry. It is an important component of training in psychiatry and this involves a considerable amount of networking with physicians in a general hospital set- up. Inadequate exposure to such an important component during training can leave the emerging specialist bemused when they face real life situations in the real world, away from the protected institutional (mental hospital) environment.

A glaring omission in residency training in most centres is one on Psychiatric rehabilitation. Unfortunately most of them offer mere theoretical inputs only, almost as an afterthought and apology. Needless to say, as most Institutions do not offer any rehabilitation services for their patients, the students also get no exposure, whatsoever, in the rehabilitation aspects of management of those suffering from chronic mental illness. Unless, at least two weeks of hands-on training is offered to these trainees, they will have no idea of what can be offered for these patients. In fact, rehabilitation planning and management of the individual and their families should form part and parcel of a total management plan especially for the chronic mentally ill. Networking between psychiatric training institutes and the voluntary sector and NGOs is vital to have trainees get an exposure to the often neglected component of 550 Psychiatry in India : Training & training centres rehabilitation in psychiatric care. Not offering rehabilitation to such patients is akin to not providing physiotherapy for the orthopedically injured after the initial treatment has been completed!

Ragins3 put forth a strong case for why psychosocial rehabilitation deserves to be included as an important part of psychiatric residents' training, and is not to be viewed as an adjunct to clinical treatment, but as an integrating model. Drawing largely from his personal experiences and work as a psychosocial rehabilitation psychiatrist, he says the view of the psychiatrist among most rehabilitation users is that of “them", as being distant and insensitive, as the outside system. Stating that it is also clearly true that very few psychiatrists have ever had substantial exposure to, training in, or work in rehabilitation/recovery settings, he advocates such exposure for trainees as it helps to change many traditional ways of working. It also calls for a lot of unlearning, as the kind of helping relationship in the psychosocial rehabilitation model is really quite different from the traditional doctor- patient relationship and probably the most difficult transition for residents to make.

The resistance towards expanding or non-traditional role (as in being part of a multi-disciplinary team) and reluctant to depart from the medical model doctor role must be addressed in the residency period. The medical model emphasizes the doctor-patient (or therapist-client) dyad as the only effective treatment modality. Sometimes, clinical practice requires a paradigm shift and the focus should be on helping people in their entirety; not on relieving symptoms or suffering, but on promoting personal growth and change2. Teaching someone how to use medications to help gain control of their illnesses is no doubt very important, but in most instances it is not enough, as the individual has to be seen in his totality and within his family and community environs.

Mental health care in our country encompasses both public and private realms of health care. The private sector has been increasing year by year and there are many independently practicing general practitioners and specialists and a network of private hospitals4. The government funded service functions on a three tier level, with primary health centres covering a defined area. The secondary level comprises various district hospitals. On the tertiary level are various medical colleges and centrally funded hospitals with sub-specialties. Psychiatric training must equip students with an understanding of the organisation of health care and integrating psychiatric care in general health care. Das et al4 recommend evolving a consistent national programme of training, and more involvement of the main organisation of Indian psychiatrists — The Indian Psychiatric Society —in the process of training and services planning. Kalyanasundaram: Networking in psychiatric training 551 Community psychiatry appears to be low on the priority list of the government and funding is a major issue. In terms of providing psychiatric care, there is a need for a more coherent and involved policy from the government and national bodies (i.e. The Indian Psychiatric Society) alike4. Training must focus on networking between various departments of the Government, between Government and the voluntary sector likewise.

Trainees also need to develop liaisons outside of the training institution into the larger professional circles. Foreman et al5 highlight the benefits for residents of participating in professional medical organizations, and how this may relate to three areas of professional life: (1) gaining a broader perspective of the residency training experience, (2) supplementing residency education, and (3) establishing a network of colleagues with similar interests. Joining professional organizations allows the resident to learn from peers about available resources in the community and expands his / her scope on patient care. Collaborating in organizations helps residents to learn about political trends that directly affect the way mental health care is delivered and provides avenues to advocate for change that is beneficial to patients and the profession

The ultimate goal of training must be to get students to be able to realize the motivation for why they choose to become a psychiatrist in the first place, and develop the human touch to be closer to the people they work with. This will certainly make their work more effective and get them closer to the lives of patients and their families alike.

REFERENCES

1. http://www.westmidlandsdeanery.nhs.uk/SpecialtySchools/PostgraduateSchool ofPsychiatry/CorePsychiatryTraining.aspx 2. http://www.hms.harvard.edu/psych/education-residency.htm 3. http://www.village-isa.org/Ragin's%20Papers/Training_PSR_pscyhs.htm 4. Das, M, Gupta N, and Dutta K Special articles: Psychiatric training in India. The Psychiatrist (2002) 26: 70-72. 5. Foreman T, Dickstein, LJ, Garakani, A (Editors) A Resident's Guide To Surviving Psychiatric Training - 2nd Edition http://www.psych.org/MinMenu/EducationCareerDevelopment/ ResidentsMembersinTraining/residentsguidetosurvivingpsychiatrictraining.aspx

S. Kalyanasundaram Principal RF PG College, Hon. CEO Richmond Fellowship Consultant Psychiatrist, Bangalore. [email protected]

57 Organicity in Psychiatry: Pitfalls and Strategies

Charles Pinto, Alka A. Subramanyam

As early as 348 B.C., Plato had described the psyche or soul and the soma or body1. He described the body as being secondary to reasoning and rational thought. Any imbalance between psyche and soma, led to illness. Perhaps these are the oldest records that we have of the mind-body connect.

Though Plato described psyche and soma, he emphasized on the division between the two. It was his student Aristotle, who through his numerous observations described the interaction between the mind and body, and the synergistic effect, rather than the divisive effect. By the 1800s the western world had started recognizing medicine as a specialized discipline, with psychiatry as a further specialty. Hysteria became a cause of much interest through the works of Janet, Charcot, Breuer, and others. Freud’s work1 with Breuer and Charcot led him to do intensive work on hysteria and neuroses, which eventually led to the evolution of the theory of mind and psychosexual developmental theory, which formed the basis for a large part of modern psychiatry and psychosomatic medicine. Thus, most of the physicians in the 18th and 19th centuries were in fact neuropsychiatrists, addressing neurological and psychiatric disorders alike.

It was the 20th century that separated neurology and psychiatry2 into two distinct and somewhat water tight disciplines. For years the terms organic and functional were used to respectively differentiate defined pathological lesions and physiological abnormalities that could not be detected by existing laboratory procedures. This artificial boundary created by scientists, was clearly dissolved by tremendous research in modern psychiatry at the cellular and biological level, genetics and imaging. Definitely today, the involvement of the ‘brain’ being the seat of involvement and pathology in mental disorders is widely accepted. Scientific advances in recent decades have made it clear that this previous separation is arbitrary and counterproductive2. 554 Psychiatry in India : Training & training centres Few know that even in the DSM-IV-TR1, the term ‘Mental’ in the title is used due to lack of an appropriate substitute and that it unfortunately implies a distinction between “mental” disorders and “physical” disorders that is a reductionistic view of mind / body dualism. DSM-IV introduced the category ‘Mental Disorders due to a General Medical Condition’ to designate psychopathological syndromes which are known to be symptomatic manifestations of a systemic medical or cerebral disorder. ICD – 10 maintains “organic” as a super-ordinate category. ICD-10 indicates that the dysfunction may be primary, as in diseases, injuries and insults that affect the brain directly or with predilection, or secondary, as in systemic disorders that involve the brain1. The ICD-10 recommends 4 very appropriate criteria for classifying a syndrome as organic, which are perhaps the best we currently have: (1) Evidence of cerebral disease, damage, or dysfunction, or of systemic physical disease, known to be associated with one of the listed syndromes. (2) A temporal relationship (weeks or a few months) between the development of the underlying disease and the onset of the mental syndrome. (3) Recovery from the mental disorder following removal or improvement of the underlying presumed cause. and (4) Absence of evidence to suggest an alternative cause of the mental syndrome (such as a strong family history or precipitating stress) In 1998,the International Neuropsychiatric Association, defined ‘Neuropsychiatry’ as “a field of scientific medicine that concerns itself with the complex relationship between human behavior and brain function, and endeavors to understand abnormal behavior and behavioral disorders on the basis of an interaction of neurobiological and psychological–social factors”. Organic psychiatry is another umbrella term for neuropsychiatry related fields and Neuropsychiatry is reemerging as an integrating conceptual focus for both psychiatrists and neurologists.

APPROACH TO A PATIENT Rambhai is a 45 year old patient, treated by you in the past, with an excellent response for Bipolar Depression. This episode, however, he has started consuming alcohol, his wife has left him and though he does respond to the treatment, there are a few residual features and you notice he remains withdrawn and irritable. His son says his mother’s absence must be the cause. How confident are you that the change in his symptomatology/response is only psychological? Charles Pinto & Subramanyam: Organicity in Psychiatry 555 It turned out that imaging revealed a frontal meningioma. Thus, virtually every patient that walks into your clinic, either new or old, could turn out to be a patient who has some underlying medical disorder, even if previously diagnosed with a primary psychiatric illness. It is thus wiser to be safe, rather than sorry and to perennially be suspicious, in the best interest of the patient, in order to pick up even the slightest suspected digression. A few helpful guidelines2 in approaching the patients: A. Always consider the possibility of organic disease2- If you do not look for it you will not find it. 1. Be suspicious of “medical clearance”. People with mental disorders get physically sick too. Even seemingly innocuous complaints like a minor febrile illness or a cough should be dealt with, with the same sincerity in both psychiatric and non-psychiatric patients. 2. Be alert for medical illnesses, especially when you get referrals for patients like these - New onset history>40 years of age - First onset, acute symptomatology - Coexistence of chronic disease - History of head injury- recent or otherwise - Change in pattern of existing symptoms eg. Headache, obsessions, delusions etc. - Distinct worsening with any psychiatric medication - Complete lack of response to optimum psychiatric treatment

3. Watch out for obvious medical symptoms: - Change in headache pattern - Visual disturbances, either double vision or partial visual loss - Deficits in speech- local like dysarthrias or central like aphasias. - Variations in vital signs like pulse, temperature and blood pressure. - Disorientation - Memory impairment either acute or chronic - Fluctuating sensorium - Abnormal involuntary movements - Frequent urination, increased thirst - Significant change in weight, either gain or loss 556 Psychiatry in India : Training & training centres 5. Do not assume that a certain symptom “must” be of psychological origin. At times even the most exciting psychological syndrome/ symptom, as demonstrated in the next table1, could be of medical origin

Delusion Content Seen in Capgras syndrome Someone, usually a family Intracerebral hemorrhage, member, has been HIV encephalopathy, temporal replaced by an identical- lobe epilepsy, hypothyroidism, appearing imposter. vitamin B12 deficiency Fregoli Syndrome A persecutor takes on the Epileptic psychoses form of others in the environment. Syndrome of The familiar person and Epileptic psychoses Intermetamorphosis the misidentified stranger share physical as well as psychological similarities. Heutoscopy (the One has an exact double Migraine, intracranial syndrome of doubles, hemorrhage, encephalitis. the doppelganger) Othello syndrome One’s mate is unfaithful Huntington’s disease,, encephalitis,general paresis De Clerambault One is secretly loved by Alzheimer’s disease, CNS syndrome (erotomania) another, usually someone tumors, toxic psychoses of higher social or economic status. Ekbom syndrome One is infected by insects Vitamin B12 deficiency, Iron (acrophobia, or vermin deficiency, toxic psychoses. parasitophobia, delusion of infestation) Lycanthropy (werewolfism) One is periodically LSD use transformed into a wolf or other animal. Delusional phantom Unwelcome guests are Alzheimer’s disease boarder living in the home Picture sign Individuals seen on Alzheimer’s disease television or in magazines are present in the home. Dorian Gray Syndrome One is not aging Alzheimer’s disease Koro One’s penis is shrinking Corpus callosum tumors, and retracting into the Right brain strokes. abdomen Reduplicative paramnesia One has been relocated, Recovery from acute usually to a position closer confusional states to one’s home. Charles Pinto & Subramanyam: Organicity in Psychiatry 557 B. Always do a basic medical work up

Most psychiatrists know how to take a remarkably good and detailed history. Most physicians do a thorough and good general and neurological examination. Unfortunately the vice-versa is not true in either of the cases.

As clinicians it is imperative that we not only learn the basics of a good examination, and help our colleagues learn the basics of detailed history taking, but continue practicing the same even as we advance in our practice; so as not to miss any symptom-medical or psychological. Therefore the following always helps:

1. A brief, but vital general examination2:

- General appearance: How does the person look? Do they appear ill or ‘toxic’ as physicians normally say? Then go to more specific observations. - Vital signs- Pulse, temperature, blood pressure - Skin: Colour and texture are perhaps the best indicators to watch out for illnesses like anaemia, jaundice, hypothyroidism etc. - Eyes: Icterus, exophthalmos, papillary reaction, nystagmus and fundus abnormalities must be ruled out. - Movements: A wide variety of movements may signify organicity: tremors, chorea, athetosis, asymmetry, ataxia, stereotypy etc. Though commonly assumed to be the side effects of medication(psychiatric or otherwise), these may require more detailed evaluation. - Gait disturbance may be present varying from gait of circumduction, shuffling, to a wide based gait.

2. Relevant laboratory investigations2

A few common lab investigations can become vital in helping differentiate or pick up medical signs and symptoms - Complete haemogram, for Hb, as well as CBC for underlying subclinical infections - Thyroid function tests(Subclinical hypothyroidism and depression are almost indistinguishable and have fooled even the best of clinicians) 558 Psychiatry in India : Training & training centres - Blood sugar analysis (along with urine sugars if required) - SGOT, S.Bilirubin (especially for substance users, or patients on medications like anti-epileptics) - HIV - S. Vit. B12, S. Homocysteine (For memory loss) - S. proteins (in cachexia, catatonia)

C. Develop a “differential diagnosis”2

It is not important that you get a specific diagnosis, but to think of possibilities that may be considered whilst dealing with these suspected symptoms.

Hence we can divide the symptoms into the following categories3:

1. Psychiatric symptoms of organic disorders

Illnesses like cerebral tumours, multiple sclerosis, SLE, HIV etc, are known to have manifestations of psychological symptoms like depression, delusions, hallucinations etc.

2. Psychiatric illnesses occurring as an indirect result of organic illness

The commonest illnesses in this group might be the post- operative depression which develops after cardiac by-pass surgeries, or other supra-major surgeries. Even the secondary depression that develops in long standing RA, Diabetes, strokes, Charles Pinto & Subramanyam: Organicity in Psychiatry 559 epilepsy etc., may be included in this group. The table below though exhaustive, provides a quick overview of common medical conditions4 that may be associated with psychiatric symptoms.

3. Organic and psychiatric illness occurring together by chance

A study done by David Katerndahl and researchers found that incidence of panic disorder and coronary plaques5 were very high. The fact that these may co-exist, or are difficult to differentiate and treat, may give us a clue that we are actually dealing with co- morbidity. In fact, patients with panic attacks and chest pain were more likely to approach a cardiologist, rather than those without, and benefit from early intervention.

10% of patients with conversion symptoms are known to develop some or the other neurological problem during the course of their illness3. The existence of seizures and pseudoseizures in the same patient too, is a well accepted scientific phenomenon.

4. Psychiatric side-effects of medication

Many medicines used in general medical practice, are known to pre-dispose to psychiatric symptoms. For eg. Chloroquine, INH and emergence of psychotic features; Reserpine and depression, Zonisamide and suicidality etc. are often seen

5. Medically Unexplained Symtoms (MUS) in psychiatric patients

A group of researchers from Taiwan have done a very appropriate study on Medically unexplained Symptoms or MUS6 where they found 9.5% of their population of psychiatric patients had significant medical symptoms, not accounted for by a diagnosable medical illness; at the same time did not fulfill criteria for somatoform disorder, yet the symptoms were significant enough to cause distress to the patients. They defined this as MUS, which promises to be an accepted phenomenon in psychiatric populations. These patients were found to have high correlation with sub-syndromal anxiety and depressive symptoms.

Conversely, another group of researchers did a study on patients diagnosed with Irritable Bowel Syndrome7- Mayer, David A. Seminowicz, PhD, and colleagues at UCLA and Canada’s McGill University used sophisticated scans to compare the brain 560 Psychiatry in India : Training & training centres anatomy of 55 women with moderate IBS to 48 age-matched healthy women.

What was interesting was their finding of thinning of the grey matter in specific areas of the brain. The affected areas involved were:

l Dampening the brain’s arousal system. IBS patients tend to be over-sensitive to (and hyper-vigilant for) bowel sensations.

l Brain thinning in this region was seen only in patients who listed pain as their most bothersome IBS symptom.

Importantly, brain areas linked to anxiety and depression were no different in IBS patients than in anxious or depressed people without IBS.

On the other hand, in chronic pain syndromes, nerves constantly send increased pain signals to the brain. But in IBS, the brain itself seems to be amplifying pain signals it receives from the bowel.

Thus here we have a medically accepted disorder, which however has, let us term it, psychologically unexplained symptoms or PUS, with a neuro-anatomical correlate to the same.

Both MUS and PUS will probably be entities which receive much attention and research in the future, and may provide the key link in helping us effectively deal with patients individualistically, rather than in groups of disorders and/or diseases.

D. Work with and actively involve other consulting physicians2

It is imperative to liaison with co-consultants in other faculties. It may be difficult in private practice particularly, as patients are reluctant to go around to numerous doctors. However, if in doubt, always consult another practitioner, regarding your own doubts while dealing with medical symptoms. Those working in multi-specialty/teaching hospitals can always refer the patient to various other specialists, in order to deal effectively and holistically with all aspects of the patient’s complaints.

These simple steps could perhaps help us go a long way in effectively treating any emergent medical events/symptoms in our patients. Unfortunately, as physicians we still tenaciously cling to the old dichotomy of two categories of illness: functional and organic, which perhaps it is time we let go off. The new approach has to accept the co- Charles Pinto & Subramanyam: Organicity in Psychiatry 561 existence of both i.e. psyche and soma and effect of both on one another as a rule, rather than an exception. In fact, the basis of psychosomatic medicine or consultation liaison psychiatry is this. Diagnosis, approach and treatment modalities then become more individualized, holistic and complete.

A beautiful view was put forth by Professor Stanley Cobb8, Bullard Professor of Neuro-pathology at Harvard we quote:

“The term ‘functional’ is frequently misused to mean ‘psychogenic.’ This is a barbarism of the clinic, but has become almost routine out-patient slang. ‘Functional’ is a useful word in physiology and architecture. It should not be spoiled by other less acceptable usages. ‘Organic’ is used in a hazy way to mean that since ‘organs’ are involved there is something ‘really wrong. ‘More specifically the users of ‘organic’ usually mean in psychiatry that there is a lesion of the brain. (‘Lesion’ being a visible abnormality.) If they mean this, why not say definitely what organ is meant and speak of ‘cerebral lesions’?. . .In a provocative fashion which would not please all modern philosophical concepts of the brain- mind relationship he averred:

“1. No biological process goes on without change in structure;

2. Wherever the brain functions there is organic change;

3. The brain is the organ of the mind.

If we accept these three we must admit that ‘organic’ change takes place whenever a person has a thought. This is an important function of the brain. All function is organic, so the slang use of the term ‘organic’ or functional’ is meaningless. If a line is drawn arbitrarily, its position is ordained by the point to which technology has advanced in the year... In other words, the line between ‘organic’ and functional’ (and between physical and mental) is an artefact.”

REFERENCES

1. Ameen S., “Organic Mental Disorders” at www.psyplexus.com/neuropsychiatry /introduction. Visited on 21st Dec, 2010 2. Diamond R., Psychiatric Presentations of Medical Illness - An Introduction for Non-Medical Mental Health Professionals - accessed on 19th Dec, 2010 – www.alternative mentalhealth.com 3. Saoud Al Mualla, Organic Mental Syndromes (Organic Causes of Psychiatric Symptoms) at http://www.articlesbase.com -website visited on 21st Dec., 2010 4. Linda Chuang, MD ,Mental Disorders Secondary to General Medical Conditions Available at www.e-medicine- Organicity in Psychiatry-DT\mental disorders in medical conditions.htm Accessed on 20th Dec, 2010 5. David Katerndahl, Panic & Plaques: Panic Disorder & Coronary Artery Disease, J Am Board 562 Psychiatry in India : Training & training centres Fam Med. 2004;17(2) © 2004 American Board of Family Medicine 6. Li CT, Chou YH, Yang KC, Yang CH, Lee YC, Su TP; Medically unexplained symptoms and somatoform disorders: diagnostic challenges to psychiatrists, J Chin Med Assoc. 2009 May;72(5):251-6 7. Daniel J. DeNoon, Irritable Bowel Syndrome in the Brain. Available at Medscape- WebMD Health News @2010. Accessed 21st Dec, 2010. 8. Cobb S. Foundations of Neuropsychiatry. 6th edn. Baltimore, Williams & Wilkins Co, 1958. 124-7.

Charles Pinto Prof. Emeritus Department of Psychiatry TNMC & BYL Nair Ch. Hospital Mumbai [email protected]

Alka A. Subramanyam Asst. Professor Department of Psychiatry TNMC & BYL Nair Ch. Hospital Mumbai 58

Assessment and management of acute alcohol intoxication

Narayana Manjunatha, Deepak Jayarajan, Vivek Benegal

ABSTRACT

Acute Alcohol Intoxication (AAI) is a most frequent and often neglected clinical condition encountered at emergency departments of hospitals. It is a transient, benign and reversible clinical condition and requires no specialized skills. Assessment and management often require prevention or management of complications of AAI or associated medical conditions rather than management of AAI per se. 'Seven consecutive steps' for assessment and management of AAI in clinical setup are presented.

Key words: Alcohol intoxication, assessment, management.

ACUTE ALCOHOL INTOXICATION

Acute Alcohol Intoxication (AAI) is a transient, mostly benign, clinical condition frequently encountered in emergency departments, in primary care hospitals, deaddiction centers and referral hospitals. Hence, all clinicians especially psychiatrists should be confident of managing this. Management of AAI predominantly focuses on prevention or management of complications of AAI rather than the management of AAI per se. The term 'alcohol' in this chapter refers to “ethanol”. Management of methanol poisoning requires a different approach.

AAI is a transient condition following the consumption of alcohol, and results in disturbances in the level of consciousness, cognition, perception, affect, behavior, or other psycho-physiological functions and responses [1]. The severity of AAI is closely related to dose of the alcohol consumed. The intensity of intoxication lessens with time as alcohol gets eliminated rapidly following zero order kinetics (at the rate of one unit/hour) 1 in all alcohol users 564 Psychiatry in India : Training & training centres and the effects eventually disappear in the absence of further use of alcohol. Recovery is therefore complete except where tissue damage or another complication has arisen.[1] CLINICAL FEATURES The common presentation of AAI in the emergency department is the presence of incoordination and confusion.[2] The patient typically has slurred speech and an unsteady gait. He or she may misinterpret perceptions from his or her environment. Inappropriate aggressive behavior or emotional outbursts are also common. Uncommon presentations include coma, syncope, any inappropriate behavior, any neurological abnormality with or without trauma/traffic accident and bodily injury, hypothermia and only behavioral problems. The World Health Organization (WHO) has standardized a grading of alcohol intoxication (ICD 10: Y91 codes) Table 1which can help medical personnel in deciding the severity of AAI.[3] . AAI is a frequent risk factor for adverse events such as traffic accidents, injuries and hypothermia. Intoxicated patients may display a variety of neurological symptoms, which may not be specific. The presence of gastro- intestinal symptoms in AAI such as nausea, vomiting and abdominal pain, could be early signs of alcohol toxicity. ASSESSMENT AND MANAGEMENT OF AAI Assessment includes history taking and physical examination concurrently. Unfortunately, most often patients or family may not give a reliable history. In addition to unreliable history, findings of physical examination in AAI are less specific and less sensitive. The breath may smell of alcohol, but it is neither sensitive nor specific i.e., alcohol-induced coma may present without alcohol smell and alcoholic smell does not prove that alcohol is the main problem. The following seven consecutive steps for assessment and management of AAI are presented. 1st Step: Assessing the vital functions is the first crucial step. This follows mnemonic “RBC” as below.[4] A. Check Responsiveness – Does the patient respond to loud talking, or shaking? B. Check Breathing – Look, check, feel. Observe for respiratory movements of chest and abdomen. If in doubt, place the palm of the hand on the abdomen of patient and feel for any movements or place

1 One standard International unit = 12g of ethanol contained in 30 ml. spirits = 330 ml. beer and xx ml. of wine. Narayana Manjunatha et. al. Acute alcohol intoxication 565 the back of the hand near the mouth or nose to feel any air movements. If inadequate, start oxygen via nasal cannula or face mask. If weak or absent, check for obstacles for breathing and prepare for intubation. C. Check Circulation – Palpate for radial artery pulsation. In case of feeble or absent radial artery pulsations, check for carotid artery pulsations. Check for pulse and blood pressure. In case of weak pulse or hypotension (systolic pressure below 90 mm Hg), start normal saline (NaCl 0.9%.500 ml) by rapid intravenous infusion; repeat if needed. Norepinephrine continuous intravenous infusion (0.5 to 1 micro gm /min) may be required if hypotension is refractory to saline. Evaluate further for causes of hypotension, e.g., bleeding, etc. * In case of unresponsiveness or inadequacy in breathing and/or circulation, advanced life support and cardio-pulmonary resuscitation is warranted in an intensive care unit. In case of relatively stable vital functions in above 'RBC' steps, there is scope for intervention at primary health centre for better outcome. 2nd Step: Assessment for life threatening head injury and other complications The second most crucial aspect for all clinicians in the management of AAI is to search actively for head trauma in every patient. Most often, there is inadequate history about head injury and clinicians have to depend on clinical signs such as pupil size and reaction, and on their clinical intuition. Please note that difference in size between pupils and absence of reaction to light is one of the most helpful clinical indicators for head injury. When there is a difference in size between pupils or the absence of a light reaction, consider recommending a non-contrast computed tomography (CT) of brain. Other indications for brain CT scan is the history of head injury, worsening/no improvement in mental status while observation within 2-3 hours after admission. After assessing vital functions and head injury, proceed to complete physical examination which must include searching for signs of alcoholic liver disease and infections. All clinicians should be aware of complications which may occur in AAI [Table 2]. While the causes for confusion and coma are manifold, clinicians should be aware of the most common causes for confusion and coma while evaluating AAI. These are hypoglycemia, hypoxia, focal neurological disease (cerebrovascular occlusion or brain hemorrhage), intoxication with other sedating agents (benzodiazepines), seizure/post-ictal state, and thiamine deficiency. The management of life threatening and other complications are given in table 3 and 4. 566 Psychiatry in India : Training & training centres 3rd Step: Assessing the severity of AAI The clinical severity of AAI in a patient may be judged easily by the WHO grading of alcohol intoxication [Table 1]. 4th Step: Investigations If the facility is available, perform bedside random blood sugar measurements with a glucometer (please note hypoglycemia is a common cause of coma in AAI which may lead to irreversible brain damage) and send for electrolytes (sodium and potassium) along with liver and renal function tests. The alcohol specific laboratory markers like gamma glutamyl transferase (GGT) and CDT, if available, may be assessed. A breath alcohol level [BAL]- assessment is helpful in assessing intoxication levels if an intoximeter is available [Table 1]. 5th Step: Management of aggression in AAI It is difficult to manage the aggressive patients in AAI. Whenever possible, clinicians need to ensure a quiet environment, and sit down and listen to patient reasonably without confrontation and the use of restraints. Clinicians should not forget to reaffirm that they are trying to help the patient. If unmanageable, try to take consent for medication from the patient. BENZODIAZEPINES SHOULD NOT BE USED in AAI as they may result in respiratory depression; and benzodiazepine action is synergistic with that of alcohol, especially when large quantities have been consumed. The preferred medication in AAI for managing aggression or behavioral problems is an anti- p s y c h o t i c , s u c h a s i n j e c t i o n h a l o p e r i d o l 1 0 m g s t a t intravenous/intramuscular, which does not significantly depress the central regulation of respiration. Physical restraints should be used as the last option in management of AAI.[2] 6th Step: Monitoring the vital functions and progress the clinical conditions After initial assessment and management of AAI, the patient needs to be monitored for progress in his/her clinical condition along with monitoring of vital functions continuously. Appropriate clinical decisions require to be taken depending on additional information, such as CT scan of brain or if there is no improvement in the clinical condition. In case of adequate improvement, patient should undergo post AAI management. 7th Step: Post-AAI management After the complete recovery from AAI, further clarification of alcohol history and level of motivation to change should be assessed to determine further plan of management. In case of patients with alcohol dependence, withdrawal symptoms may be expected to appear soon after the resolution of Narayana Manjunatha et. al. Acute alcohol intoxication 567 intoxication and can be managed with adequate doses of benzodiazepines for detoxification along with usual treatment of the alcohol withdrawal syndrome. In case of first timers or persons with hazardous use of alcohol, motivational interviewing to facilitate change and prevent the emergence of dependence pattern should be done using a 5A's model (Table XX). Arranging for follow up of patients is required for further management, especially in cases of dependence that require long-term management. CONCLUSION AAI is a frequent encountered clinical condition in emergency department. Since it is a benign and reversible condition, clinicians should focus predominantly on prevention or management of complications of AAI rather than the management of AAI per se. To simplify practice, authors described the seven consecutive steps in the management of AAI. REFERENCES 1. World Health Organization. F10-F19 Mental and behavioral disorder due to psychoactive substance use. In; The ICD-10 classification of mental and behavioral disorders. Clinical descriptions and diagnostic guidelines. WHO. Geneva; 2002. Pp 72-74. 2. Pechlaner C, Joannidis M, Weidermann C. Acute alcohol intoxication. In: Handbook of alcoholism, (Eds) Zernig G, Saria A, Kurz M, O'Malley SS. CRC Press, Boca Raton- Florida; 2000; pp 49-64. 3. WHO; ICD 10: Y91 codes http://www.nimhans.kar.nic.in/deaddiction/1221/html/ publications.html 4. Bossaert L, European Resuscitation Council Guidelines for Resuscitation, Elsevier, Amsterdam, 1998.

Narayana Manjunatha Assistant Professor of Psychiatry Department of Psychiatry, MS Ramaiah Medical College Bangalore – 560054, INDIA E-mail id: [email protected]

Deepak Jayarajan Senior Resident Centre for Addiction Medicine, Department of Psychiatry National Institute of Mental Health and Neuro Sciences (NIMHANS) Bangalore- 560029, INDIA

Vivek Benegal Additional Professor of Psychiatry Centre for Addiction Medicine, Department of Psychiatry National Institute of Mental Health and Neuro Sciences (NIMHANS) Bangalore- 560029, INDIA 568 Psychiatry in India : Training & training centres Narayana Manjunatha et. al. Acute alcohol intoxication 569 570 Psychiatry in India : Training & training centres 59

Acute Management of Alcohol and Opioid Dependence.

Vishal Indla, Girish Menon, I.R.S Reddy.

Alcohol Dependence:

Alcohol dependence is a major problem in India. An estimated 34-42% of adult Indian population report having used alcohol in their lifetime while about 5-7% have been estimated to be having abuse of alcohol and 10-20 million people have been estimated to be in need of treatment for alcohol dependence.[1]

Nosology of Alcohol Dependence

The term “alcoholism” was split into “alcohol abuse” and “alcohol dependence” in DSM-III, and in DSM-III-R behavioural symptoms were moved from “abuse” to “dependence. Alcohol abuse is the repeated use of alcohol despite recurrent adverse consequences. Harmful use is a pattern of psychoactive substance use that is causing damage to health. The damage may be physical (e.g. hepatitis following injection of drugs) or mental (e.g. depressive episodes secondary to heavy alcohol intake).

According to the DSM-IV criteria for alcohol dependence, at least three out of seven of the following criteria must be manifest during a 12 month period:

o Craving: A strong desire or sense of compulsion to take the substance. The symptoms are elicited by internal and external cues that evoke memory of the euphoric effects of alcohol and of the discomfort of withdrawal.

o Tolerance: as defined by either of the following:

• A need for markedly increased amounts of alcohol to achieve intoxication or desired effect.

• Markedly diminished effect with continued use of the same amount of alcohol. 572 Psychiatry in India : Training & training centres o Withdrawal symptoms or clinically defined Alcohol Withdrawal Syndrome.

o Loss of control: Use in larger amounts or for longer periods than intended. Considerable amount of time is spent in obtaining alcohol or recovering from its effects. Persistent desire or unsuccessful efforts to cut down on alcohol use.

o Salience of drinking: a dependent individual’s drinking occupies higher priority than other interests or obligations. Typically, hobbies and interests, once important, have been put aside to make room for a greater focus on drinking.

o Use is continued despite knowledge of alcohol-related harm (physical or psychological)[2]

Types of Alcoholics:

Type I: Subjects who develop dependence after the age of 25 years, with no family history of alcohol dependence, and possibility of Co morbid disorder.

Type II: Subjects who develop dependence before the age of 25 years, usually having poly substance abuse, externalizing symptoms, positive family history.

Alcohol and liaison with other specialities :

Gastrointestinal Problems: The gastrointestinal (GI) system can be severely affected by heavy drinking. The liver and the pancreas are especially vulnerable to alcohol. In the liver, increasing alcohol doses result in the accumulation of fats and proteins in the cells, producing a reversible swelling often described as a fatty liver. Inflammation of the liver cells accompanied by a subsequent intense increase in liver function tests and other signs of alcohol-induced inflammation, or hepatitis, can lead to the deposition of excessive amounts of hyalin and collagen near blood vessels, an early stage of cirrhosis, a condition seen in approximately 15 percent of alcohol dependent subjects. As liver failure progresses, secondary cognitive impairment can develop as a result of hepatic encephalopathy. Perhaps 10 percent of alcoholic people develop an inflammation of the pancreas that can present as the abdominal emergency of acute pancreatitis.

Cerebrovascular and Cardiovascular Problems: Heavy intake of alcohol and associated withdrawal increase the blood pressure and elevate both LDL cholesterol and triglycerides, thus enhancing the risk for myocardial infarction and thrombosis. At high doses, alcohol is also a striated-muscle Dr. Vishal Indla et. al: Alcohol and Opioid Dependence. 573 toxin with a resulting deterioration in the heart muscle that manifests itself as beating irregularities and signs of heart failure (alcoholic cardiomyopathy).

Peripheral Neuropathy: Approximately 10 percent of alcohol dependent subjects develop peripheral neuropathy. A thiamine deficiency, especially in the context of a pre-existing vulnerability such as a transketolase deficiency, can present as any of several neurological syndromes, including a sixth cranial nerve palsy (Wernicke’s) and a severe anterograde amnesia that is out of proportion to the general level of confusion (Korsakoff ’s). Two additional, potentially fatal central nervous system (CNS) syndromes include a loss of myelin in the central pons that can present as quadriplegia, lethargy, and cognitive impairment (central pontine myelinolysis), and a thinning of the corpus callosum along with a change in consciousness, ataxia, and dementia (Marchiafava-Bignami syndrome).

Other Medical conditions caused by alcohol

Alcohol can also cause increased risk of protein-energy malnutrition. It can lead to cancers especially tumors of the head, neck, esophagus, stomach, liver, colon, lungs, and breast tissue. There is also evidence to suggest that it increases risk of gouty arthritis.

Effects of alcohol on the nervous system:

Acute alcohol intoxication: Criteria for alcohol intoxication are based on evidence of recent ingestion of ethanol; the legal definition of intoxication requires a blood concentration of 80 or 100 mg ethanol per decilitre of blood (mg/dL), which is the same as .08 g/dL. Concentrations between 100 and 200 mg/dL produce a progression to more severe problems with coordination (ataxia), increasing lability of mood, and progressively greater levels of cognitive deterioration.

Management:

• Cardiovascular and respiratory support to control blood pressure and maintain airway. Closely monitor until withdrawal begins and then start treatment.

• Intravenous fluids (Normal saline or Ringer lactate with thiamine or MVI).

• Assess for other drug use especially benzodiazepine’s or opioids, as antagonists can be used.

Alcohol Withdrawal: Withdrawal or abstinence syndrome is characterized by a group of symptoms that are the opposite of what was initially 574 Psychiatry in India : Training & training centres experienced with intoxication. These include a coarse tremor of the hands, insomnia, anxiety, and increased blood pressure, heart rate, body temperature, and respiratory rate. Withdrawal phenomena are likely to begin within approximately 8 hours of abstinence, peak in intensity on the second or third day, and markedly diminish by the fourth or fifth day.

Management: Benzodiazepines are the drugs of choice for the management of alcohol withdrawal because of following reasons: ameliorate the symptoms of alcohol withdrawal and prevent seizures and delirium tremens.

• Fixed schedule dosing: Chlordiazepoxide 50mg every 6 hours for 4 doses on the first day, (an additional one or two doses during the 1st 24 hours can be used if the patient is jittery or shows signs of autonomic dysfunction). Decreasing the benzodiazepine dose by 20% on each subsequent day, with a resulting need for no further medication after 4-5 days.

• Front- loading : Diazepam 20mg doses every 2 hours until resolution of symptoms (usually three such doses are required).The long acting medications have a self tapering effect over the time .The period of medication is substantially shorter.

• Symptom triggered therapy: Chlordiazepoxide 50-100mg initially, followed by repeated doses as needed until agitation is controlled. The medication is delivered only when the patient is symptomatic.

• Oral vitamins are absorbed poorly during the early stages of detoxification; hence parenteral route may be preferred. For patients at risk for Wernicke’s encephalopathy, thiamine 200mg in 100ml of Normal saline over 30 min, once daily for 3-5 days, should be given. [3,4]

Alcohol Withdrawal Seizures (Rum fits): Alcohol withdrawal seizures are mostly grand mal seizures.They usually occur 24-48 hours after last drink but may occur within 8 hours . Evaluation for other causes of seizures like head injury, cerebrovascular accident or CNS infection needs to be done. Work up includes brain imaging and EEG.1 in 4 patients have a second seizure within 6- 12 hours.

Management:

• Parenteral benzodiazepines should be started.

• Seizure precautions to be taken. Dr. Vishal Indla et. al: Alcohol and Opioid Dependence. 575 • Anti-convulsants are generally not indicated unless the diagnosis is in doubt.

Delirium Tremens: Begins 3 to 5 days after last drink. Occurs in less than 5% of withdrawal patients. This is marked by disorientation , global confusion and hallucinations(visual more than auditory). Mortality is usually 2-10%. Death occurs due to cardiovascular, metabolic or infective causes.

Management:

• Supportive Care which includes quiet environment. Nutrition and Nursing care (reassurance/orientation).

• Hydration - may have 6 L volume deficit with Delirium tremens. Electrolyte correction and parenteral administration of thiamine (100 mg daily for at least 3 days, IV or intramuscularly)

• Diazepam is usually the preferred drug of choice. 10mg I.V. hourly till adequate sedation is obtained, followed by maintenance of sedation till 24 hours with Diazepam 10mg I.V. 6 hourly, followed by switch to oral Diazepam 10-20mg every 6 hours for 2 days, then taper in the next 5 days.

• Short term antipsychotic like haloperidol is required to control the abnormal behaviour.

• Physical restraints often needed to ensure patient and staff safety. [4,5]

Alcohol Associated Cognitive Dysfunction:

Wernicke’s encephalopathy: It is caused due to Thiamine deficiency which is a cofactor in metabolic reactions. Triad of Encephalopathy includes agitated delirium, oculomotor dysfunction, nystagmus, gait ataxia.

Management:

• Parenteral Thiamine: 200mg given in 100ml of normal saline over 30min.

• For prophylaxis against Wernicke’s encephalopathy, IV infusion once daily for 3-5 days. For established or presumptive diagnosis of Wernicke’s encephalopathy IV infusion three times daily for 3 days, then once daily for 5 days.

Korsakoff ’s Amnestic Syndrome: This is a late neuropsychiatric manifestation of chronic alcohol abuse. Typically follows episode(s) of 576 Psychiatry in India : Training & training centres Wernicke’s encephalopathy, retrograde and selective anterograde amnesia with confabulations. Relative preservation of long-term memory is seen. It is associated with Lesions in the medial temporal lobes, and mamillary bodies.

Alcohol-induced psychosis: Alcohol Related Psychosis is a condition in which hallucinations ( often visual) occur during alcohol intoxication or during withdrawal from alcohol. It affects about 3% of people with alcohol dependence.

Typically these hallucinations stop and do not continue once the crisis of intoxication or withdrawal is over. Alcohol hallucinosis typically occurs in a later stage of alcohol withdrawal - usually 48 hours after abruptly decreasing or stopping alcohol intake. According to DSM-IV the hallucinations or delusions should have developed during or within a month of substance intoxication or withdrawal.

Management:

• Antipsychotics like haloperidol controls psychosis and provides rapid tranquilization.

• Administer with a benzodiazepine to protect against lowered seizure threshold.

Maintenance treatment in ADS

There are only three FDA-Approved treatments for Alcohol dependence over the Past 60 Years. They are

Disulfiram (1951)- Aldehyde dehydrogenase inhibitor

Naltrexone (1994) - Opioid antagonist

Acamprosate (1994)- Glutamate receptor modulator

Disulfiram (Antabuse): An aversive pharmacotherapy.

Rationale : If alcohol ingestion elicits an unpleasant reaction, the patient will avoid alcohol in order to avoid the aversive experience.It also protects them from giving in to sudden urges to drink, or pressure from friends.

Disulfiram is a sulfhydryl (—SH, thiol) group reagent and inhibits enzymes concerned with oxidation of active (—SH group) sites on enzymes’ protein molecules. Normally, ethanol is metabolized to carbon dioxide and water, but in the presence of disulfiram, the metabolic chain of reactions stops after the production of acetaldehyde, leading to the accumulation of this substance. Dr. Vishal Indla et. al: Alcohol and Opioid Dependence. 577 Acetaldehyde is an important factor for the development of disulfiram–alcohol reaction, which occurs within the course of 5 to 10 minutes after the ingestion of alcohol.

The clinical picture of disulfiram–alcohol reaction includes a number of unpleasant symptoms which includes intense flushing of the face, difficulty in breathing, palpitations, throbbing headache, nausea, and vomiting. Ingestion of large amounts of alcohol may cause a significant fall of the blood pressure, resulting in fainting and the risk of cardiovascular shock.

DOSAGES: Supplied in the form of 250 mg tablet, 125 to 500 mg a day. It should not exceed 500 mg a day. Disulfiram should be taken for 6 weeks to 6 months as required. A review of the effectiveness of therapy should be undertaken before continuation on a longer-term basis. A few patients would require higher doses of disulfiram and longer duration of treatment under close supervision.1-2 wks may be needed before disulfiram is totally eliminated from the body after the last dose has been taken. Disulfiram treatment is more effective if supervised by the wife of the patient or a close family member. [7]

Precautions: Disulfiram should not be taken by children, pregnant women, patients having Liver damage (Cirrhosis, Acute hepatitis), epilepsy and Psychosis. Patients having severe myocardial disease, and coronary occlusion should not take disulfiram. People with diabetes taking disulfiram are at an increased risk for complications . It is better to avoid disulfiram in those unwilling to take, or those who do not know that they are being covertly given the medication.

Side effects:

Lethargy,Drowsiness (45%),Decreased memory (40%),Headache (35%),Itching (33%), Decreased Sleep(27%),Dizziness (22%) ,Peripheral Neuropathy – Tingling and numbness of hands and legs (10%),Worsening of depression and psychosis in some cases (5%), Sexual Side effects is also noted .

Precautions before starting Disulfiram:

• Liver function test.

• Rule out psychiatric illness.

• Check motivation.

Treatment of Dusulfiram ethanol reaction:

• Symptomatic. Maintain airway, breathing and circulation. Adequate 578 Psychiatry in India : Training & training centres ventilation with oxygen.

• Raise the foot end of the bed. Treat the hypotension and electrolyte imbalance.

• Parenteral antihistaminic. Ascorbic acid 1g should be given parenterally.

Things to be avoided on disulfiram:

Cough Syrup, Vitamin tonics, After Shave Lotions, Perfumes, Spirits, Spirit based paints, glues, thinners etc.

Reaction may occur as long as one or two weeks after the last dose of Disulfiram. A good outcome can be expected if the person is highly motivated, daily use of Disulfiram can be supervised, patient is abstinence prior to treatment and there is a regular contact with the doctor or treating team.

Acamprosate: It works by Blockade of glutamate NMDA receptors and activation of GABA-A receptors. It normalizes the ethanol altered GABA-A receptors. Acamprosate restores the imbalance in the excitatory & inhibitory neurotransmitters caused by alcohol.

Dosage: 333 mg tablets. For those who weigh less than 60 kilograms, it is given as 1-1-2 in the morning, noon and night respectively. For those who weigh more than 60 kilograms , it is given as 1-2-2 or 2-2-2 in the morning, noon and night respectively . It is usually taken with or without food three times a day. It reduces the intensity of post cessation alcohol craving on exposure to cues. It is usually a well tolerated drug .

Side effects: Diarrhea (Most common; about 10%),fullness in stomach, loss of appetite ,dry mouth ,dizziness, itching, weakness .As it is excreted unmetabolized, there is no risk of hepatotoxicity. It should be used with caution in individuals with renal impairment.

There are no interactions with concomitant use of alcohol, diazepam, disulfiram, or imipramine. Hence patients with alcohol dependence can continue to use acamprosate during a relapse. [8]

Naltrexone: This is a opioid receptor antagonist. Endogenous opioid system is the neurological substrate for drug reward, mediated through actions in the dopamine system. It is not helpful in preventing patient from having one drink, but rather in breaking the cycle where one drink leads to many more. Naltrexone significantly reduces rates of relapse to excessive drinking, with minimal side effects. Dr. Vishal Indla et. al: Alcohol and Opioid Dependence. 579 DOSAGES: 50 mg tablet given once a day. It is usually started at 25mg tablet per day for 5 days, and then increased to 50 mg per day later on for maintenance.

COMBINATION THERAPY:

NALTREXONE AND ACAMPROSATE: This combination is efficacious and safe .Naltrexone decreases positive craving for alcohol, acamprosate attenuates negative or conditioned craving post-drinking cessation. Acamprosate can increase blood levels of naltrexone, thereby augmenting its neurochemical effects.

Disulfiram is useful in combination with anticraving medications like naltrexone and acamprosate . It is used to maintain abstinence attained with help of anticraving medication. It also adds an additional deterrent to drinking. Evidence from clinical trials -combining these medications is both safe and effective.[9]

NEWER APPROACHES:

SEROTONERGIC SYSTEM:

Ondansetron: This is a 5-HT3 antagonist approved as an antiemetic for chemotherapy induced nausea. It is supposed to have better efficacy in young onset alcoholics. Low doses of 4µg/kg b.i.d is well tolerated. It is also safe and efficacious.

Adverse effects: Headache, GIT disturbances, fatigue, drowsiness .

GABA:

Baclofen: It is a GABA- B agonist. It is a centrally acting skeletal muscle relaxant .It has shown efficacy in young onset alcoholics for acute withdrawal state and relapse prevention.

Dosage : 30-60mg in 2-3 divided doses..[12]

Adverse reactions: Transient drowsiness, fatigue (10-63%), confusion, insomnia, euphoria, excitement, tremors, dystonias (1-11%), increased urinary frequency (2-6%), lowered seizure threshold. Caution needs to be exercised while using it in renal impairment

GLUTAMATE AND GABA:

Topiramate: Glutamate antagonist and GABA A agonist. It has shown efficacy as an adjuvant agent in late onset alcohol dependents . 580 Psychiatry in India : Training & training centres Indications: In co morbid: Alcohol dependence with Nicotine Dependence, Seizure disorder, Bipolar affective disorder and obesity.

Dosage: started at 25 mg b.i.d, increase at weekly intervals by 50 mg upto 200 - 300 mg.

Adverse reactions: Dizziness, ataxia, parasthesias, psychomotor slowing, memory difficulties (15-30%,) weight loss, nephrolithiasis (1.5%), hyperchloremic metabolic acidosis, acute myopia with secondary angle closure glaucoma (very rare).

Contraindications: Elderly, history of renal impairment, nephrolithiasis, glaucoma, Psychosis, cognitive deficits.

Role of Family in the treatment of Alcohol dependence: Among the various treatment modalities, family intervention is the most notable current advance in the area of psychosocial treatment of alcoholism. Family intervention is a method of understanding and encouraging the role of family, and it imparts positive effect in decreasing alcohol consumption. [ The ingredients of this mode of therapy include (1) building up an alliance with relatives (2) reducing adverse family atmosphere (3) enhancing problem- solving capacity of family members (4) decreasing of anguish and repentance (5) maintaining reasonable expectations for patient performance (6) achieving changes in family members’ behavior and belief system.

Many alcoholics have extensive marital and family problems, and hence positive marital and family adjustment is associated with better outcome. It has been reported that even at the onset of recovery from alcohol dependence, marital and family conflicts may often precipitate and lead to relapses in abstinent alcoholics.

CONCLUSION: Newer treatment approaches based on better understanding of the neurobiology of addiction have been are under development. Initial results with Ondansetron, Baclofen, Topiramate are promising. However, large scale trials are needed to establish efficacy. Search for newer receptor mechanisms are still required.

OPIODS:

Opioids are commonly prescribed because of their effective analgesic, or pain-relieving, properties. Although opioid receptors’ biology is well known, the physiological systems regulated by opioids and responsible for the analgesic effects and for other actions are partially known. Opioids bind to specific opioid receptors in the central and peripheral nervous system and other tissues. Dr. Vishal Indla et. al: Alcohol and Opioid Dependence. 581 There are three principal classes of opioid receptors, μ, κ, δ (mu, kappa, and delta), although up to seventeen have been reported. Increasing evidence indicates that the mesolimbic dopamine system - consisting of dopaminergic neurons in the ventral tegmental area (VTA) and their projection regions, most notably the nucleus accumbens (Nac) - plays an important role in mediating the reinforcing actions of opiates on brain function. Opioid Classification: Opium alkaloids Phenanthrenes naturally occurring in opium: • Codeine • Morphine • Thebaine • Oripavine[46] Preparations of mixed opium alkaloids, including papaveretum, are still occasionally used. Semisynthetic derivatives • Diacetylmorphine (heroin) • Dihydrocodeine • Hydrocodone • Hydromorphone • Nicomorphine • Oxycodone • Oxymorphone Synthetic opioids Anilidopiperidines • Fentanyl • Alphamethylfentanyl • Alfentanil • Sufentanil • Remifentanil • Carfentanyl • Ohmefentanyl 582 Psychiatry in India : Training & training centres Phenylpiperidines

• Pethidine (meperidine) • Ketobemidone • MPPP Diphenylpropylamine derivatives • Propoxyphene • Dextropropoxyphene • Dextromoramide • Bezitramide • Piritramide • Methadone • Dipipanone • Levomethadyl Acetate (LAAM) • Difenoxin • Diphenoxylate • Loperamide (used for diarrhoea, does not cross the blood-brain barrier) Benzomorphan derivatives • Dezocine - agonist/antagonist • Pentazocine - agonist/antagonist • Phenazocine Oripavine derivatives • Buprenorphine - partial agonist • Dihydroetorphine • Etorphine Morphinan derivatives • Butorphanol - agonist/antagonist • Nalbuphine - agonist/antagonist • Levorphanol • Levomethorphan

Opioid antagonists

• Nalmefene Dr. Vishal Indla et. al: Alcohol and Opioid Dependence. 583 • Naloxone • Naltrexone Opioid withdrawal: Symptoms include craving for an opioid drug, rhinorrhoea or sneezing, lacrimation, nausea or vomiting, tachycardia or hypertension , restless sleep and diarrhoea . In more severe cases or as the syndrome progresses, additional signs and symptoms that may be observed include increasingly dilated pupils, piloerection (waves of gooseflesh, from which comes the term “Cold turkey” to describe withdrawal). The phrase “Cold turkey” probably comes from the appearance of goose bumps all over the body, which resembles a plucked turkey. Cold turkey is also used to describe abrupt withdrawal from opoids and the ensuing severe withdrawal features. Also often observed are twitching of muscles and kicking movements of the lower extremities (from which comes the phrase “kicking the habit”). It is important to remember that substantial subjective distress can develop before the more obvious physical signs appear. Management of opioid dependence: Opioid Agonist Pharmacotherapy: For many patients with chronic relapsing opioid dependence, the treatment of choice is maintenance on long acting opioids. Methadone is the most thoroughly studied and widely used treatment for opioid dependence. Methadone: Reduces opiate cravings and symptoms of withdrawal. Dosage: For maintenance treatment of opioid dependence the usual starting dose of methadone is 20-30 mg, with 5 to 10 mg increases every other day as tolerated. The goals of Methadone treatment are suppression of opioid withdrawal symptoms and cessation of illicit opioid use. The usual dose of methadone administered in methadone maintenance programmes ranges from 30-100 mg. Higher doses (80-100 mg / day) are more effective than moderate doses of methadone (40 to 50 mg/day) in reducing illicit opioid use. While methadone is the most researched treatment modality through observational studies examining the effectiveness of methadone maintenance treatment there have been few controlled experimental studies.. Methadone treatment is only suitable for those patients with a history of illegal opioid dependence usually longer than 12 months..[13] Buprenorphine: It is a derivative of Thebaine, an extract of opium. It has less sedation and respiratory depression .No significant impairment of cognitive or motor skills occurs. Like methadone, buprenorphine reduces cravings for heroin and other opiates and reduces withdrawal symptoms. When taken sublingually, buprenorphine is slower acting, and does not 584 Psychiatry in India : Training & training centres provide the same “rush” as heroin. It blocks the effects of heroin by binding to the same opiate receptors as heroin; consequently, opiate addicts who use buprenorphine are not able to get a high from heroin. It is less susceptible to abuse than other opiates. Side Effects : Nausea and vomiting, drowsiness, dizziness, headache, itch, dry mouth, meiosis, orthostatic hypotension, male ejaculatory difficulty, decreased libido, urinary retention and constipation. Buprenorphine was the only opiate addiction therapy drug that can be prescribed in a physician’s office; others must be dispensed in a clinic. Extended-release formulation of buprenorphine, called a depot formulation, currently is being developed. Designed for administration in a physician’s office once every 4 to 6 weeks and could further safeguard against diversion by eliminating the need for patients to possess buprenorphine in tablet form..[14] Naltrexone: an opioid antagonist, it blocks opioid receptors competitively. It is orally effective and can block opioid effects for 24 hours when administered as a single daily dose of 50 mg, doses of 100-150 mg can block opioid effects for 48 to 72 hrs. Naltrexone is generally not favoured by opioid addicts because, unlike opioid agonists and partial agonists, it produces no positive reinforcement effects. It is associated with poor compliance, low retention rates. Kappa-opioid system overdrive causes dysphoria and psychosomatic symptoms. Levomethadyl acetate (LAAM) is a derivative of methadone. Its long duration of action (48-72 hrs) allows dosing at 48-72 hr interval for opioid maintenance treatment. However, LAAM is no longer available due to cardiac adverse effects that led the only drug manufacturer to cease production and distribution. There is also limited research on the use of LAAM for opioid withdrawal. Other combinations: Buprenorphine – Naloxone combination 4-16mg. Buprenorphine’s unique formulation with naloxone, an opioid antagonist , limits diversion by causing severe withdrawal symptoms in those who inject it to get “high”. The naloxone contained in Suboxone guards against abuse—if an abuser crushes and injects or snorts the Suboxone tablet, the naloxone in it precipitates withdrawal symptoms.but its bit expensive..[15] Buprenorphine – Naltrexone: Higher retention rates are observed when combined. Dysphoric and psychosomatic symptoms during Naltrexone treatment seems to be counteracted, at least in part, by buprenorphine. Doses of 50mg Naltrexone +4mg Buprenorphine (sublingual) can be effective. Dr. Vishal Indla et. al: Alcohol and Opioid Dependence. 585 Conclusion: Although there are several pharmacotherapies that are useful in the treatment of opioid dependence, it is not uncommon for medications to be used for relatively short periods (e.g., for medically supervised withdrawal), followed by counselling services that seek to maintain abstinence. Maintenance treatment for opioid dependence has been available for more than 40 years and can be remarkably effective, but medication is only one part of the treatment. Psychosocial services should be an integral part of all opioid addiction treatments. REFERENCES 1. UNDCP-ROSA. Country Profile - India. In : Ray R. editor. South East Asia Drug Demand Reduction Report. UNDCP Regional Office for South Asia: New Delhi; 1998. p. 259-61. 2. DSM-IV. American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, DC. 3. Mayo-Smith MF. Pharmacological management of alcohol withdrawal. A meta-analysis and evidence-based practice guideline. American Society of Addiction Medicine Working Group on Pharmacological Management of Alcohol Withdrawal. JAMA. Jul 9 1997;278(2):144-51. 4. Daeppen JB, Gache P, Landry U, et al. Symptom-triggered vs fixed-schedule doses of benzodiazepine for alcohol withdrawal: a randomized treatment trial. Arch Intern Med. May 27 2002;162(10):1117-21. 5. Jaeger TM, Lohr RH, Pankratz VS. Symptom-triggered therapy for alcohol withdrawal syndrome in medical inpatients. Mayo Clin Proc. Jul 2001;76(7):695-701. 6. Fuller RK, Branchey L, Brightwell DR, Derman RM, Emrick CD, Iber FL, James KE, Lacoursiere RB, Lee KK, Lowenstam I: Disulfiram treatment of alcoholism. A Veterans Administration cooperative study. JAMA. 1986;256(11):1449 7. Littleton, 1995; Rammes et al, (2001). 8. Fuller RK, Gordis E. Does disulfiram have a role in alcoholism treatment today. Addiction 2004;99:21–4 9. Tollefson et al., 1992; Kranzler et al., 1994; Malcolm et al.,1992 10. Mason BJ, et al (2003) 11. Rosenbloom A. Emerging treatment options in the alcohol withdrawal syndrome. J Clin Psychiatry. 1988;49:28-32. 12. Addolorato, Alcohol & alcoholism, 2002. 13. Ward et al. 1998c, 1999f; National Policy on Methadone Treatment 1997 14. Johnon RE, Eissenberg T, Stitzer ML. et al. (1995) A placebo-controlled trial of buprenorphine as a treatmeent for opioid dependence. Drug Alcohol Depend 40, 17-25. 15. Fudala, et al. New England J Medicine 349(10):949-958, 2003.

Vishal Indla Chief Psychiatrist VIMHANS Hospital Vijayawada [email protected] Girish Menon Consultant Psychiatrist

I.R.S. Reddy Director VIMHANS Hospital Vijayawada 60 Clinical Evaluation of Suicide and Related Issues

P. B. Behere, S. M. Reddy

ABSTRACT

Despite suicide being a major cause of mortality worldwide, clinicians often miss to identify people with high risk for suicide. Moreover the physician may be hesitant to enquire about such issues. This necessitates the need for a proper knowledge on clinical evaluation of suicide and related issues. It involves identifying proper risk factors pertaining to age, sex, race, employment, mental illness, past attempts, family history and childhood history. Further proper evaluation of a suicide attempt is essential. In addition to clinical evaluation, an objective evaluation of suicide risk is essential for documentation as well as to quantify suicide risk. Various scales are used in different setups for different high risk groups. However despite these objective measurements of suicidal risk, nothing can replace a close supervision by an experienced psychiatrist who provides proper feedback and reinforcement.

Suicide is known since the birth of humanity. It is the tragic and untimely loss of human life, all the more devastating and perplexing because it is a conscious volitional act. Death is a tragedy and suicide the ultimate tragedy. [1] In 2002 suicide accounted for approximately 877,000 deaths worldwide, which makes up to 1.5 % of the global burden of disease. [2] The scenario in India is not very different with the national crime records bureau stating 1,27,151 people committed suicide in the year 2009, which makes up to 10.9 per 100,000 population. It goes on to state that India is second highest in total number of suicides in world.

Despite its high prevalence, suicidal behaviour is often underestimated and neglected by healthcare providers, thereby going undetected. Suicide should and can be prevented. Eighty three percent of people who commit suicide have had contact with a physician within a year of their death and up to 66% of people who commit suicide have had such contact within a month of their 588 Psychiatry in India : Training & training centres death. [3] Studies have revealed that as many as 83% of suicide attempters are not identified as a danger to themselves by healthcare providers, even when examined by clinicians in the months before their attempt.[4], [5] Moreover, evidence exists that few attempters receive care, even after a suicide attempt. [6] This shows a gross neglect in the proper evaluation and management of patients with suicide and related behaviour.

Initiating screening of any disease or condition is appropriate and recommended if the condition causes significant morbidity or mortality, can be effectively treated, prevalence is not too rare and earlier detection is critical. [7] Suicide risk fulfils these criterion, assuming effective treatments exist for depression, which is thought to be present in 50–79% of youth suicide attempts. [8] Early identification of mental health problems such as depression followed by symptom relief is a key component to prevention and treatment of suicidal behaviour. [9], [10] So to detect and manage suicide risk one has to do a proper clinical and objective evaluation. The psychiatric evaluation is the essential element of the suicide assessment process. [11]

Physicians might be hesitant to inquire about suicidal thoughts, worried that inquiry might itself lead to suicide attempts. But in contrast to what physicians feel, patients with such thoughts often comfortably discuss them, but may not verbalize their concerns without being prompted. Although patients may be reluctant to divulge their intent to commit suicide, if asked, patients with suicidal ideation usually will tell their physicians about such thoughts. [12]

Clinical Evaluation of Suicidal Risk: l The clinical evaluation of the medical and psychiatric history of a patient and of their current state is the crucial and essential element of the suicide assessment process. During the mental evaluation, the interviewer obtains information about the patient's psychiatric and other medical history and current mental state through direct questioning and observation about suicidal thinking and behaviour as well as through collateral history. This information enables the psychiatrist to 1) identify specific factors and features that may generally increase or decrease risk for suicide or other suicidal behaviours and that may serve as modifiable targets for both acute and ongoing interventions, 2) address the patient's immediate safety and determine the most appropriate setting for treatment, and 3) develop a multiracial differential diagnosis to further guide planning of treatment. [13] l It is important for the psychiatrist to focus on the nature, frequency, depth, timing, and persistence of suicidal ideation. [11] If ideation is Behere & Reddy: Clinical Evaluation of Suicide 589 present, request more detail about the presence or absence of specific plans for suicide, including any steps taken to enact plans or prepare for death. [11]Where there is a history of suicide attempts, aborted attempts, or other self-harming behaviour, it is important to obtain as much detail as possible about the timing, intent, method, and consequences of such behaviour. [11] It is also useful to determine the life context in which they occurred and whether they occurred in association with intoxication or chronic use of alcohol or other substances. l If the patient reports a specific method for suicide, it is important for the psychiatrist to ascertain the patient's expectation about its lethality, for if actual lethality exceeds what is expected, the patient's risk for accidental suicide may be high even if intent is low. [11] In general, the psychiatrist should assign a higher level of risk to patients who have high degrees of suicidal intent or describe more detailed and specific suicide plans, particularly those involving violent and irreversible methods. [11] Various risk factors to look for are age, sex, and race, employment, mental Illness, past attempts, family history, childhood History and protective factors. l The majority of suicides (37.8%) in India are below the age of 30 years. 71 % of the suicides in India are by persons below the age of 44 years. [14] Despite the higher prevalence of suicides in men in western countries [15] there are near equal suicide rates of young men and women and consistently narrow male: female ration of 1.4:1. [16] Unemployed and unskilled individuals are at increased risk compared to those employed and skilled; occupational failure may lead to higher risk. Physicians, particularly female physicians, may be at increased risk; a 25-study meta-analysis yielded a suicide rate ratio for female physicians of 2.3 and for male physicians of 1.4 compared with the general population. [17] Suicides are mostly associated with psychiatric disorders such as depression, bipolar disorder, alcoholism or other substance abuse, schizophrenia, personality disorders, anxiety disorders (including panic disorder), post-traumatic stress disorders, and delirium. [18] Patients with multiple psychiatric conditions appear to be at higher risk than those with uncomplicated depression or an anxiety disorder. [19] Presence of anxiety disorder along with depression further increases the risk of suicide. [20] l Half of the suicide completers attempted suicide previously and 1 out of 100 suicide attempt survivors die by suicide within the next year, a risk 100-fold greater than that in the general population. [21] Having a first- degree relative who committed suicide increases risk six fold. The heritability of suicide is in the 30% to 50% range. [22] Individuals who have never married are at the highest risk for completed suicide, followed in 590 Psychiatry in India : Training & training centres descending order by those who are widowed, separated, or divorced; married without children; and married with children. Patients who live alone, who have lost a loved one, or who have experienced a failed relationship within one year are also at increased risk for suicides. [23] Suicide rates are more in survivors whose spouse has committed suicide. [24] Abuse and other adverse childhood experiences increase the risk for suicide in adults, at least partially mediated by the presence of alcoholism, depression, and illicit drug use, which also are strongly associated with adverse events in childhood. [22] l Family connectedness and social support are protective. Family discord increases the risk for suicide. [22] Parenthood, particularly for mothers, and pregnancy decrease the risk for suicide. [25] The risk factors can also be divided into underlying causes such as biological and psychological factors, and more proximal stressors such as life events or a major depressive episode. [26]

Biological risk factors for suicide: Low cerebrospinal fluid 5- hydroxyindolacetic acid levels, hypothalamic-pituitary-adrenal axis dysregulation, low blood cholesterol levels, medical or neurological illnesses (such as multiple sclerosis, stroke, Huntington disease, and epilepsy) and cigarette smoking. [27]

Psychological risk factors: acceptability of suicide, a childhood history of physical or sexual abuse, discouraged help-seeking behaviour, aggressive/impulsive traits, pessimism, hopelessness, low self-esteem, poor access to psychiatric treatment.

More proximal stressors that indicate an increased suicide risk: Relationship problems, financial troubles, a family history of suicide, personal history of previous suicidal attempt, major depression and substance use.

The Clinical Practice Guidelines (CPG) [28] published by the Indian Psychiatric society states that a careful assessment of patient's risk for suicide is important. An assessment of presence of suicidal ideation is essential, including the degree to which the patient has made plans for or begins to prepare for suicide. The availability of means for suicide and lethality of those means should be inquired. The clinical factors like presence of psychotic features, command hallucination, severe anxiety, alcohol or substance abuse may increase the likelihood of patient acting on suicidal ideation.

Objective Evaluation of Suicidal Risk:

Further in an effort to objectively ascertain the suicidal risk, there are many self-report and clinician –administered scales that measure different aspects Behere & Reddy: Clinical Evaluation of Suicide 591 of suicidal behaviour or mental health conditions related to it. Following is an account of a few objective evaluation tools to assess the suicide behaviour.

1) Beck Scale for Suicide Ideation (BSS)[29], [30]

The BSS developed by Beck and Steer, is a 21 item self report scale to assess severity of suicidal ideation in adults and adolescents. Each item contains three statements that are graded in severity from 0 to 2. The first part (items 1-5) evaluates an individual's attitudes towards living and dying, active suicide attempt and passive suicide attempts. The second part (items 6-19) evaluates suicidal ideation and anticipated reactions to those thoughts. The third part (items 20-21) evaluates previous suicide attempts and suicidal intent during last suicide attempt. Strength of the BSS is its brevity and ease of administration. However it should not be used as a solitary assessment and should be add on to the comprehensive clinical evaluation. The reliability of the BSS is good, with a coefficient alpha reliability estimate of 0.90 for inpatients and 0.87 for out patients. Test-retest stability over one week provided a correlation of 0.54.

2) California Risk Estimator for Suicide [31], [30]

California risk estimator for suicide, developed by Motto et al, is a 15-item interviewer-rated scale to assess the risk of suicide in depressed or suicidal patients. The scale item includes demographic characteristics, psychosocial factors and clinical features. Each item is given a weighted score, with a total score used to assess relative risk of suicide as very low, low, moderate, high and very high. A primary strength of the Risk Estimator is its brevity, although there is minimal information on validity/reliability of the scale. Moreover it should not be used as a solitary assessment.

3) Beck Hopelessness Scale [32], [30]

The BHS is a 20-item self-rated scale used to evaluate hopelessness in depressed individuals. The BHS is an indirect evaluation of suicidality. BHS was developed over Beck Depression Inventory; however it is more comprehensive in its evaluation of suicidal ideation. The authors propose that hopelessness represents negative attitudes about the future that may indicate suicide risk. The BHS consists of 20 true/false items that either endorse or deny pessimistic or optimistic statements. BHS should not be used as a solitary assessment. It demonstrates high internal consistency, with KR-20 coefficients generally 0.90 or higher, retest reliability over 0.60, and concurrent validity with clinician's rating of hopelessness. 592 Psychiatry in India : Training & training centres 4) Suicide Probability scale (SPS) [33], [30]

The SPS is a 36-item, self-reported scale used to evaluate suicide risk in adolescents and adults. Each item on the SPS is a statement describing a feeling or behaviour. Individuals are asked to rate how often the statement is true for them on a 4-point scale, ranging in severity from none to most or all of the time. The scale provides a total score and four subscale scores which include hopelessness, suicidal ideation, negative self evaluation and hostility. SPS should not be considered in solitary. Internal consistency of the scale has been reported to be good, with alpha=0.93 for the total score, and alpha coefficients ranging from 0.62 (negative self evaluation) to 0.89 (suicide ideation) for the subscales. Retest reliability over three weeks provided a correlation of 0.92.

5) HARD Diagram [34]

The HARD diagram is used to study the clinical aspects of depression and to ascertain the suicidal index. It has four components mood, anxiety, retardation and danger which are individually rated on a scale of 18 and then plotted on the HARD diagram. The shape of the resulting image is then compared to ascertain the clinical type of depression such as melancholic, anxiety with depression, anxiety with compulsion, depression with retardation, asthenic masked depression and anxio- somatic masked depression. The HARD diagram is also used to measure the suicidal index as low, moderate or high. The total score of the components is used to classify depression as mild (20-34), moderate (35- 49) and severe (50-72).

6) Pierce Suicide Intent Scale [35]

It is a 12 item self rated scale which is to be completed after a suicidal attempt. The total score of all the items is then used to state the level of suicidal intent as low, medium or high. It is practical and reliable. Results show that the scores derived from it are closely related to the similar Beck Scale; they are also related to age, sex, social isolation method of self- injury, previous history of self-injury or of psychiatric treatment, physical health at the time of self-injury and alcohol abuse. These results are discussed with particular reference to suicide prediction and the future validation of the scale by long-term follow-up.

7) Columbia Suicide Screen [36]

The leading screening tool used in school settings is the Columbia Suicide Screen (CSS), an 11-item self-report measure embedded in a general health questionnaire that investigates lifetime suicide attempts, suicidal Behere & Reddy: Clinical Evaluation of Suicide 593 ideation, and negative mood and substance abuse issues. As part of the Columbia University Teen Screen program, this widely used tool was validated using the National Institute of Mental Heath Diagnostic Interview Schedule for Children, IV (NIMH DISC-IV) with a sensitivity of 0.75, a specificity of 0.83, a PPV of 0.16 and an NPV of 0.99. Overall, research using the CSS suggests that screening can identify suicide risk in children whose thoughts and behaviours may have gone otherwise undetected.

8) Suicide Risk Screen (SRS) [37]

SRS is a 20-item tool validated on 'at-risk' students. It showed an 87–100% sensitivity and 54–60% specificity. In a 'real-world' high school setting, 29% of the screened students were found to be at risk for suicide according to SRS.

Other rating scales to assess suicidal ideas for paediatric age group are a voice based DISC-IV, Rapid assessment for Adolescent Preventive Services (RAAPS) and Youth Risk Behaviour Survey (YRBS)

9) Risk of Suicide Questionnaire (RSQ) [38]

In 2001, the Risk of Suicide Questionnaire (RSQ) was developed to assist ED triage nurses in rapidly assessing mental health patients. The four- item tool has good sensitivity (0.98), low specificity (0.37), good NPV (0.97) and a fair PPV (0.55). It takes less than 2 min for a triage nurse to administer with an endorsement of any answer to one of the four questions considered a positive screen. The RSQ was created in conjunction with a risk of suicide clinical practice guideline.

10) Geriatric Depression Scale(GDS) [39]

GDS is a common screen for late-life depression, with reference to presence of suicide ideation in a primary care sample of older adults. The GDS yes/no response key is easy to score and the measure is available in longer (30-item) and shorter (15-item and 5-item) formats. The GDS does not include an item directly assessing presence of suicide ideation, which is an obvious limitation. However, research indicates that GDS total scores and a 5-item subscale can effectively differentiate older adults with higher versus lower levels of suicide ideation. The 5 items of this empirically derived subscale assess perceived hopelessness, worthlessness, emptiness, an absence of happiness, and lack of perception that it is “wonderful to be alive,” all of which are variables theoretically and empirically associated with suicide ideation. 594 Psychiatry in India : Training & training centres 11) Suicide risk eleven (SRE) [40]

This is a visual analogue scale by Verma et al. (1998), developed in the Department of Psychiatry, PGIMER. It is a self-administered scale. It has items ranging from "It is a sin to commit suicide," "I do not have suicidal thoughts" to "I have tried suicide many times."

Although many of these scales are used in varied setups catering to different high risk groups and these scales are reliable and have adequate concurrent validity, they should always be used in association with a proper clinical psychiatric evaluation.

Early training of residents in suicide assessment through lectures and posted guidelines may improve the quality of documentation and thereby lead to a proper patient evaluation. [41], [42] A 2008 study [41] noted that participation in suicide risk assessment educational sessions improved documentation quality and self-rated scores of suicide risk assessment knowledge. Such an addition to the education of residents can also be a cost-effective means in providing care for this patient population. But all said suicide assessment is an inductive process in which clinical experience continues to play a vital role, [43] close supervision from an experienced psychiatrist who provides feedback and reinforcement should be considered equally important in resident education.

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Crisis 2002;23:98-103. 17 Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry 2004;161:2295-302. 18 Palmer BA, Pankratz VS, Bostwick JM. The lifetime risk of suicide in schizophrenia: a reexamination. Arch Gen Psychiatry 2005;62:247-53. 19 Lonnqvist JK. Psychiatric aspects of suicidal behavior: depression. In: Hawton K, van Heeringen K, eds. The International Handbook of Suicide and Attempted Suicide. New York, NY: Wiley; 2000. 20 Sareen J, Cox BJ, Afifi TO, et al. Anxiety disorders and risk for suicidal ideation and suicide attempts: a population-based longitudinal study of adults. Arch Gen Psychiatry 2005;62:1249-57. 21) Hawton K.Suicide and attempted suicide. In: Pankel E (ed). Handbook of affective disorders. 2nd edition. New York,NY;Guilford;1992. 22) Goldsmith S, Pellmar T, Kleinman A, Bunney W, eds. Reducing Suicide: A National Imperative. Washington, DC: Institute of Medicine National Academies Press; 2002. 23 Heikkinen M, Isometsa E, Marttunen M, Aro H, Lonnqvist J. Social factors in suicide. Br J Psychiatry 1995;167:747-53. 24 Agerbo E. Risk of suicide and spouse's psychiatric illness or suicide: nested case-control study. BMJ 2003;327:1025-26. 25 Qin P, Mortensen PB. The impact of parental status on the risk of completed suicide. Arch Gen Psychiatry 2003;60:797-802. 26 Ganz D, Braquehais MD, Sher L (2010) Secondary Prevention of Suicide. PLoS Med 7(6): e1000271.doi:10.1371/journal.pmed.1000271. 27 Jules A, Paula JC. Personality, smoking and suicide: A prospective study. Journal of Affective Disorder 1998;51(1):56-62. 28 Gautam S, Batra L. Clinical Practice Guidelines for Management of Depression, Gautam S (ed). IPS Clinical Practice Guidelines 2005. Indian Psychiatric Society,2005;83-119. 29 Beck AT and Steer RA, Manual for the Beck Scale for Suicide Ideation, San Antonio, TX: The Psychological Corporation. 30 Martha S, Luis FR. Suicide risk assessment scales. Martha S, Luis FR (eds). Rating scales in mental health, 1st edition, New Delhi. Jaypee, 2003. 31 Motto JA, Heilbron DC, and Juster JP, “Development of Clinical Instruments to Estimate 596 Psychiatry in India : Training & training centres Suicidal Risk,” Am J Psychiatry 1985;142(6):680-6. 32 Beck AT, Weissman A, Lester D, et al, The Measurement of Pessimism: The hopelessness Scale. J Consult Clin Psychol 1974;42(6):861-5. 33 Cull JG and Gill WS, “The Suicide Probability Scale,” West Psycholog Serv, 1982. 34 Von Frenckell R, Ferreri M, Caille Ph. Validation factorielle de l'e'chelle HARD dans deux groups de déprimes. Encéphale 1989;15:423-25. 35 Pierce DW. Suicidal intent in self-injury. Br J Psychiatry 1977;130:377-385. 36 Shaffer D, Scott M, Wilcox H, et al. The Columbia Suicide Screen: validity and reliability of a screen for youth suicide and depression. J Am Acad Child Adolesc Psychiatry 2004;43:71–79. [PubMed: 14691362] 37 Hallfors D, Brodish PH, Khatapoush S, et al. Feasibility of screening adolescents for suicide risk in “real-world” high school settings. Am J Public Health 2006;96:282–287. [PubMed: 16380568] 38 Horowitz LM, Wang PS, Koocher GP, et al. Detecting suicide risk in a pediatric emergency department: development of a brief screening tool. Pediatrics 2001;107:1133–1137. [PubMed:11331698] 39 Sheikh JL, Yesavage JA. Geriatric Depression Scale: recent evidence and development of a shorter version. In, Brink TL (ed). Clinical gerontology: a guide to assessment and intervention.New York, Howarth Press;1986:165–73. 40 Verma SK, Nehra A, Kaur R, Puri A, Das K. Suicide risk eleven: A visual analogue scale. Rupa Psychological Centre; 1998. 41 McNiel DE, Fordwood SR, Weaver CM, Chamberlain JR, Hall SE, Binder RL. Effects of training on suicide risk assessment. Psychiatric Serv 2008;59:1462 -1465. 42 Woo BK, Ma AY. Psychiatric inpatient care at a county hospital before and after the inception of a university-affiliated psychiatry residency program. J Psychiatr Pract 2007; 13:343 -348. 43 Suicide: facts at a glance. Centers for Disease Control and Prevention Web site. August 2008. Available at: http://www.cdc.gov/ViolencePrevention/pdf/Suicide-DataSheet-a.pdf. Accessed June 16, 2009.

P. B. Behere Professor and Head Department of Psychiatry, M.G.I.M.S. Recipient of Dr. B.C. Roy National Award Sevagram-442102, Dist Wardha, Maharashtra, India [email protected]

S. M. Reddy Resident Department of Psychiatry, M.G.I.M.S. Sevagram-442102, Dist Wardha, Maharashtra, India 61 Psychiatric Emergencies: Recognition and General Management in Psychiatric and Medical setup

Sanjay Kumar Munda, Dushad Ram

ABSTRACT

Psychiatric emergencies constitute an important component of medical emergency and are seen mostly in the emergency department of general hospital, though these can be encountered in any routine psychiatric setup. An understanding of the basic emergency psychiatric services is important as there are numerous hybrids or idiosyncratic versions of service delivery model for psychiatric emergencies. Psychiatric emergencies do not mean that patients are suffering from only psychiatric disorders. They may present due to medical conditions or conditions unrelated to medical field, like accident, rape or violence. The framework within which the emergency care is delivered and the underlying causes of psychiatric emergencies might have an impact on the appropriate recognition and management of psychiatric emergencies, but the general guiding principles of evaluation and management is same. The goals of the intervention are rapid evaluation, containment and referral to appropriate follow up.

Keywords: Psychiatric emergencies, Emergency services

Introduction:

An emergency refers to a set of circumstances in which a catastrophic outcome is thought to be imminent and the resources available to understand and deal with the situation are unavailable at the time and place of the occurrence [1]. A psychiatric emergency is an acute disturbance of behaviour, thought or mood of patient, which if left untreated may lead to harm, either to the self or others in the environment. Thus the definition of a psychiatric emergency differs from other medical emergencies in that the danger of harm to the society is also taken into account [2]. For a variety of reasons, such as the 598 Psychiatry in India : Training & training centres growing incidence of violence, the increased appreciation of the role of medical disease in altered mental status, and the epidemic of alcohol dependence and other substance related disorders, the number of emergency patients is on the rise [3]. The American Psychiatric Association (APA) while attempting to operationalise emergency psychiatry programme have proposed the following principles [4]:

l Every contact that presents itself as a psychiatric emergency must be accepted as such until examination shows otherwise; in the same way, fire departments and police departments answer any calls.

l Appropriate locus for handling psychiatric emergencies is within a psychiatric facility and the appropriate personnel for handling them are mental health professionals.

l Emergency services should be extended to persons who are seriously disturbed but not sufficiently socially disruptive.

l Though family tolerance emergency may not qualify as psychiatric emergency within usual limits, immediate services should be available in these cases because of the distress that the remaining members of the family experience when no professional service is available.

Psychiatric emergency differs from usual psychiatric contact and medical emergency. Here patients visit to emergency room at any hour of time without any appointment, often appear threatening and frequently do not want treatment. The difference is also reflected in the tense and chaotic atmosphere, time constraint, transient doctor patient relationship, lack of confidence and faith by relatives of the patients in psychiatrists [5]. In traditional medical emergency, monitoring is based on vital signs, but for psychiatric patients, the discriminators are subtler and much different [6].

Models of delivery of care and management of psychiatric emergencies

With increased demand of emergency care, varied emergency psychiatry service delivery models have developed to meet the regional needs. Such factors as the total attendance of psychiatric patients, the geographic catchment area of the emergency setting, the availability of psychiatrists and other mental health professionals, local trends of mental health treatment and mental health laws, and economic constraints all play a role in determining which model is implemented. And as the quantity of patient contacts change, a system may convert from one model into another.

There are three basic models of emergency psychiatry delivery in fixed Munda & Ram: Psychiatric Emergencies 599 settings: the psychiatric consultant seeing patients in the medical emergency department; a separate section of the medical emergency department dedicated to mental health patients, with specially-trained and dedicated staff; and the stand-alone PES (Psychiatric Emergency Services), a facility separate from a medical emergency department that is solely for treatment of acute mental health patients [7].

I. Consultant in Medical Emergency Department:

In this model a mental health professional, optimally a psychiatrist, consults patients in a medical emergency department. In many systems the consultants are clinical psychologists, psychiatric social workers or psychiatric nurses.

Apart from being the lowest in cost and easiest to implement in a medical emergency department, other advantages include a thorough medical screening of all patients by an emergency medicine physician, so that physical concerns are evaluated and organic causes of psychiatric symptoms can be ruled out prior to consultation. Also there is lesser opportunity for stigma and delays in treatment than segregation might cause, since patients are treated in the same setting as other patients in the emergency department.

Few potential disadvantages include delay in initiation of treatment, as diagnosis and interventions must usually await the consultant's arrival, which may take several hours, during which time the patient may be receiving little or no treatment. Also the consultant's decision is usually restricted to the choice either to admit for psychiatric hospitalization or to discharge, with little chance to observe a patient sufficiently to see if improvement or decline in status might change the disposition. The emergency department setting is less likely to be conducive enough to extend psychiatric treatment and observation.

The tense and chaotic atmosphere of the emergency department may not be the most supportive or healing environment for those in mental health crisis. Emergency department environment with easy access to instruments and various equipments may not be a safe environment for suicidal patients. Additionally, many patients including suicidal patients in general emergency departments are often restrainted if 1:1 observation is not available.

Further, emergency department staff may be undertrained in mental illness, which can lead to staff callousness and disregard for psychiatric patients, resulting in poorer care and pressure to move them out quickly to open up bed space. 600 Psychiatry in India : Training & training centres While advancing towards a more multi-disciplinary approach to treatment, the use of non-psychiatrist consultants restricts the ability to recommend medications or to comfortably diagnose conditions such as delirium and sometimes such consultants are seen as lesser authorities by emergency medicine physicians; thus challenging the physician's decision becomes difficult.

II. Dedicated Mental Health Wing of Medical Emergency Department:

There is provision of a separate, often more nurturing and calming environment which is staffed by nurses or others with extra training in mental health, thus allowing for more focused and appropriate care for individuals in crisis, and thus avoiding some of the pitfalls that may confront the psychiatric patient in the general emergency room. Since its location is within a medical emergency department, patients can receive full general medical care as part of their evaluation. Additionally, because of a separate setting, there may be less urgency to move patients out and therefore permit time for medications and interventions to have effect prior to disposition decisions.

However, this model has its drawbacks. The distribution of patients to a separate space permits their marginalization and potential stigma as “different” or crazy”; some facilities have even been known to dress crisis patients in different colored gowns (e.g., bright red) to identify them as psychiatric. And sometimes, on especially busy days there may be demands to overflow non-psychiatric patients into the mental health wing because of limited space of many emergency department or float staff away from the mental health section. Too often these sections are little more than holding areas or “dumping” sites with little actual psychiatric treatment, and seen as a way of taking the patients out of the main part of the emergency department until placements are made.

III. The PES (Psychiatric Emergency Services) Model:

The PES is dedicated solely to the treatment of individuals in mental health crisis, the facilities of which can either be locked, unlocked, or a combination of the two, and located in hospital or community based. The former would ideally be situated near a medical emergency department [8]. It is staffed around the clock with psychiatric nurses and other mental health professionals, with psychiatrists either onsite or readily available, rendering diagnosis and treatment to proceed far more prompt than in the models which await a consultant's arrival. Once in a PES, a patient's psychiatric treatment can begin without delay, with the potential for patients to stabilize quickly. Munda & Ram: Psychiatric Emergencies 601 Where the first two models most often practice emergency psychiatry in a method described as the “Triage Model,” with “rapid evaluation, containment and referral,” [9] a typical PES follows the “Treatment Model,” where in addition to Triage Model capability, many patients can also be treated to the point of stabilization onsite [10]. Because of extended observation capability, it is possible to treat patients for up to 24 hours or even longer which can be sufficient for many patients to stabilize and thus avoid inpatient hospitalization. By avoiding unnecessary inpatient and getting stabilization within a PES, the patient has a path to recovery which is more timely and focused, and it is also cost effective while preserving inpatient bed availability. A PES with extended observation capacity can dramatically lower inpatient admission rates over a program using the Triage Model; one study revealed a drop in admissions from 52% to just 36% [11].

A PES also can be very advantageous for the medical emergency departments located in the same area, in decompression of overcrowding, allowing psychiatric patients to be transferred for evaluation and treatment rather than waiting for consultants to arrive at a facility or an inpatient bed to become available. Many PES programs can also accept ambulances, police deliveries, and self-referrals directly, allowing crisis patients to avoid medical emergency departments completely.

Chief among the drawbacks of a PES is that it is more expensive than the other models, with the cost of 24/7 staffing and of maintaining its own physical space.

General approach to recognition and management of psychiatric emergencies:

Psychiatric emergencies could in theory, form three groups: 1) Cause and effect are clear and identified: that is symptoms result from specifiable cause; 2) effects or symptoms are known, but the etiology is either unknown or indeterminate; and only a clearly identified predisposing condition or agent is present; 3)effects or long term sequelae are, as yet, undetermined.

The initial clinical tasks conforming to this classification involve screening for identifiable precipitants, particularly treatable organic or medical etiologies; formulating a treatment plan to alter or remove the identifiable causal conditions by the most effective short- term technique, such as medication, or referral for long term treatment; and using strategic forecasting to manage the short-term symptomatology and obviate the possibility of longer- range traumatic consequences. Thus management goals in psychiatric emergency include the following: 602 Psychiatry in India : Training & training centres

l Exclude medical etiologies for symptoms.

l Rapid stabilisation of acute crisis.

l Avoid coercion.

l Treat in the least restrictive setting.

l Form a therapeutic alliance.

l Appropriate disposition and aftercare plan

The process of emergency care and management involves four phases: triage, assessment, treatment and disposition. Actually these phases overlap or occur in combination.

I. Triage:

Triage is a term derived from military medical practice, which means sorting. It is the process of prioritizing patients according to how ill they are and how quickly their problems must be addressed in order to maximize their chance for recovery considering whether delay in treatment will adversely affect the patient outcome. Triage in psychiatric emergency helps to reduce patient's anxiety, minimize staff confusion, and in case of severe disruptive patients, allow other patients to feel less apprehensive. Patients can be triaged and assigned to the following categories:

Emergency:

l Abnormal vital signs

l Impending or active delirium tremens

l Violent behaviour

l Drug toxicity

l Suicidal attempt

Urgent or Acute:

l Overwhelming anxiety or acute agitation

l Bizarre behaviour

l Suicidal ideation or gesture

l Suicidal or homicidal risk

Non-emergency or Non-acute:

l Situational disturbances

l Mild to moderate anxiety Munda & Ram: Psychiatric Emergencies 603

l Medication questions or desire for medication or information about side effect

l Known patients needing ongoing support and continued involvement in community treatment programme

In a busy emergency service, several patients may require treatment simultaneously, so a prioritizing mechanism needs to exist. Sometimes non emergency cases also use it as an easy way to be in contact with psychiatric services leading to loss of valuable time. According to the principles of triage, the clinician must first determine if the patient has a life threatening problem. The safety of the patient, his family, other emergency patients, and the staff is the priority. Once any life threatening problems are identified and contained, the assessment proper can begin.

II. Assessment:

During the assessment phase, patients in emergency should be evaluated with respect to general psychological and medical condition, interpersonal adjustment, functional disability, nature of support network, etiologic and diagnostic considerations, and capacity to use available treatment resources. This diagnostic classification has traditionally been assigned the greatest weight in treatment planning and disposition.

There is no demonstrated connection between therapeutic alternatives with reliable outcomes and the diagnostic classification. In fact, therapeutic outcome may have more to do with such variables as the patient's general psychological and medical condition, the severity and chronicity of symptoms, the quality of interpersonal network, and congruence of treatment options with patient's resources, motivation and general emotional- cognitive style than with the actual nature or type of psychopathology. The assessment phase of the emergency intervention should therefore focus on variables that affect management and dispositional decisions, such as the immediate crisis, the longer range clinical forecast, and the available treatment options.

History:

Whenever a relatively controlled situation permits, information about the nature, duration, and course of present illness should be obtained along with history of medication use and drug abuse and current and past major medical and psychiatric illnesses and their treatments.

Mental status examination (MSE):

To elicit relatively objective data about the patient's behavioural, 604 Psychiatry in India : Training & training centres psychological, and intellectual functioning, mental status examination consists of initial impressions, systematic observations, and standardized questions that generally can be gathered informally.

Neurological and mental functioning can be assessed from patient's level of consciousness, size and reactivity of pupils, extraocular movements, skin colour and turgor, gait, speech, thought flow and content, perceptions, judgement, and insight. An agitated patient, however, may be unable to answer specific questions, thus limiting the usefulness of mental status examination.

Vital signs and physical examination:

Vital signs should be monitored closely as they may point to the presence of medical or toxic problems and at least, provide a baseline that can be used to monitor the patient over time.

Without compromising the patient's stability, a physical examination, even a brief one, should be done. If it is necessary to restrain or medicate the patient to complete the examination or obtain essential laboratory tests, it should be done promptly. Normal findings, however, do not necessarily rule out organic etiology.

Determination of the problem:

Based on the findings from history, mental status examination, and vital signs and physical examination, an attempt should be made to ascertain the exact nature and underlying basis of the problem. It focuses on four specific questions [12]:

What is wrong?

Why now?

What was the patient like before?

What does the patient expect?

The emergency psychiatric interview:

In order to develop a style of interview that enables rapid yet accurate assessment and considering the time constraint and challenges of the emergency room, three skills are required:

l A crisp, direct interviewing style

l Ability to hold an interview with emphasis on patient's immediate life Munda & Ram: Psychiatric Emergencies 605 situation.

l Mastery of formal mental status examination

Attending to the patient as promptly as possible reduces patient's anxiety and encourages development of rapport. Allow the patient uninterruptedly to narrate his problems for the first 5-10 minutes and reassure the patient. As interview progresses and clinician begins to fill in details through direct questioning, patient is more likely to give answers. Studies have shown that clinicians who talk less than usual in the first third of the interview and more than usual in the last third were more likely to have a successful outcome. Neither an authoritarian, aggressive approach, nor a passive, blank screen listening approach was productive of a good outcome [13].

An appropriate emergency room interview can be broken down into five stages:

l A courteous respectful introduction.

l Active listening of the patient problem.

l Summarizing what has been told by the patient.

l Recommending clear, direct advice about the patient’s problem.

l Evaluating patient's response by asking how he feels about the recommendations, which is helpful in building a therapeutic relationship and increasing compliance.

There is not a fixed methodology for assessment, but there are a few general guidelines:

l Focus on the presenting complaint or symptomatology

l Work backwards through time to substantiate the clinical picture and to suggest or verify the operation of particular pathogenic factors.

l Use the mental status examination to verify areas and levels of disruption in current functioning. In combination with the presenting clinical picture, the examination might also suggest areas for further medical or organic screening.

l Compare current level of functioning to the premorbid level.

l Maintain high level of suspicion about the presence of organicity. Symptoms and signs include:

l Fluctuating level of consciousness with some lucid intervals

l Disorientation and short term memory loss

l Perceptual distortions and predominantly visual 606 Psychiatry in India : Training & training centres hallucinations.

l Sudden acute onset of symptoms.

l Abnormal vital signs

l Any physical complaints and abnormal physical findings.

l Use the psychiatric history specifically to provide evidence about prior symptomatic episodes or patterns of crisis with particular modes of resolution and adaptation.

l Use the quality of the therapeutic relationship to clarify relative degrees of interpersonal reactiveness, independence, need for distance, empathy, and insight.

III. Treatment Strategies:

Environmental Measures:

Stimulation of a busy emergency department can escalate patient's symptoms. Environmental controls are needed to protect the other patients and to ensure that patient does not abscond unnoticed before the evaluation is complete. Decreasing the noise level, activity and anxiety exhibited by other patients or by the medical personnels around the patients can reduce the symptoms.

Crisis Intervention: Crisis is a time-limited unexpected event or series of events that precipitate a distressful acute response or reaction which results in disruption of usual coping mechanisms. Crisis intervention needs to begin immediately to prevent the development of chronic psychological complications. By applying the ABC principles of crisis intervention, a specific, concrete plan can be developed to reverse the disorganisation, immobilization, and demoralization that occur during the time of crisis. The ABC model of crisis intervention [14] provides a problem focussed method of intervening in a brief time period. It begins with identifying the person's perception of the event that triggered the crisis, a process best started within 4 to 6 weeks of the crisis event. It is a three-stage process which was developed by several clinicians. The ABC model is a process in which several stages of change – that is, A= Achieving rapport; B= Beginning of problem identification; and C = Coping – are introduced so that individuals reach their pre-crisis level of functioning. Criteria for recommending crisis intervention are:

l Presence of clear precipitant for patient's decompensation

l Strong social support

l Good premorbid personality Munda & Ram: Psychiatric Emergencies 607 In general, effective crisis intervention should lead to:

l Stabilizing symptoms of distress

l Mitigation of symptoms

l Restoring adaptive level of functioning

l Facilitating access to further support

Limitation of crisis intervention is inability of the physician to see the cases in follow up and relative contraindications include overwhelming suicidal thoughts, poor premorbid functioning and continuing deterioration over first two or three sessions[13].

De- escalation techniques: With advances in the understanding of aggressive behaviour, attention has turned more recently towards prediction and early intervention to reduce the incidence of physical assault. De-escalation is defined as a complex interactive process in which a patient is redirected towards a calmer personal space. The psychiatric emergency unit has an unavoidable role in setting limits to disturbed behaviour and thus is an excellent location for development and practice of de-escalation. Three basic components for effective face to face de-escalation have been described:

l Assessment of the immediate situation: A situational analysis model [15] is used which describes a progression of five factors through which aggression can result.

l Situation: Events that are focus of patient's attention immediately prior to aggressive response

l Appraisal: Conclusion drawn by the patient about reasons and circumstances of the situation

l Anger: Emotional response to a negative appraisal.

l Inhibitions: Content of patient's mental state in terms of attitudes, values and personal controls against aggression.

l Aggression: Behavioural result of the progression to the model's other components.

l Communication skills designed to facilitate co-operation: The communication skills are merely tools that are to be used by the practitioner and moulded by their individual style and personality. The content of communication needs to appear genuine and sincere and not just a regurgitation of artificial techniques. A successful de- escalation will be firmly based within the principles of therapeutic 608 Psychiatry in India : Training & training centres relationship.

l Tactics aimed at problem solving: There is a set of general de- escalating tactics that may be modified to suit individual situation.

[16] l The Win–lose equation : Based on a perceived conflict of interest between the patient and staff member which result in win or lose scenario e.g. negotiating with a patient to accept unwanted medication. Through the process of negotiation, a win-win is sought.

l Debunking: This may be achieved by unconditionally accepting the content of the patient's grievance [17].

l Aligning goals: The perceived state of affair where a patient feels he has completely different goals to the staff may be tackled by aligning these goals during the process of de- escalation.

Rapid Tranquilisation: Rapid tranquilisation is defined as the use of psychotropic medication to control agitated, threatening or destructive psychotic behaviour [18].It should not be confused with rapid neuroleptisation that entails giving high loading dose of neuroleptics to achieve an early remission. The aim is to reduce patient suffering, allow improved communication, reduce risks to the patient and others, and to do no harm. It is used only when less coercive approaches such as diversion and verbal de- escalation have failed. Antipsychotics are often used in rapid tranquilisation, and can bring about rapid improvement in symptoms of psychosis and mania, to a greater extent than benzodiazepines [19].

Patients requiring rapid tranquilisation tend to fall into two groups: those who require repeated injections due to persistent refusal of oral medication and resulting aggressive behaviour and those who require only one or two injections early on in their treatment [20]

There is no national or international consensus on the most effective drug treatment. The drugs most frequently used are antipsychotics and benzodiazepines, separately or together. Whenever possible, rapid tranquilisation drugs should be given orally. It is sometimes necessary for these drugs to be administered by intramuscular injection while a patient is being restrained. Intravenous administration is the most hazardous route and should be limited to situations where immediate tranquilisation is deemed essential. Associated adverse effects include respiratory depression, hypotension, irregular or slow pulse, neuroleptic malignant syndrome and acute dystonia. Munda & Ram: Psychiatric Emergencies 609 Physical Restraint: Use of physical restraints is controversial and should be considered only when other methods have failed and a patient continues to pose a significant risk of harm to self or others. Restraints may be needed to hold the patient long enough to administer drugs, do a complete assessment, or both. The combination of a struggling patient, intramuscular injection and physical restraint must be considered a potentially dangerous mix [21].The traumatic, humiliating nature of restraint and its effect on the development of trusting professional relationships between patients and staff cannot be underestimated.

Restraints are used to:

l Prevent clear, imminent harm to the patient or others

l Prevent the patient's medical treatment from being significantly disrupted (eg, by pulling out tubes or IVs) when consent to the treatment has been provided

l Prevent damage to physical surroundings, staff members, or other patients

l Prevent a patient who requires involuntary treatment from leaving (when a locked room is unavailable)

Restraints should not be used for:

l Punishment

l Convenience of staff members (e.g., to prevent wandering) Caution is required in overtly suicidal patients, who could use the restraint as a suicide device.

IV. Disposition:

Proper disposition depends on an accurate assessment of patient's emotional and physical problems, his social or environmental support and community resources. Expectation of the family should also be taken care of while making final disposition. There are four dispositional choices [22]:

l Hospitalisation

l Refer for outpatient follow up

l Refer to a medical/ surgical service

l Release without additional treatment

Conclusion:

The recognition and effective management of psychiatric emergencies is 610 Psychiatry in India : Training & training centres influenced by the framework within which care is delivered, but the general guiding principles are similar in all the settings. The keys to handling these situations are to keep the patient and others, including the clinician, safe; to recognise the potential underlying causes, to provide timed, immediate and planned interventions and to make an appropriate disposition or referral.

References:

1. Allen MH. Level 1 Psychiatric emergency service – The tools of the crisis sector. The Psychiatr Clin North Am 1999; 22 (4): 713-734. 2. Sudarsanan S, Chaudhury S, Pawar AA, Salujha SK, Srivastava K. Psychiatric emergencies. Med J Armed Forces India. 2004; 60:59–62. 3. Khalid A, Regmi SK, Koirala NR, Nepal MK, Pokhare A. Psychiatric emergencies in a general hospital setting. J Inst Med. 1999; 21: 12- 14. 4. Glasscote RM, Cumming E, hammersley DW. The Psychitric Emergency – A study of patterns of Service. Washington D. C.: Joint Information Service of the American Psychiatric Association and National Association for Mental Health 1996; 9-13. 5. Jena S. Psychiatric emergencies. In: Vyas JN, Ahuja N. Textbook of Post Graduate Psychiatry. New Delhi. Jaypee Brothers. 1999: 521-525. 6. Walker JI. Basic concepts of emergency care. In: Psychiatric emergencies intervention and resolution. London. J. B. Lippincott 1983:1-20 7. Zeller SE. Treatment of psychiatric patients in emergency setting. Primary Psychiatry. 2010; 17(6):35-41. 8. Allen MH, Forster P, Zealberg J. Task force on psychiatric emergency services report and recommendations regarding psychiatric emergency and crisis services. Washington, DC: American Psychiatric Association; 2002. Availableat:http://archive.psych.org/ edu/other_res/lib_archives/tfr/tfr200201.pdf. Accessed April 22, 2010. 9. Gerson S, Bassuk E. Psychiatric emergencies: an overview. Am J Psychiatry. 1980; 137(1):1- 11. 10. Allen MH. Definitive treatment in the psychiatric emergency service. Psychiatr Q. 1996; 67(4):247-262. 11. Gillig PM, Hillard JR, Bell J, Combs HE, Martin C, Deddens JA. The psychiatric emergency service holding area: effect on utilization of inpatient resources. Am J Psychiatry. 1989; 146(3):369-372. 12. Fauman BJ. Other Psychiatric emergencies. In: Kaplan and Sadocks Comprehensive Textbook of Psychiatry. 7th edition. Philadelphia, USA: Lippincott Williams and Wilkins. 2000; 2041-2055. 13. Rusk TN, Gerner RH. A Study of the process of Emergency psychotherapy. Am J Psychiatry. 1972; 128: 882-886. 14. Khouzam HR. Crisis Intervention. In: Khouzam HR, Tan DT, Gill TS. Handbook of emergency psychiatry. Philadelphia. Mosby 2008: 1-5. 15. Frude N. The physical abuse of children. In: Clinical approaches ton violence, eds: Howells K, Hollin C. Chochester: Wiley, 1989:155-181. 16. Le Poole S. Never take no for an answer: A guide to successful negotiation, London: Kogan Page. 1987. 17. Maier G. Managing threatening behaviour. The role of talk down and talk up. J Psychosoc Nurs. 1996; 34(6): 25-30. 18. Ellison J, Hughes G, White K. An emergency psychiatry update. Hosp Community Psychiatry. 1989; 40 (3): 250- 260. 19. Agid O, Kapur S, Arenovich T. Delayed onset hypothesis of antipsychotic action. A hypothsis tested and rejected. Arch Gen Psychiatry. 2003; 60: 1228-1235. Munda & Ram: Psychiatric Emergencies 611 20. Pilowsky LS, Ring H, Shine PJ, Battersby M, Lader M. Rapid tranquilisation. A survey of emergency prescribing in a general psychiatric hospital. Br J Psych. 1992; 160: 831-834. 21. Paterson B, Leadbetter D, McComish A. Restraint and sudden death from asphyxia. Nurs Times. 1998; 4: 62-64. 22. Walker JI. Basic concepts of emergency care. In: Psychiatric emergencies intervention and resolution. London: J. B. Lippincott. 1983: 1-20.

Sanjay Kumar Munda Assistant Professor of Psychiatry Central Institute of Psychiatry Kanke, Ranchi - 834006 Jharkhand India [email protected]

Dushad Ram Assistant Professor of Psychiatry JSS University, JSS Medical College Mysuru, Karnataka -570004 [email protected]

62

Risk and its assessment in Psychiatry

Rajeev Krishnadas, Seethalakshmi Ramanathan, K. Kuruvilla

ABSTRACT

Risk assessment is an often neglected area in routine clinical practice and psychiatric training. It is a procedure conducted alongside a clinical interview that identifies circumstances pertaining to the individual that increase the likelihood of an unfavourable outcome. This involves identifying and quantifying risk factors, assessing the acceptability of an identified risk factor and preventing unacceptable risks. Different approaches to risk assessment include clinical, actuarial and structural professional judgment methods. In the context of vanishing extended family structure, increasing trend towards litigation and medical science being viewed as any other consumer based service, clinicians will be held responsible and accountable for the care of their patients. A “reasonable” risk assessment should help us reach a defensible decision, i.e. a decision that can be defended from an ethical, logical and last but not the least, legal viewpoint. The authors use 2 hypothetical case vignettes to discuss the concept of risk, the types of risks clinicians should look out for, approaches to risk assessment, what constitutes a reasonable risk assessment and limitations of risk assessment.

Key words: Risk, Risk assessment, suicide, violence, mental health

Introduction

“Uncertainty is the only certainty there is, and knowing how to live with insecurity is the only security.” - John Allen Paulos

Nothing comes closer in spirit to the above statement than the prediction of suicide or homicide. The estimated global burden of suicide is a million deaths per year. [1] Studies from India have reported that more than a hundred thousand lives are lost ever year to suicide. Conservative estimates suggest 614 Psychiatry in India : Training & training centres that up to 80% of those who committed suicide had a diagnosable mental disorder at the time of committing the act. [2] It is thought that up to a third of the people who committed suicide met with a health care professional during the weeks leading to the attempt. [3]

Up until the 1980s, it was thought that the mentally ill were no more likely to be associated with violence than the general population. Violence in this population was more often associated with socio-economic deprivation and substance use. More recent studies have however shown an increased association between mental illness and violence even after controlling the above mentioned factors. [4] A recent systematic review showed a two to six fold increase in the risk of homicidal violence in people with mental illness. A diagnosis of schizophrenia increased the risk of violence six to ten times. [5]

Risk assessment is an often neglected area in routine clinical practice and training. But, as the above statistics highlight, its importance cannot be overemphasized. Contrary to popular belief, risk assessment is not merely a diagnostic interview. It is a procedure conducted alongside the diagnostic interview and repeated with every review. The clinician identifies circumstances pertaining to the individual that increases the likelihood of an unfavourable outcome. These clinical intuitions are then verified by actively probing and quantifying the likelihood of the expected negative outcome. Some examples include suspicion of non-adherence to the medication regime that may lead to a relapse of psychotic illness or the occurrence of significant life events that may lead to an attempted suicide. In our society, these risks are usually detected and managed by the patient’s caregivers to a considerable extent. For e.g.: they make sure that the patient is adherent to the treatment plan or spend more time with the patient and keep potentially dangerous items away.

We use two hypothetical clinical case vignettes to illustrate the importance of risk assessment. With these vignettes, we also attempt to suggest methods to help clinicians to perform a reasonable risk assessment.

Clinical Case Vignettes:

Vignette 1 - The girl who attempted suicide

Ms X was a 20- year old computing student. She recently moved to the city for her education and was living in the college hostel, sharing a room with another student. She was admitted to the medical ward of a teaching general hospital following ingestion of pesticide. She was referred to the psychiatry department at the general hospital and was assessed by the psychiatry resident on call at the medical ward. He took a history of her presenting complaints. She claimed that she mistook a bottle of pesticide for cough Dr Rajeev Krishnadas et. al: Risk and its assessment 615 medicine in the dark at night. She was found unconscious by her roommate, who alerted the authorities. Enquiring about any past history of mental illness, the girl reluctantly admitted to being seen by a psychiatrist two months back for being “under stress of exams” and was started on some medications which she took for about a month and then stopped on her own as she felt better. She denied any thoughts or attempts of self harm in the past. Ms X also denied any symptoms suggestive of depression or psychosis. Corroborating history about her past psychiatric problems could not be obtained as her parents lived in a different state and could not be contacted. Ms X further reported that she did not have many friends in her college. The resident gave her a diagnosis of accidental self harm and discharged her. A few days later, the girl was admitted to the orthopaedic ward with a broken leg after she jumped off her first floor room.

Vignette 2 - The man who assaulted his parents

Mr.Y, a 25-year-old male who lived with his parents in the suburbs of a metropolitan city, was brought at night to the Casualty department of a general hospital by his parents. At the casualty, they reported to the psychiatry resident on call, that following an argument with a neighbour 3 days ago, their son had not been sleeping at night, was getting angry and shouting at the neighbours. The patient was un-cooperative during mental status examination, but admitted that he was very angry towards his parents because “they did not understand” him. The psychiatry resident made a diagnosis of ‘Acute Psychosis’, prescribed antipsychotics to be taken that night and next morning after which the patient was advised to attend the regular psychiatry out-patient clinic next day. The parents however insisted on admitting the patient to the hospital as it was difficult for them to administer any tablets. The patient was therefore admitted to the psychiatry ward.

Once in the ward, Mr.Y refused to take the tablets, became very agitated and demanded immediate discharge. When his demand was not complied with, Mr.Y became very disruptive, pacing up and down, threatening the staff and banging on the doors and windows. When the staff intervened, he became violent and hit one of them. He was physically restrained and subjected to rapid traquilisation.

On interviewing Mr.Y’s parents next day they admitted that he had been violent in the past also. They reported that over the past two years, their son had become increasingly irritable and had anger outbursts with minimal provocation. He was also reported to have been smoking cannabis regularly. They revealed that a year ago, the patient was taken to a psychiatrist, who diagnosed him with a ‘serious mental disorder’ and started him on anti- 616 Psychiatry in India : Training & training centres psychotic medications. Mr.Y’s symptoms improved within a month and he thereafter refused to go back to the doctor for follow-up care or take the medicines any more. Parents did not compel him to do either, as he was not showing any major problem behaviour. However about 6 months prior to the present admission, he was becoming increasingly suspicious about their neighbours. He spent a lot of time making plans to save him and the country from the neighbours, who he felt were terrorists. When his father tried to point out the irrationality of his beliefs, Mr.Y became intensely angry and assaulted him. After that incident, he was relatively quiet for the next couple of months till the current presentation.

During a repeat mental status examination Mr.Y divulged to the psychiatrist that by locking him up in the ward, the staff was preventing him from saving the country. In the ward, at times he was found to be muttering and gesticulating as if he was responding to hallucinations.

What does the term ‘Risk’ imply?

Risk simply measures the likelihood of occurrence of a particular event. This event could refer to anything. Generally, however “risk” is used to denote unpleasant events. We assess risks on a routine basis as a part of our everyday decisions. A common example from our daily life would be: The “risk” of falling down from the 8 AM local train in the morning is definitely higher than the 8.30 AM local due to the rush and crowd. But the “risk” of reaching the workplace late is much lower compared to the 8:30 AM train. In both cases, risk refers to the likelihood of an event happening - one being the adverse event of “falling from the train” and the other being “reaching the work place late”.

What is ‘Risk’ in clinical practice?

As clinicians, much of our clinical practice involves the process of weighing the risks and benefits for each of the intervention that we intend to prescribe. In psychiatry, we have to often consider the risk of a 25-year-old girl developing polycystic ovarian disease on treatment with sodium valproate or the risk of a 75-year-old man with agitation having a fall on treatment with benzodiazepines or restarting a patient who had developed agranulocytosis on treatment with Clozapine.

How do we assess ‘Risk’ in Psychiatry?

Traditionally, risk assessment has been used to predict or identify risk. Hart [6] defines risk assessment as “the process of identifying and studying hazards to reduce the probability of their occurrence”. More recently however, the emphasis has shifted to assessing the acceptability of a risk and preventing Dr Rajeev Krishnadas et. al: Risk and its assessment 617 unacceptable risks. Nevertheless, the identification of risks remains the first step towards a reasonable risk assessment. A detailed history and mental state examination form important initial processes in risk assessment. Bouch and Marshall [7] recommend 3 types of approaches towards risk assessment: “clinical”, “actuarial” and “structured professional judgment”.

1) The clinical approach is the traditional method wherein the clinician makes decisions based on purely clinical judgment. This makes the approach subjective, intuitive and dependent more on clinical experience and less on evidence base. The process has been criticised that clinical judgments are invariably affected by a clinician’s feelings, and hence may not be accurate. In fact, Simon [8] states that clinical experience, unaided by evidence-based research, can be idiosyncratic, insufficient, uninformed, or just plain wrong when applied to complex, fact-specific suicide cases.

2) The second approach called the actuarial approach involves assessment methods that are formal and algorithmic. The approach follows objective procedures, and often uses standardised instruments. Actuarial instruments attach specific statistical weightage to different variables which assess the risk. They are premised on the idea that, if accuracy of prediction is the most important factor, it is best to find out how members of a comparable group of individuals conduct themselves over time. This type of assessment helps the professional to ultimately reach a decision based on a numerical statement of the risk of a future outcome. For example, actuarial approach can come to conclusions such as: Patient ‘A’ has a 50% chance of committing suicide in the next 5 years. This method is frequently used in forensic settings in the assessment of violent and sexual offenders. Some of the actuarial instruments used in forensic settings in the west include Violence Risk Appraisal Guide (VRAG) and the Historical/Clinical/Risk Management 20-item (HCR-20). [9] The down side of the actuarial approach is the fact that it is excessively historical and does not take into consideration the fact that the risk changes with change in circumstances. Despite these criticisms, most of the actuarial methods involve a clinical interview and diagnosis of a clinical condition.

3) Bouch and Marshall [7] suggest a third method called “Structured professional judgment”, which combines the evidence base for risk factors with individual patient assessment. In this method, clinicians make a structured assessment, which is used in the formulation of a risk management plan. “Structured professional judgment” is useful not only for supporting evidence-based practice but is individually tailored and useful for increasing the transparency of decision-making. (See Bouch and Marshall, 2005 for a detailed review) [7]

What kind of ‘risks’ should a psychiatrist look for? 618 Psychiatry in India : Training & training centres All kinds of risks are important. Some risks are more acceptable than others. For example the risk of a person developing mild tremors with lithium may be considered acceptable, while the same person developing lithium toxicity may not be acceptable. In psychiatry, the most important unacceptable risks involve outcomes that are dangerous to patients or others. Prime among these are suicide and violence. (Table I) [10] Broadly speaking they refer to the risk of progression of illness – risk to physical and mental health of the individual; the risk of deliberately induced harm to self including suicide; the risk of unintentional harm to self, or exploitation; the risk of intentional or unintentional violence, or fear-inducing behaviour towards others. A generalised framework of the factors to be considered for the assessment of risk is given in table 2. [10] There are standardised instruments that aid in the assessment of the risk of violence or suicide. A few of them are used routinely in clinical practice for e.g. the Beck’s suicide intent scale or the Sainsbury risk assessment tool (this tool is available free of cost on-line along with the manual). [11-12]

A practical and simple method is to classify risk factors into Static (long term), Dynamic (current and modifiable) and Protective factors. Static historical factors include variables like age, demographic factors, past history of mental illness, medical illness, past history of suicidal or violent behaviour, etc, which are unlikely to get modified with time. Dynamic (modifiable) risk factors, on the other hand, include the current history, the mental state examination and those situational factors that may contribute to increasing the risk of harm to self or others e.g.: living alone, availability of methods of suicide or violence to others etc, which can be modified in order to alter the risk. Protective factors are factors which may be involved in reduction of the risk, such as good family support, good compliance with medication regime and adherence to treatment plan, etc. Since risk itself is a very fluid concept a careful weighing of these factors should help us reach a fairly reasonable decision. [13] The model can be summarised as follows:

Static factors + Dynamic factors – Protective factors = Current level of risk

Clinical case vignettes revisited:

Let us look at the case vignettes again.

Case vignette 1 continued:

With the limited data available in the above case, and the risk assessment framework in mind, the factors associated with risk could be presented as Table 3. It is clear from the table that the risk factors outweigh the protective factors. A fairly reasonable risk assessment would have led to measures aimed at controlling the immediate risk factors. This may have included admitting Dr Rajeev Krishnadas et. al: Risk and its assessment 619 the patient in order to get additional information regarding the presenting complaints.

Employing a structured risk assessment, let us recreate the scenario with some changes, beginning with a new decision by the on call psychiatrist to admit Ms X. Her parents are contacted, who provide further information about Ms X. She had a rural upbringing and was quite close to her family. Her parents described her as a good-natured girl, who kept to herself most of the time. She was above average in her studies, which led to her obtaining admission into a prestigious course at the university. Her move to an urban area and consequent change in lifestyle had put her under considerable amount of stress. The need to retain high grades further compounded her ongoing stress. Being “a loner” prevented her from forming social support networks in her new environment. A repeat mental state examination, after establishing an improved rapport with the patient, revealed that she has had psychotic symptoms for some time. She reported a voice asking her to kill herself. She had partial insight into her illness, and was willing to take her medication under the supervision of her parent. She was also willing to ask for help if the “voices” became overwhelming. Finally, her parents agreed to move to the city while she completed her studies.

Using the framework, how does the girl’s risk profile change in light of the change in circumstances?

The static/ long-term factor remained the same. The current/ dynamic factors have changed with the presence of a psychotic illness with command hallucinations.

The vignette is a clear case where a diagnosis of accidental overdose, a seemingly innocuous diagnosis led to the patient being discharged. A careful risk assessment revealed that the patient needed further evaluation. Further assessment and change in her personal situation, in spite of the potentially more serious diagnosis – “psychotic illness”, again led to the discharge of the patient, but this time, with an appropriate treatment plan. The psychiatrist also worked at improving the protective factors significantly. At the time of discharge, the girl had good support from her family, and despite her partial insight, she agreed to take her medications under her parents’ supervision and also agreed to be followed up with her psychiatrist. (Table 4)

This example demonstrates that risk is a dynamic concept that changes with circumstances. Risk assessment and management involves a coherent amalgamation of these various dynamic factors that help us quantify risk and thus, reach an informed decision on the patient’s management plan. 620 Psychiatry in India : Training & training centres Case Vignette 2 continued:

An important concern that the second vignette brings out is the potential for violence in psychiatric patients. Recent reports suggest that 6-month prevalence rates of violence among individuals with schizophrenia range from 9- 19% [14], with Odds Ratios of 1.2 to 1.3 [15-16] compared to the general population. The MacArthur Risk Assessment Study, reported prevalence rates of violence in discharged patients in the community of 19% for depression, 15% for bipolar disorder, 17.2% for other psychotic disorders and 25% for personality disorder. These numbers increased with co-morbid substance misuse. [16] Indeed, studies have reported that psychiatry residents, nurses, staff on the psychiatric wards and psychiatrists have a higher risk of being attacked.[17-18]

A number of individual case reports have attributed violence to serious mental illnesses like Schizophrenia. One of the most famous cases from India is that of Raman Raghav. He terrorised the streets of Mumbai in the 1950’s till he was finally captured by the police. Raman Raghav was diagnosed with paranoid schizophrenia. Raghav believed that the people around him were attempting to convert him into a homosexual making it necessary for him to kill them to defend himself. McNaughten (of the McNaughten’s rule) also suffered from paranoid delusions of persecution by the Tories.

Some important factors that need to be considered in the assessment of violence include the individuals’ attitudes towards violence, their capacity to carry out a threat, the thresholds they have already crossed, their intent, reactions and attitudes of others and non-adherence to the treatment plan. [19] Risk factors that predict violence in schizophrenia and other serious mental illnesses are similar to predictors in the general population.

Mr Y first presented to the casualty with anger outbursts and aggressive behavior of 3 days’ duration only. The parents initially did not reveal the long history of altered behaviour, patient’s delusions, substance abuse or past history of aggressive behaviour, on their own. The time of presentation as well as the restricted environment in the casualty devoid of any privacy possibly prevented the psychiatry resident from obtaining a detailed longitudinal history from the parents and subjecting the patient to a systematic mental status examination. These seem to have led to the wrong initial diagnosis of ‘Acute Psychosis” and prevented the doctor from recognising the risk for violence, non-compliance with oral medication and cautioning the ward staff about the potential for aggression. Once the details were obtained (perhaps necessitated by the un-anticipated aggression) not only did the diagnosis change to paranoid schizophrenia, but also the patient’s behaviour became understandable in the context of his delusion. He Dr Rajeev Krishnadas et. al: Risk and its assessment 621 believed that there was a conspiracy against him and the nation. His agitation on the wards resulted from attempts to stop him from doing what he assumed were his duties to save himself and the nation. Immediately prior to the violence, he demonstrated subtle signs of increased agitation, like pacing up and down and banging on the doors. Indeed, his actively psychotic positive symptoms increased the risk of violence. [14] He also had a history of substance abuse, history of non-compliance [20] and a past history of “striking his father” that substantially increased his potential for violence. In certain cases, wherein an individual reports violent thoughts towards particular people, it is the psychiatrists’ duty to inform and protect the concerned people of these risks (Tarasoff ’s rules). [19]

To conclude, as both vignettes demonstrate, risk assessment is based on individual needs. Unlike medical management, there are no golden rules or guidelines that should be followed in all cases. A careful assessment of the contributing factors may reveal areas that need to be addressed and modified in order to decrease the risk. These need to be tailored on an individual basis.

What are the limits of risk assessment?

The nature of risk makes it difficult to assess with absolute certainty. Even the most sophisticated risk assessments can go wrong at times. Incidents of suicide and violence are often unpredictable and even the most experienced clinicians can get it wrong. In fact, a widely quoted axiom is, “if it has never happened to you, it means you are probably seeing the wrong kind of patients”. For e.g. the girl in the first scenario may agree to a plan of action and then may leave the doctor’s office and kill herself on the same day. A good risk assessment should help us make a decision that is defensible from an ethical, logical and last but not the least, legal viewpoint. Since risk is a dynamic concept, it also needs to be assessed regularly whenever there is a change in a circumstance or situation, which is likely to influence the outcome.

As clinicians, we have a duty to protect our patients. In the context of increasing westernisation of the society, the vanishing extended family structure, increased trends towards litigation and medical science being viewed as any other consumer based service, clinicians (service providers) will be held responsible and accountable for the care of their patients (increasingly referred to as a “service users” or “clients” in the consumer market era). Clinicians will also be accountable for their clinical decisions and serious adverse events arising from these decisions. It therefore becomes vital that these decisions are based on “reasonable” risk assessments. A “reasonable” risk assessment should help us reach a defensible decision, i.e. a decision that can be defended from an ethical, logical and last but not the 622 Psychiatry in India : Training & training centres least, legal viewpoint. In fact the Royal College of Psychiatrists identifies risk assessment as a core competency that is a direct responsibility of a psychiatrist. [21] The question that this raises is what is a reasonable risk assessment? Sadly, as has been discussed above, there are no clinical gold standards for risk assessments. The structured professional judgment seems to be a reasonable approach towards risk assessment.

Lastly, hindsight bias is the inclination to see events that have occurred as being more predictable than they were before they took place. [22] When things go wrong, it is very easy to look back and ruminate over ways in which we could have acted differently or engage in a blame-game (self or others). It is important that a clinician (particularly in training) gets adequate supervision and support when things go wrong. An adverse event should be used to train the clinician to identify different scenarios and strategies and thus prevent unfortunate events in the future.

Summary

In today’s society, where a psychiatrist has the responsibility to protect the patient and relevant others, the importance of risk identification and management cannot be emphasized enough. The process of risk assessment is definitely complex and fraught with inaccuracy, but if meticulously applied can help save lives. [11] Clinicians should incorporate risk assessment into their routine clinical practise. And training programs should consider incorporating supervised risk assessment into their curriculum.

REFERENCE

1. Hawton K, van Heeringen K. Suicide. Lancet 2009; 373:1372-81. 2. Vijaykumar L. Suicide and its prevention: The urgent need in India. Indian Journal of Psychiatry 2007; 49:81-84 3. Pirkis J, Burgess P. Suicide and recency of health care contacts. A systematic review. Br J Psychiatry 1998; 173:462-74. 4. Stuart H. Violence and mental illness: an overview. World Psychiatry 2003; 2:121-4. 5. Richard-Devantoy S, Olie JP, Gourevitch R. [Risk of homicide and major mental disorders: a critical review]. Encephale 2009; 35:521-30. 6. Hart S. The role of psychopathy in assessing risk for violence: conceptual and methodological issues. Legal and Criminological Psychology 1998; 3:123–40. 7. Bouch J, Marshall L. Suicide risk: structured professional judgement. Advances in psychiatric treatment 2005; 11:84-91. 8. Simon RI. Suicide risk assessment: is clinical experience enough? J Am Acad Psychiatry Law 2006; 34:276-8. 9. Lewis A, Webster C. General Instruments for risk assessment. Current opinion in psychiatry 2004; 17:401-05. 10. Ministry of Health. Guidelines for Clinical Risk Assessment and Management in Mental Health Services. Newzealand. 1998. Dr Rajeev Krishnadas et. al: Risk and its assessment 623 11. Harriss L, Hawton K, Zahl D. Value of measuring suicidal intent in the assessment of people attending hospital following self-poisoning or self-injury. Br J Psychiatry 2005; 186:60-6. 12. Range L. The Family of Instruments That Assess Suicide Risk. Journal of Psychopathology and Behavioral Assessment 2004; 27:133-40. 13. Matthews S, Paxton R. Suicide risk - A guide for primary care and mental health staff. 2001. 14. Swanson JW, Swartz MS, Van Dorn RA, Elbogen EB, Wagner HR, Rosenheck RA et al. A national study of violent behavior in persons with schizophrenia. Arch Gen Psychiatry 2006; 63:490-9. 15. Fazel S, Buxrud P, Ruchkin V, Grann M. Homicide in discharged patients with schizophrenia and other psychoses: A national case-control study. Schizophr Res 2010. 16. Fazel S, Langstrom N, Hjern A, Grann M, Lichtenstein P. Schizophrenia, substance abuse, and violent crime. JAMA 2009; 301:2016-23. 17. Antonius D, Fuchs L, Herbert F, Kwon J, Fried JL, Burton PR et al. Psychiatric assessment of aggressive patients: a violent attack on a resident. Am J Psychiatry 2010; 167:253-9. 18. Schwartz TL, Park TL. Assaults by patients on psychiatric residents: a survey and training recommendations. Psychiatr Serv 1999; 50:381-3. 19. Borum R, Reddy M. Assessing violence risk in Tarasoff situations: a fact-based model of inquiry. Behav Sci Law 2001; 19:375-85. 20. Swartz MS, Swanson JW, Hiday VA, Borum R, Wagner HR, Burns BJ. Violence and severe mental illness: the effects of substance abuse and nonadherence to medication. Am J Psychiatry 1998; 155:226-31. 21. Royal College of Psychiatrists. Roles and responsibilities of the consultant in general adult psychiatry council report CR140. 2006. 22. Bradfield A, Wells GL. Not the same old hindsight bias: outcome information distorts a broad range of retrospective judgments. Mem Cognit 2005; 33:120-30.

Rajeev Krishnadas Clinical Lecturer in Psychological Medicine Southern General Hospital University of Glasgow, UK. [email protected]

Seethalakshmi Ramanathan Department of Psychiatry and Behavioral Sciences SUNY Upstate Medical University, Syracuse, NY-13210.

K. Kuruvilla Emeritus Professor of Psychiatry PSG Institute of Medical Sciences & Research, Coimbatore, India 624

Ta ble 1: Principle categories of Risk

Psychiatr RISKS TO SELF RISKS TO OTHERS Self -harm (suicidal acts, deliberate self violence (including emotional, sexual y inIndia:T harm) and Poor health (substance use, neglect of physical violence) physical/ mental health) intimidation/threats and harassments Poor quality of life (dignity, social and neglect/abuse of dependants raining &trainingcentr financial status) property damage Increased vulnerability (including public nuisance exploitation, sexual abuse and violence reckless behaviour from others) Self-neglect

es

Adapted from GUIDELINES for CLINICAL RISK ASSESSMENT and MANAGEMENT in MENTAL HEALTH SERVICES, Ministry of H ealt[9] h, New Zealand 1998

Table 2: Factors to consider when assessing risk HISTORICAL ENVIRONMENT/CURRENT MENTAL STATE Protective INFORMATION FACTORS (Dynamic) factors

(Static/ long term (Dynamic factors) (Dynamic) Dr RajeevKrishnadas factors) Psychiatric history Immediate stressors Behaviour Cognitive Patterns of illness, Substance use, intoxication Dangerous or Flexibility; including past history or withdrawal threatening actions Strong social of adverse events like Relationship breakdown Verbal/non-verbal Support;

self harm and Presence or absence of risks Lack of et. al: violence. support Deliberate self harm precipitating

History of incidents Presence/absence of Aggression live events; Risk anditsassessment (and context) treatment, non-compliance Negative symptoms No losses; Treatment and with treatment – especially for Hopefulness; Outcomes in the past Persecution or threats from neglect Treatment of Substance use in the others Affect psychiatric past Arrest or criminal charges Arousal, anger, disorder; Features of past Loss including death of a hostility, Treatment of crises peer irritability, personality Persona l history Financial stress suspiciousness, fear disorder (Contd.) 625 Table 2: Factors to consider when assessing risk (Contd.) 626 HISTORICAL ENVIRONMENT/CURRENT MENTAL STATE Protective INFORMATION FACTORS (Dynamic) factors (Static/ long term (Dynamic factors) (Dynamic) factors) Personality Access Low mood or Usual coping style To means of harm, e.g.: weapons, elevated mood Psychiatr Family background pills, poison, rope, victims, etc Cognition

Demographics, age, Situation Thoughts of y inIndia:T sex Home, prison, hospital, etc deliberate self harm Culture Individual’s attitude or harm to others Co-operation Persecutory Refusal to co-operate thoughts, delusions raining &trainingcentr (including fear of External locus of compulsory treatment control Confusion process) Préoccupation, obsession, jealousy

Perceptions es Command hallucinations Derogatory hallucinations

Adapted from GUIDELINES for CLINICAL RISK ASSESSMENT and MANAGEMENT in MENTAL HEALTH SERVICES, Ministry of Health, Newzealand 1998 Table: 3. Case vignette 1: Risk factors involved in the case of the accidental consumption of

pesticide Dr RajeevKrishnadas Static factors/ Long term factors Dynamic/ Immediate factors Young Self harm attempt Female Currently living away from family Possible schizoid personality traits Poor social support network Possible past history of mental health Stressful period – exams

problems Possible inability to cope with the new et. al: Possible non compliance with course medications Possibly defensive on MSE Risk anditsassessment Access to means – pesticide freely available

Protective factors Outcome There was at least one episode where Further history and assessment required she had asked for help for the way she Getting family involved was feeling. 627 628

Table 4: Case vignette 1 continued: Risk assessment in the light of new information Static factors/ Long term factors Dynamic/ Immediate factors Young Self harm attempt

Female Psychotic illness with command Psychiatr Schizoid personality traits hallucinations Past history of mental health problems No emotional insight y inIndia:T Non compliance with medications Stressful period – exams Inability to cope with the new course and lifestyle

raining &trainingcentr Protective factors Outcome Support from family –help with coping The patient was discharged under the with the stressful period including the care of her parents with regular support exams and the change in environment. from her clinician. Willing to take medications Willingness to adhere to plan Good rapport established with clinician es Access to means restricted by the presence of parents

Dr RajeevKrishnadas Table: 5. Case vignette 2: Risk factors involved in the case of the attack on parents Static factors/ Long term factors Dynamic/ Immediate factors Young Active positive psychotic symptoms Male Paranoid schizophrenia

Substance abuse et. al: Non-compliance on medications History of violence Risk anditsassessment

Protective factors Outcome Supportive family members Ensuring compliance and psychoeducation of parents.

629

63 Critical Care In Psychiatry

Debjani Bandopadhyay, Gautam Saha, Om Prakash Singh

Mrs. Ray has been visiting our OPD on and off as a patient of Bipolar Affective Disorder for the last four years, but she hadn't visited for the last 6 months. She was suddenly brought one day with severe agitation, shouting, and screaming. But her responsiveness was also altered, unlike pure manic agitation. As a psychiatrist, one gets a gut feeling that the cause of agitation lies elsewhere. But the Department of Medicine refused to take her in, and she was kept in Psychiatry Ward. By evening she was diagnosed as having Diabetic Ketoacidosis, but she was continued to be kept under our Dept. At the end we ended up buying a glucometer and her condition resolved smoothly with close monitoring and helpful visits by the internal medicine resident.

A patient was admitted for alcohol; detoxification; he develops delirium tremens, psychiatry ward has no facility to monitor, physicians are not confident enough to manage.

The purpose of sharing this anecdote was that currently we live in an age when every other faculty of medicine is extending its boundaries. Dermatologists are taking up cosmetic surgeries; cardiologists are turning more interventional than ever before. So when our patients need intensive care either due to their underlying condition or due to our medications, we must be able to treat them or at least hold the fort till we get the support of critical care specialists.

This is a time of liberalization of psychiatry from its confines. When we turn a book on emergency psychiatry or on call psychiatry we only get to see pages either on aggressive and violent psychotic patients or suicidal patient. But emergency and critical care psychiatry is not just limited to these psychiatric conditions.

Psychiatric medications are frequently an essential component of care for critically ill patients. Their use may lead to medical complications, as a result of [1] direct toxicity from psychotropic medications, [2] drug-drug interactions, or [3] intoxication or withdrawal states. These complications may be a 632 Psychiatry in India : Training & training centres nuisance (e.g., dry mouth and nausea) or serious and life-threatening (e.g., neuroleptic malignant syndrome [NMS] and cardiac arrhythmias). The name critical care rings a bell to anyone who practices medicine. It is nothing but specialized and dedicated care given by a team to a patient who is critically ill. The aim of the critical care is to see that one provides a care such that patient improves and survives the acute illness or tides over the acute exacerbation of the chronic illness. Intensive care has developed in the last decade in our country. It is being imparted to both critically as well as to terminally ill patients. Various regional, political factors, and problems associated with our health care delivery are to be overcome to provide an ideal setting for care of these patients

The Unmet Challenge

One of the factors which dissuade us as psychiatrists from getting involved in the care of critically ill patients is the difficulty in diagnosis since it requires modification of some of our conventional approaches. For example the diagnosis of delirium may be easy but the diagnosis of the cause which is imperative for the management of delirium involves intricate knowledge of internal medicine, biochemistry and physiology. The concomitant use of various medicines for the treatment of both physical and psychiatric complications increase the risk of drug interactions and demands intricate knowledge of pharmacology. We are often confronted with situations where patients' condition has worsened due to our medication but we are unable to manage them and have to rely on other professionals' example being drug induced electrolyte imbalance. In other words, the recognition of Psychiatry as a specialized medical specialty will happen only when we develop competence to render all the specialized service that our patient population demands.

In 1971, Dennis pointed out that a psychiatrist should be: a physician, a scientist, a psychotherapist and a leader. Later it was postulated that a psychiatrist should also be a teacher. But today, in the current scenario, a psychiatrist must also acquire knowledge and skill in critical care arena.[1]

Sharpening our medical skills to deal with intensive care patients becomes particularly valuable in the case of those patients who are seen in centers where only psychiatric patients are taken care of. Thus there is great need for increased concern in this area.[2]

Education

If we have to achieve the goal of producing psychiatrists, who are capable of treating not only psychotic emergencies but also nonpsychotic critically ill psychiatric patients, our training programmes need to be significantly Debjani et al: Critical Care In Psychiatry 633 modified. Many training programmes in this country are psychiatric hospital based and the trainees often are unprepared to deal with sudden critical conditions that they may have to face later as consultants in general hospital set up or in private practice. This can be remedied only by having mandatory training in an Intensive Care Unit (ICU). The psychiatrist's presence in an ICU may also help indirectly in giving a psychiatric orientation to ICU specialists and their trainees.[3,4]

In our country the Indian Psychiatric Society, has attempted to standardize undergraduate and postgraduate psychiatric training and improve its quality. The situation demands that a post graduate from residency education in psychiatry must be able to manage the critical conditions arising in his /her patients either due to psychotropic medication or due to the psychiatric condition itself or as a result of substance abuse and withdrawal. To develop these skill we have given an example of new aspects that can be added to the existing training modules.

Example of the training program

The postgraduate specialization course in psychiatry should be divided in modules of theoretical and practical experience of different lengths. The resident will be trained in biological, psychotherapeutic and community treatment both in the psychiatric hospital and in the general hospital.

a. Rotation in internal medicine. b. Rotation in neurology. c. Activities in consultation liaison psychiatry, minimum of 6 months, with both inpatients and outpatients of the various services of the general hospital. This should include 1 month medical intensive care. d. Rotation in deaddiction department (3-6 months). e. Training in handling and learning how to use the complicated instruments.

Critical care unit layout

It requires intelligent planning. One must keep the need of the hospital and its location. One ICU may not cater to all needs. An institute may plan beds into multiple units under separate management by single discipline specialist viz. medical ICU, surgical ICU, psychiatry ICU etc.

Keeping in mind the economic factors duplication of services and equipment is to be avoided. Critically ill patients develop the same pathophysiological process no matter whether they are classified as medical, surgical or 634 Psychiatry in India : Training & training centres psychiatric. They require the same approaches to support the organs.

The unit should be easily accessible to both the psychiatry outpatient clinic and also the inpatient ward and offices of the on duty psychiatrists. Also it should be close to the hospital engineering department because the complicated machinery malfunction may require their service during emergency. Ideally this critical care unit should also be close to the laboratories and the imaging unit.

Size of the unit depends on turnover of the concerned hospital. Small units of 6 to 8 beds may suffice an average psychiatric hospital which caters to about 150 to 200 patients per day. ICUs with fewer than 4 beds are not cost effective and over 20 beds are unmanageable [5]. For general hospital set up, a fixed number of beds (2 to 4), in the general ICU reserved for psychiatry unit may suffice.

It is desirable that the critically ill patients be separated from general psychiatric patients because the former need quieter environment.

Regarding equipments, the minimum of ICU equipments like Oxygen supply, suction outlets, power outlets to attach instruments, etc are must. Facilities to estimate blood glucose, blood gases, electrolytes, haemoglobin is essential. Ventilators, infusion pumps, portable x-ray unit, portable light, defibrillators, and difficult airway management equipment are necessary. Other more advanced equipments are necessary too but can be commanded from the respective departments when needed.

Conclusion

Critical care is an attitude and an approach. Psychiatrists intervening in critical care have a significant impact on patients in crisis. Taking the crisis out of critically ill psychiatric patients could have a lasting effect on these patients' lives and their confidence on us. Critical care in Psychiatry is at the crossroads of development. The beginning looks good but a long part still has to be travelled. Highly dedicated efforts can only lead to humane, scientific meaningful service for the multitude of our critically ill patients. Future challenges include the development of guidelines, the consolidation of training activities and research on the outcome of critical problems which are unique to our specialty.

REFERENCES

1. Ellis J. The teaching of psychiatry. BMJ 1963;2:585-588. 2. Kisley S R, Goldberg D P. The effect of physical ill health on the course of psychiatric disorder in general practice. Br J Psychiatry 1997;170:536-540. 3. Pardes H P. A changing psychiatry for the future. Am J Psychiatry 1996;153:1383-1387. Debjani et al: Critical Care In Psychiatry 635 4. Saravay S M. Psychiatric interventions in the medically ill. Psychiatric Clinics of North America.1996;19:467-480. 5. Batra YK, Praveen BV, Singh H. Intensive care in India. Expectance of a major teaching hospital. Intensive Care World 1991; 8(9): 186-90.

Debjani Bandopadhyah Consultant Psychiatrist MANSIJ, Burdwan West Bengal [email protected]

Gautam Saha Consultant Psychiatrist Clinic Brain Barasat, West Bengal

Om Prakash Singh Prof and HOD, Psychiatry Burdwan Medical College Burdwan

64 Measuring Disability and Functioning

R. Thara

Introduction

Disability caused by mental disorders may be relatively a new concept in India, but was recognized many decades ago in many developed countries of the world. In the USA, schizophrenia is called the “youth's greatest disabler” and the mentally ill form a bulk of the beneficiaries of the social welfare programmes there.

What is mental disability and why is it important? How is it measured and what are we doing for the mentally disabled? This chapter outlines the various measurement tools of disability caused by mental illness. It does not deal with intellectual disability, or mental retardation also known as mental disability.

Measurement of disability caused by psychiatric disorders is becoming an increasingly important issue. Measuring disability and providing the mentally disabled with a rating of disability permits them to avail of the benefits of the welfare programmes for the disabled. A number of measurement tools have been developed within and outside India which have enabled disability to be quantified.

It is also important to focus on disability while planning psychosocial programmes for the mentally ill. Research in this area has also assumed importance since disability is now seen as an outcome indicator for many serious mental disorders.

It is also important for policy planners since resource allocation decisions will have to be made based not just on prevalence, but also on chronicity and disability. The economics of many illnesses now depend heavily on disability caused by these disorders which contribute to direct and indirect costs.

Definitions: Disability has been defined in several ways.

The World Health Organization defined disability as “Disturbances in or 638 Psychiatry in India : Training & training centres inability to perform social roles that would be normally expected of an individual in his habitual milieu, arising in association with a physical or mental disorder”. It has also defined disability as “inability to participate or perform at a socially desirable level in such activities as self care (eg. activities of living), social relationships, work and situationally appropriate behavior.”

The four general areas of disability of Mental Illness (MI) are:

1) Activities of Daily Living : These include day to day adaptive activities such as cleaning, shopping, cooking, transporting oneself, maintaining a home, self care, using public facilities etc. In the context of the individual's overall situation, the quality of these activities is judged by their independence, appropriateness, and effectiveness.

2) Social functioning: This refers to the individual's capacity to interact appropriately and effectively with other individuals. Social functioning includes the ability to get along with others in one's environment. Impaired social functioning may be demonstrated by a history of altercations, evictions, fear of strangers, avoidance of social occasions and interpersonal relationships, social isolation, etc.

3) Concentration, task persistence and pace refer to the ability to sustain focussed attention sufficiently long to permit the completion of tasks commonly found in work settings.

4) Deterioration or decompensation in work or work-like situations refers to the repeated failure to adapt to stressful circumstances which cause the individual either to withdraw from the situation or experience subjective distress, and an exacerbation of signs and symptoms with an accompanying difficulty in maintaining activities of daily living, social relationships, and or maintaining concentration and task persistence.

International classification of disabilities

The only classificatory system for disability was the International Classification of Impairments Disability and Handicap (ICIDH) of the World Health Organization (WHO). It was decided to revise ICIDH based on the changes in the health care scene from acute to chronic disease and from disease focus to consequence focus. Added to this was the need to have a common international language to understand disabilities and to serve the persons with disabilities.

The World Health Organization therefore revised the ICIDH and after nine years of international revision efforts, the World Health Assembly on May 22, 20011, approved the International Classification of Functioning, Disability Thara: Measuring Disability and Functioning 639

and Health and its abbreviation of "ICF." [1] One of the significant changes proposed has been in that of terminology. The words impairment and handicap are no longer used.

The ICF is structured around the following broad components: l Body functions and structure) l Activities (related to tasks and actions by an individual) and participation (involvement in a life situation) l Additional information on severity and environmental factors

Functioning and disability are viewed as a complex interaction between the health condition of the individual and the contextual factors of the environment as well as personal factors. The picture produced by this combination of factors and dimensions is of “the person in his or her world.” The classification treats these dimensions as interactive and dynamic rather than linear or static. It allows for an assessment of the degree of disability, although it is not a measurement instrument. It is applicable to all people, whatever be their health condition. The language of the ICF is neutral as to etiology, placing the emphasis on function rather than condition or disease. It also is carefully designed to be relevant across cultures as well as age groups and genders, making it highly appropriate for heterogeneous populations.

Measurement of disabilities

A commonly used tool is the WHO’s Disability Assessment Schedule (DAS) [2]. The DAS, like many other pioneering instruments, had a few intrinsic 640 Psychiatry in India : Training & training centres problems, especially when administered in the South Asian situation. After considerable use, an adaptation of DAS, named the Schedule for Assessment of Psychiatric Disability (SAPD) was developed to make the instrument more specific to the region [3]. SAPD follows a similar conceptual orientation as DAS, but eliminates some of the items found in the latter, apart from regrouping the items under the following categories: personal disability, marital disability, occupational disability and social disability.

The six domains of DAS II are:

1. Understanding & communicating 2. Getting around 3. Self care 4. Getting along with people 5. Life activities ( Household and Work) 6. Participation in Society

Each item is scored on extent of difficulty and the number of days the difficulty is experienced. The DAS II has been extensively used for the measurement of physical and psychiatric disability.

The SCARF Social Functioning Index was another tool developed at SCARF for measurement of functioning [4]

IDEAS ( Indian Disability Evaluation and Assessment Scale)

In India, it was only in 1996 that disability of mental disorders was taken cognizance of, albeit after intensive and prolonged lobbying by various agencies. The Persons with Disabilities Act of the Ministry of Social Justice and Empowerment, Govt. of India in 1996 included this and placed it on par with other disabilities. However, even after a decade and more, very little has trickled down to the mentally disabled in terms of welfare benefits.

Resistance for inclusion of mental disability sprung from many quarters. The other disability groups did not want to lose their share of the pie and resented the new entrant. The policy planner wanted the measurement of this disability to be streamlined and looked for an appropriate tool for this. The task of formulating and developing an appropriate instrument to measure disability was therefore taken up by the Indian Psychiatric Society when the author was the Chair of the Rehabilitation Committee of the Society [5]

Taking into consideration the paucity of trained mental health professionals in the country, the instrument had to be simple, easy to administer even in Thara: Measuring Disability and Functioning 641 busy clinical settings, and in rural areas.

The scoring pattern also had to be simple with the scores converted into percentage of disability, as is the case with other disabilities.

The tentative instrument formed was field tested in 8 centres all over the country with SCARF being the co-ordinating center.. Different types of settings such as Government institutes, NGOs, private clinics were included as sites for field testing in order to ensure generalizability.

Rating of IDEAS is done based on interviews of the primary care givers, case records and patient interviews. Probe questions help to guide one through the interview and to help identify dysfunction in one or more activities.

IDEAS was gazetted by the Ministry of SJE, GOI in Feb.2002 as the official instrument to measure psychiatric disability for the purpose of certification. While administration of IDEAS can be done by trained Social Workers, Psychologists, or Occupational Therapists, the diagnosis and certification can be done only by a Psychiatrist.

The following domains of functioning are measured:

Self Care (Personal hygiene, eating habits, personal belongings, living space), Interpersonal activities, (social relationships, emotional response, physical intimacy etc) Communication and understanding (spoken and written language, ability to converse, use of communication devices) Work (Employment, house work, student, regularity and competence at work) The scoring ranges from no disability (zero) to profound (4).

IDEAS is being used extensively by students and researchers to measure and compare disability in various psychiatric conditions.

Why Measure Disability?

Valid measures of disability are required for a number of reasons. To understand patient prognosis, monitor patient care, plan and implement direct research on improving treatments and improve policy and program planning are some of those. But the most important reason, in a developing country like India is probably to facilitate the mentally disabled to avail of Welfare benefits such as travel concessions, transfer of pensions etc.

Measuring disability and functioning is also key in formulating and 642 Psychiatry in India : Training & training centres implementing psycho social rehabilitation programmes for both patients and family members.

Conclusion

Mental disability is here to stay. The inclusion of mental disorders in the Persons with Disabilities Act, 1995, was the first step in the recognition of this disability. The formulation of the instrument IDEAS and its recognition as an official tool to measure disability was the next milestone. However, although several research studies have used IDEAS, its utilization for welfare benefits varies greatly from state to state, dependent on the whims and fancies of policy makers and the mental health community proffesionals.

Research in this area warrants the need for a systematic and integrated approach keeping in mind the growing trends in India’s population. This approach will also facilitate the need for policy makers to understand the implications of disability associated with mental illness and its contribution to the global burden of disease.

Clinicians and rehabilitation professionals need to be totally familiar with the concept of disability and functioning in managing care for their patients. Most patients and families are more distressed by the lack of gainful activity or unemployment than by isolated delusions and hallucinations. It is therefore disability which is the more important outcome indicator and should therefore form the corner stone of all interventions.

REFERENCES

1 World Health Organization International Classification of Functioning, Disability and Health. 2001. WHO, Geneva. 2 World Health Organization .Disability Assessment Schedule. 1988 Geneva, WHO 3 Thara R., Rajkumar S, Valecha V. Schedule for the assessment of psychiatric disability a modification of DAS. Indian Journal of Psychiatry, 1988; 30(1): 47-53. 4 Padmavathi R, Thara R, Srinivasan L, Kumar S. SCARF Social Functioning Index Indian Journal of Psychiatry 1995; 37(4): 161-164. 5 Indian Psychiatric Society. IDEAS – a scale to measure disability IPS, 2002.

R. Thara Director, Schizophrenia Research Foundation Chennai, India www. scarfindia.org [email protected] 65 Expanding horizons of psychiatric social work

V.S.T. Krishna, Nawab Akhtar Khan, T.S. Sathyanarayana Rao

Social work is a professional and academic discipline that seeks to improve the quality of life and wellbeing of an individual, group, or community by intervening through research, policy, community organizing, direct practice, and teaching on behalf of those afflicted with poverty or any real or perceived social injustices and violations of their human rights. Development of psychiatric social work is closely related to the development in the field of social work on the one hand, and to the advance and the changing concepts in the field of psychiatry on the other. The outline of the history of the field of social work is same as that of the other professions. Social work is as old as human race but as a profession it is very young. Throughout world, changing socio-economic order created new social needs and new social problems, which fell in the hands of social workers to handle. The development and advance in social sciences, including dynamic psychiatry gave the social workers an instrument to understand these needs and at the same time gave them a tool to help the individual to meet these needs of patients with mental illness [1]. The term Social Worker and Psychiatric Social Work was used interchangeably before 1920 and got separated because of Freudian Psychoanalytic concept proposed around 1920.

Due to lack of appropriate literature in the field of psychiatric social work it is a big challenge among professionals regarding the definition of psychiatric social work ……. One way to define Psychiatric social as Florence hollis (1972) says that “applications of social work methods in psychiatric setup”, the benefit of this definition is apparent but lacks comprehensiveness, considering this we can define.… “Psychiatric Social Work is an important part of the social work which deals with the social problems arising directly or indirectly out of the nature of the mental illness. In this way, it facilitates and extends the psychiatric and psychological treatment.” 644 Psychiatry in India : Training & training centres Historical background

To understand the development of Psychiatric Social Work we first need to understand the historical background and developments in the field of mental health. The history of mental health services can be divided into three periods, covering the rise of the asylum and traditional hospital care; the decline of the asylum; and the appearance of balanced care [3]. These developments were significantly related to the involvement and development of Psychiatric social work in the field of psychiatry or mental health services.

The rise of the asylum occurred approximately between 1880 and 1950 in many economically developed countries [4]. It was marked by the construction and enlargement of asylums in the remote areas offering mainly custodial containment and bare necessities of survival to patients with a wide range of clinical disorders and social abnormalities. This period prepared the platform for the involvement of the community in management of mentally ill patient. World wars played a vital role in the development of social work in mental health. The surgeon general asked American Red Cross to establish Social Work federation in hospitals after World War I and II and emphasized need of Social Work for war veterans. In India first Psychiatric Social Worker was appointed by Tata Institute of Social Science, Mumbai in the year 1936. First time training started at National Institute of Mental Health and Neurological Sciences (NIMHANS).

The decline of the asylum occurred in many economically developed countries after about 1950. The profound effect of asylums was apparent on patients with their progressive loss of life skills and the accumulation of “deficit symptoms” or “institutionalism” [5]. Other concerns included repeated cases of ill-treatment to patients, the geographical and professional isolation of institutions and their staffs, poor reporting and accounting procedures, failures of management, leadership and administration, insufficient finances, ineffective staff training, and inadequate inspection and quality assurance measures. The resulting response was deinstitutionalization, which was characterized by three essential components.

Preventing inappropriate mental hospital admissions by providing community facilities.

Discharging long-term institutional patients who had received adequate preparation into the community.

Establishing and maintaining community support systems for patients who are not institutionalized.

During this period Psychiatric Social Work in India had witnessed many VST Krishna et. al.: Expanding horizons 645 challenges and developments. Consequently, the Psychiatric Social Work educators and researchers have been actively involved with making suitable attempts to change the curricular framework to suit to the needs of the persons with mental health problems and their distressed families.

As early as 1964, Gourie Rani Banerjee observed that Psychiatric Social Work in India should be broad based as the practice of the social work and not just case work in psychiatric settings. National Mental Health Program started in 1982 focusing mainly on training mental health professionals within the state and spreading awareness about mental health problems services for early detection and to provide data and experience for future planning and research in this field. Under District Mental Health Program (DMHP) which started in 1996, it is mandatory to have a psychiatric social worker in more than 20 districts of 18 states. These developments created a royal road to establish Psychiatric social work as a recognised profession in the field of mental health.

Need for Psychiatric Social Work

The constant growth, demands, and changes in mental health care had a serious impact on the viability and need for psychiatric social workers in all areas and settings of health care world over. The biopsychosocial–spiritual perspective recognizes that health care services must take into account the physical or medical aspects (bio), the emotional or psychological aspects (psycho), the socio-cultural, sociopolitical, and socioeconomic issues in our lives (social) and how people find meaning in their lives (spiritual). This approach draws strengths for social work practice. A psychiatric social worker has to play 3 important roles: 1.Preventive, 2. Promotive and Augmentative and 3.Rehabilitative. A Psychiatric Social Worker has to clearly remember that he/she is not a pseudo professional and not going to do duplication of a medical expert's work or not on same line of any other professional's work in the clinical team or otherwise known as multi-disciplinary team of specialists. As other specialists do have their cut and dry tailor made tasks to do, psychiatric social workers too have very highly specified roles to play and perform not to prove their professional expertise but to enrich the functioning of clinical team or multidisciplinary team in the fields of psychiatry in order to provide comprihensive survice to patient care.

In the field of psychiatry though family members do not directly experience the illness the patient undergoes, all the consequences of the illness straight away fall on the shoulders of the family members irrespective of their age, education, occupation, sex and social status. In case of mental illness the person experiencing mental health challenge may or may not be aware of his circumstances and consequences of the illness that grip their day to day life, 646 Psychiatry in India : Training & training centres where as family or primary care givers do recognize it more aggressively due to overload of illness. In spite of emergence of modern drugs and advanced understanding of medical sciences the levels of reacting to and perceiving the illness is entirely unique to each family member which can never be in the limits of medical regiments, as human reactions are typically unique and there can never be a single most correct way to classify, typify and diagnose them into systematic orders and measures. Hence the need and existence of psychiatric social worker in the profession of Psychiatry is of a necessity more than a formality in order to pay attention to the wide range of vibrations in cencequence to mental health challenges experienced by family in social setting.

Key Principles for Balanced Community-Based Mental Health Services

Thornicroft and Tansella [6] suggested nine principles which is important in guiding the development of community-orientated mental health services and almost impossible to follow and achieve them without a role function of psychiatric social worker. These are:

Autonomy: The patient's ability to make independent decisions and choices, despite the presence of symptoms or disabilities. Autonomy should be promoted by effective treatment and care.

Continuity: The ability of relevant services to offer interventions that are either coherent over short term both within and among teams (cross- sectional continuity), or are an uninterrupted series of contacts over the long term (longitudinal continuity).

Effectiveness: The ability to provide the proven, intended benefits of treatments and services in real-life situations.

Accessibility: Patients' ability to receive care where and when it is needed.

Comprehensiveness: A service characteristic with two dimensions. Horizontal comprehensiveness means the extent to which a service is provided across the entire range of mental illness severity, and the wide range of patient characteristics. Vertical comprehensiveness means the availability of the basic components of care, and their use by prioritized groups of patients.

Equity: The fair distribution of resources. Both the rationale used to prioritize competing needs and the methods used to allocate resources should be explicit.

Accountability: The answerability of a mental health service to patients, their VST Krishna et. al.: Expanding horizons 647 families and the wider public, all of whom have legitimate expectations of how such a service should carry out its responsibilities.

Coordination: A service characteristic resulting in coherent treatment plans for individual patients. Each plan should have clear goals and necessary and effective interventions, no more and no less. Cross-sectional coordination means the coordination of information and services within an episode of care. Longitudinal coordination means the interlinkages among staff members and agencies over a longer period of treatment.

Efficiency: Minimizing the inputs needed to achieve a given level of outcomes, or maximizing the outcomes for a given level of inputs.

Based on above principles, a psychiatric social worker has a multifarious and multiple role depending on the setting it is employed. A Psychiatric Social Work can be applied in various settings like: Primary, Secondary and Tertiary. In primary setting psychiatric social work can be applied as the core method of service along with relevant team of experts, for e.g. School Social Work, Rehabilitation services for the Geriatric group of population, Rehabilitation Services for people with Disabilities.

In secondary setting psychiatric social work is applied in liaison with other core specialty, mental health services, psychiatric treatment services, medical college based psychiatric departments etc.

In tertiary settings, psychiatric social work is applied as a service program to assist series of other specialties. For instance application of psychiatric social work in judicial and police settings is to augment series of other service experts like judiciary, police, law & order systems, etc.

It is important to understand that there is no room to think that the importance of psychiatric social work expertise depends on the type of setting. It is wrong to consider that in primary setting psychiatric social work is key service and tertiary service it is negligible. Instead the expertise of psychiatric social work carries more value in tertiary setting rather than primary setting depending on the merit of the case undertaken and not purely by the type of setting. Keeping in mind the various setting of employment a psychiatric social worker can have various roles and functions. For e.g.

I.Promotive, Preventive Function: With the advent of modern drugs and advanced investigations and interventions in Biomedical aspects concerning brain, most of the psychiatric illnesses are now crumbling down to a span of few months of treatment and the patient is capable of attaining near normal functioning. But psychiatric diagnosis cannot be looked as cross sectional 648 Psychiatry in India : Training & training centres challenge. An individual suffering from a psychiatric problem may not only have bio-chemical change in the brain responsible but can have other psychosocial factors responsible for the illness.

The events in life are not under the grip of medicines they are independent of medical treatment, these events are known as “life events” in psychiatric terminology. Hence the management and stabilization of life event cannot be dragged into medical regiment. These life events could be worked out with the entire coordination of the total family in question and at times the community and society in which the affected person is an inseparable part. Hence it will always be a beneficial endeavor to draft the resources from the social network to which the person belongs and immensely under its influence irrespective of the affected persons likes and dislikes. Hence, the need to work with the interiors of the family and community along with a systematic psychiatric intervention arises. It is extremely essential to work with the individual concerned and the family or the primary caregivers to understand what the illness or a specific psychiatric condition means to them irrespective of the scientific truths that were established. This kind of endeavor enlists the cooperation and compliance of the client and their family care givers to serve them better. This is a need based approach very much required in the field of psychiatry, without which the public acceptance and building of confidence on a delicate treatment approach gets into fluctuations and the impact will be seen in irregular follow up and lack of drug compliance.

II. Curative and Augmentative Function

In the field of Psychiatry, the psychiatric social worker need to work for curative and augmentative functions as well which are as follows:

· To make detailed history collection of psychosocial circumstances woven around a specific psychiatric condition.

· To conduct individual and group interventions to assist the primary care givers to cope with the treatment process and to come to grip with the illness in a constructive manner instead of a resignation oriented manner.

· To generate positive attitudes and consideration regarding the person with illness to reduce patient rejection and getting repulsed by the patient in family dynamics.

· To communicate with the primary care givers to facilitate functional abilities in the patient over a period of time.

· To associate with various agencies and resources to mobilize services to VST Krishna et. al.: Expanding horizons 649 the client and family from government, nongovernmental and other support systems to raise the levels of adaptation.

III. Rehabilitative And Reintegration

Apart from the above clinical services, psychiatric social worker in the field of Psychiatry has to carry following rehabilitative and reintegration tasks to generate near normal or pre-morbid level functions in the affected individual and concerned families. a. To make systematic evaluation of post illness and pre illness potentialities of the client concerned and to organize a systematic action plan to accentuate and utilize the unaffected abilities of the person concerned and in liaison with family. b. To elicit the active cooperation of key persons of the client in his day to life, in order to obtain their complimentary thinking and decision making process about the process of reintegration of the client to his original work, family and social systems. c. To bring the involvement of tertiary support systems, social networks, colleagues and employment area and other care giving persons to relocate his individualized role play in society as a meaningful contributor. d. To extract the resources of the society from legally sanctioned offices and administrative systems to augment the resources of the client following the illness process.

Current Status of Psychiatric Social Work

Relation with other Departments: Psychiatric Social Work is a well connected program in the field of psychiatry in discharging its responsibilities as described above. It maintains an organic interaction with all other related disciplines not because of a necessity but because these interactions give better services to the client and caregivers.

Clinical Psychology is a profession with which psychiatric social work is involved with and it deals with basic knowledge of psychology. Hence clinical psychology is essentially an applied discipline, it essentially work to understand and measure the behavior of individual with a psychosocial derailment or challenged condition. Psychiatric Social worker by bringing in the active inter play of the family, individual and key care givers does facilitates continuous base of effective interactions with his rapport establishment skills and regular understanding he acquires with the entire functioning of the family. While implementing behavior modification, 650 Psychiatry in India : Training & training centres psychotherapy and counseling services of a clinical psychologist, psychiatric social workers ensures their proper reception and absorption into the family and community systems by specially working with the social dynamics and thus facilitates more time and energy to clinical psychologist to fully focus on the psychodynamic angle of the psychiatric conditions.

Psychiatric Nursing is another specialized branch with which a psychiatric social worker corroborates. The core function of a psychiatric nurse is to administer the treatment process in the ward and later ensure the clinical follow up. Psychiatric nurse is specially trained to provide medical treatment and care of psychiatric conditions. Psychiatric Social Worker not only provides the valuable information and data that is acquired from the client and family systems, but also incorporates the information obtained from the psychiatric nurse who is capable of spending very lengthy amount of time and by involving in to deeper issues of therapeutic environment designing with patient's family. Psychiatric social worker offers support to psychiatric nurse by facilitating the ward intervention by applying basic social work methods such as case work and group work and community organization.

A psychiatric social worker also has to maintain a close bond with other specialty called occupational therapy and vocational rehabilitation wing. Occupational therapy essentially functions on the basis that a meaningful activity promotes, prevents and cures deviant or non functional behaviours. Further a specially designed activity will generate therapeutic effect on neuro-motor and cognitive areas of a person and along with augment musculo-skeletal functions.

Thus, Occupational therapy has a strong loading of medical sciences in its day to day application by the qualified occupational therapist. The success of occupational therapist is purely lies in follow up. The effort rolls back totally without having long term validity in the absence of systematic and continuous follow up, which is determined by the family environment ultimately.

Future Direction for Psychiatric Social Work

Psychiatric social work services, training and research in future would focus on the following 14 areas.

1. Nature, processes, extent and efficacy of psychosocial intervention service to children, adolescents, adults and the elderly, offered in the mental health institutions, de-addiction centers, rehabilitation centers, family counseling centers, child and adolescent mental health centers, neurology, neurosurgery and allied services. 2. Identification and assessment of psychiatric social work services VST Krishna et. al.: Expanding horizons 651 associated with community based on the guidelines of National Mental Health Programme and District Mental health Programmes. 3. Evaluation of involvement of psychiatric social workers in training of paraprofessionals, non professionals and personnel from voluntary agencies to extend their services to the needy in their areas. 4. Exploratory, descriptive and experimental studies related to psychosocial aspects of crisis intervention and disaster mental health care (suicide prevention, disaster preparedness etc). 5. Patterns of utilization of social security measures by mentally disabled persons and their families and factors associated with non utilization. 6. Scope of psychiatric social workers in the agencies related to general health, mental health, development, education, industry and welfare especially quantification of such activities. 7. Objective analysis of contents of psychiatric social work in BSW, MSW and M.Phil courses including field work activities. 8. Content analysis of Indian literature, ancient and modern, to call out the essential elements of mental health and psychiatric social work for the purpose of education, training and there any activities. 9. Documentation and development of existing researches in schools of social work, national and international social welfare/development agencies. 10. Feasibility of incorporating the developments in information technology into psychiatric social work research – internet, usage of computers for analysis, networking for research communication etc. 11. Formulation and evaluation of promotional/preventive activities like stress management programmes, school mental health programmes, effective parenting, marital and family enrichment, and community based rehabilitation services. 12. Differential impact of various strategies at micro and macro levels to counteract the stigma attached to mental illness mainly dealing with materials, methods and time frame. 13. Researches on the felt needs of the public, and improvement of quality of services at individual family and community levels – Self Help Groups/Peer support 14. Gather newer areas related to Hospice care, HIV/AIDS care, community based rehabilitation, implementation of policies and legislation related to mental health, issues related to team work/interdisciplinary approach, spirituality in Psychiatric social work and standardization of instruments for Psychiatric social work Research.

Conclusion: 652 Psychiatry in India : Training & training centres To outline, a psychiatrist works with the patient and a psychiatric social worker with the family, or a psychiatrist works with the internal factors and a psychiatric social worker with the external or a psychiatrist works with the intra-psychic institutions and a psychiatric social worker with the environment. As the knowledge of the inter-relatedness between the individual and the environment is increasing this dichotomy is gradually losing its meaning and the line of demarcation is fading away culminating in the community mental health service where a psychiatric social worker functions independently as a mental hygienist. The functions of a social worker now extend beyond the four walls of the hospitals and the child guid- ance clinics into the community. Dr. Ackeman talked about the inter- relatedness of function and roles among psychiatrist and psychiatric social work and elaborated the role of psychiatric social worker “is to bring social reality and group behavior pattern in the patient” whereas the role of psychiatrist “is to handle individual behaviour pattern, ego adaptation and conflict between conscious and unconscious impulses in the patient”. He further explained that neither both areas as they stand today are equipped technically to deal as a whole. Thus the co-operation and function between the psychiatrist and the psychiatric social worker cannot remain on a level of mutual exchange of information but on mutual acceptance of each other as a distinct discipline very closely interrelated. The patient as an individual within the family being the common interest and joint responsibility of both the professionals.

Though psychiatric Social Work is an advancing profession born out of Social Work base and has the essential functioning in augmenting psychiatric services to the client and primary care givers in close liaison with all the concerned multi-disciplinary team. There is lot more to be evolved in this field and we can comfortably say the profession of psychiatric social work is still in the foot hills of Himalayan Mountain. Hardly few decades back it took its active expression in India. The profession can evolve better with more legislations and public awareness of this profession's future will be very bright in coming few decades.

REFERENCES

1. Batliwala B.M, Psychiatric social work (PSW) & Its relation to psychiatry Indian J Psychiatry, 1959; 1: 2: 64-65 received 3rd auguest 1958. 2. Hollis F. Casework:A Psychosocial Therapy (second edition). New York, Random House. 1972; pp xxii + 393. 3. Desjarlais R., Eisenberg L., Good B., Kleinman A. World Mental Health: Problems and Priorities in Low Income Countries. New York: Oxford University Press; 1995. 4. Leff J. Care in the community: illusion or reality? London, Wiley, 1997. 5. Wing JK, Brown G. Institutionalism and schizophrenia. Cambridge, Cambridge University Press, 1970. 6. Thornicroft G, Tansella M. Translating ethical principles into outcome measures for VST Krishna et. al.: Expanding horizons 653 mental health service research. Psychological Medicine, 1999, 29:761–767. 7. Thornicroft G, Tansella M, eds. The mental health matrix: a manual to improve services. Cambridge, Cambridge University Press, 1999. 8. Saleebey, D. (2003). Strengths-based practice. In R.A.English (Ed.in Chief) Encyclopedia of social work (19th ed. 2003 supplement, pp. 150-162). Washington, DC: NASW Press. 9. Tomaszewski, E. P. (Ed.). (2004).The role of social work in medication treatment adherence. Washington, DC: National Association of Social Workers, HIV/AIDS Spectrum Project. 10. U.S. Census Bureau. (2004) Health insurance coverage: 2003/highlights. Retrieved April 15,2005, from http://www.census.gov/hhes/ www/hlthins/ hlthin03/hlth03asc.html

V.S.T. Krishna Asso. Professor (PSW) Department of Psychiatry JSS Medical College & Hospital M G Road, Mysore-570004 [email protected]

Nawab Akhtar Khan Lecturer, (Clinical Psychology) Department of Psychiatry JSS Medical College & Hospital M G Road, Mysore-570004

T.S. Sathyanarayana Rao Prof. & Formerly Head, Department of Psychiatry JSS University, JSS Medical College Hospital M.G. Road, Mysuru - 570004 66 ABC of Training for Psychiatrists: Carer's Perspectives

Nirmala Srinivasan

This article is not written from either the Left or the Right brain but straight from my heart loaded with human emotions, rambling thoughts and recollections, the beauty and mystery of which underlines the challenges for the Psychiatrists to develop a bond between the nano, self and the cosmic Society. The views presented here are from the ground zero carer's perspectives to highlight the agenda for HRD training for Indian psychiatrists. Apart from the insights of a care giver, the views expressed here are also strongly influenced by my decade old professional experience as a Resource and facilitate in the field of Management (HRD) training.

Being a psychiatrist in India is more demanding than the West because of the inevitable presence of the Family as a channel partner between the doctor and the patient. Let us admit the fact that it is the primary responsibility of the doctor to transform passive players to active partners for handling challenges in the coming millennium. While our Psychiatrists are abundantly aware of this, their awareness many a time falls short of expectations perhaps because of the pressure of work ; still more, lack of an orientation to what the West calls as Partnership Protocols in training. Based on my two decade experiences from ground zero , we prefer to say "Physician train thyself" than "Physician heal thyself". Social ramifications of mental illness are far reaching and hence the Clinic is a microcosm of the social reality outside its four walls. In other words, the clinical setting is a social and not a medical encounter. Hence social skills are as important for a Psychiatrist as it is for his/ her client patient, the only difference being the product mix.

I learnt about the term "Partnership with families" first time when I was invited by Prof. Norman Sartorius to participate in a panel presentation on the subject in the 1998 WAP at Hamburg. The mystery about mental disorders adds to the mystique shrouding psychiatrists, just like faith healers, so much so that neither the family nor the patients are conditioned to look upon the therapeutic alliance with psychiatrists as partnership deals. But now the 655 Psychiatry in India : Training & training centres impact of non medical factors on the therapeutic encounters are abundantly clear, especially in the post modern discourses on the practice of Psychiatry.

Since causes of mental disorders are not as clearly known as is the case with Diabetes, the diagnosis remains a phenomenological enterprise. Given this, the psychiatrist would gain significant mileage in the relationship by consciously practicing certain well developed Communication skills including Body language, NLP etc. Combining the maturity of an adult with a healthy curiosity of a child is believed to be the hallmark of a good Professional and Psychiatrists are no exception.

Announcing the diagnosis of mental illness is like pronouncing death sentence. The consultant – client interaction is a dynamic one, determined by many factors of which time factor or the phase of the illness is crucial to subsequent harmony characterizing the partnership. The needs and expectations of the quintessential Indian families and their patients, keeps changing under different phases of the illness. Emotional support and information needs dominate the initial diagnostic phase as against legal and community supports in the rehab phase. Sensitivity to time based client needs is as important as the manner in which it is communicated.

Real life situation, we know, do not permit such neat differentiation of time zones. Even after lapse of many years, a lurking doubt does prevail among the relatives and even patients as to the diagnosis being right or wrong. Especially when the drugs for bipolar are given to schizophrenia or vice-versa, the suspicion is strong enough to warrant a change of doctor. So the time zones are artificial barriers; yet it does help the psychiatrist as a heuristic device to cope with the multiplicity of demands made on their managerial and human skills over and above their professional expertise.

Foremost in the area of non-clinical skills is Communication skills. Many patients suffer in silence from the aftermath of negative discourse like a software engineer who told me that her marriage could have been saved if only the doctor had educated her husband about mental illness and medication. 'Some patients like you never recover" said one to a non- compliant patient. We realize the devastating impact of this when we compare it with " It is good for you to take medicines so that you can get back to cricket soon". EE(Expressed Emotions) does not spare even the specialists! Incidentally why not reinterpret EE as Enriched Emotions and consciously apply it in clinical settings to enrich bonds of partnerships. Perhaps had the partnership concept was in force, many families would have refrained from the notorious doctor shopping! The famous Sanskrit saying “Satyam bruyaath priyam bruyaath; asatyame na bruyaath” (speak the truth but pleasantly; never speak untruth) is a powerful communication tool that needs training in Skills Srinivasan: Training for Psychiatrists 656 and value Orientation.

From Partnership to Advocacy

As the millennium enters its teenage, new challenges in the pipeline are likely to take the professional community by surprise. The expanding knowledge base of Psychiatry, shift of emphasis from illness to deficit bound functionality, growing influence of international human rights lobby on families and user patients demand a radical transformation of attitudes and skills. India's ratification of the UN CRPD and the current amendments to the Mental Health Act 1987 focuses on Rights based approach in Clinical practice. Its almost a Cultural revolution for the care givers- Professionals and families as well - to internalize the concept of Rights and still more to practice it within the framework of the new Mental Health Care Bill 2010. CRPD almost marks a watershed by ushering a radical thought process unparalleled in the history of Indian Psychiatry. For example, by expanding the definition of mental health professional to include the Nurse is perhaps likely to be a novel experience in a hierarchy bound society such as India. Skills to function under Rights based and not Position or Knowledge power patterns of authority, skills for out of box thinking with entrepreneurial drive, and ability to lead by example than hospital Rules are the basics of Best Practice required for the future. Under such circumstances, the blurring of the lines between clinical and non clinical inputs cannot be ruled out that calls for revising the existing HRD packages. Adequate training as an integral part of the PG curriculum in Psychiatry will be the USB for the emerging reality of Rights based therapeutic alliance.

Nirmala Srinivasan (Ashoka Fellow) Director, ACMI Bangalore -India +91 9886031659 [email protected] 67 Media and Mental Health

Harish Shetty

One of the major shifts in the last two decades in our patients is the faith on the 'written word/audio visual word'. Since the last many years the help seeking populace are cutting newspaper articles, carry pamphlets and other printed matter for discussion and clarification with health professionals including Psychiatrists. A predominantly oral culture has opened its eyes to the glitter of science and rational thinking propagated by the 'practitioners'. This is the most exciting development advantageous to all those who are fighting 'stigma' of mental illness and passionately devoted to promote awareness. The audio-visuals on the television, the street plays and the internet are also the extensions of our Psychiatry O.P.Ds and clinics. All the mediums are bubbling with joy and slowly encroaching the 'space' of Quacks and manipulative god men. The media space also is full of spiritual healers, experts in alternate sciences and mental health professionals all in very close handshaking distance from each other.

The media revolution in health & mental health has also coincided with the rapid globalization in our country and around where 'health', crime and 'spiritualism' are T.R.P hunters for thousands of publications, hundreds of T.V channels and the web. Hitting the 'Google' for information of good doctors and information of illness is a common practice both in the metros and part of the rural sector. The era as of now is pulsating with joy and poses new challenges for mental health professionals. Gone are the days when Indian health professionals were invisible to the public eye and today on the contrary many hire P.R agents to help them sell ideas .

Following are some issues and strategies for the future:

Articulate science in simple words

Articulating science in simple words without over simplifying it is a 'groom' that survives a marriage with the 'media'. When the science is clear in the minds of M.H.Ps the vocabulary is simple. I have made a conscious effort to practice the art of articulation through practice. Very few seniors were of any 658 Psychiatry in India : Training & training centres help as they had no experience and viewed media with suspicion and associated them with 'Sensationalism' always. When I wrote an article on 'Aggression' for the biggest newspaper in India in 1993 following the riots in Mumbai it was returned with the comment that it was 'pedantic' and not interesting. For a moment my ego was hurt and a bout of expletives passed through my mental health screen. But that was my first lesson in understanding the public space. A little later there was an incident when the 'ganesh' idol drank milk in Mumbai. And I felt a strong urge to write. I called up the Mumbai office of the biggest newspaper and sent an analytical piece on the issue. The editor was not encouraging. So I sent the hard copy of the article to the Delhi office and forgot about it. And I was surprisingly woken up on a Sunday with a flurry of calls as the same appeared on the edit page. I had no writing background nor had an ancestry in Psychiatry. Dr Prakash Pradhan was the only Psychiatrist who congratulated me in Mumbai. And the journey began.

Sachin Tendulkar

Sometime around then I called up the Week magazine and asked them to carry a booklet on Depression and they agreed. The number of responses we got was tremendous. The learning then was 'one can do it alone with a little help from friends'. Since many years I have been calling editors whenever any event provided an opportunity to write. 9/10 times they have agreed. The media needs good stories/articles and they do not care where they come from. The mental health professional needs to see an opportunity where there is none during societal events that have mental health significance. Calling up the editors may not have the sanction of the A.P.A but that is the best strategy. The 'Week' magazine put me in a dilemma when they called me and asked me whether I could do reportage on Sachin Tendulkar life in 1998 and impulsively I said yes. I was very tense as I had no idea of him nor had any contacts. Somehow I landed myself in his area and managed to write the cover story. Well many criticized me for treading in an area where I had no expertise but I looked at the human side of Sachin through many interviews including that of his first nanny. Mental health professionals who increase their activity latitudes and redefine the boundaries of mental health sciences are very good Ambassadors of the subject.

The snobs

Many a time my colleagues have shared that they believe in keeping the media at a long distance. These professionals have been hurt over a misquote and swear that they will never talk to the press. Sound /Word bites are not Gold bites is something one forgets. This has happened to all and once my quote of nocturnal enuresis was published as nocturnal emission. The sub editor Harish Shetty: Media and Mental Health 659 changed it without the permission of the journalist who had written the piece believing that emesis made more sense than enuresis. Here the only intervention was a gentle phone call to the journalist. Many of my colleagues when misquoted have raised a big hue and cry and fled the ring after a perceived phobic response. We all know that many of our patients land up with a mess due to our medications inadvertently yet most of them leave us in peace. Same is with the journalist who can err. Time, Tide and the Media does not wait for anyone and also does not bother which department one head's or which medical body one leads. They want scientists who can articulate their science well in any medium.

Media loves Research

Today's media is looking for figures to substantiate facts. A research paper published that has relevance for the common man should always be published again as an article in the newspapers or an interview on television. Dr Vikram Patel's article in the Lancet a few years back on ‘Depression in Women in Goa’ made big headlines. Many other research papers published across the world are always splashed all over. Positioning the papers across important social events or important days such as Mental Health Week, Women's Day etc helps. Controversies, a new finding, a landmark research, a new adverse effect are all opportunities to increase the number of eyeballs exposed to mental health conversations. Being media shy means abdicating the mental health space to quacks and dangerous ‘God men’.

Events and Campaigns

All events related to mental health needs to be magnified by the media. Here strategies are important. Cultivating the' health reporter/ News Editor' across all borders is the key. Every journalist is obliged to get as many good ideas to the table during the edit meetings in the office. Sell them as many ideas and let them grow in their profession through articles on mental health. I can never forget the story of a woman who lived in the jungles of Maharashtra for 20 years. In the day she would work in the fields and during the night live in the jungles. When his son migrated to Mumbai he understood that his mother was suffering from Schizophrenia and I treated her. As she left my clinic I realized that this was the right story to educate the people about Schizophrenia. After obtaining the consent this lady became the vehicle to understand a severe mental illness. 'Jungle Laxmi’ made headlines. Helping journalist looking at different angles in a mental health story is the consequence of a symbiotic alliance between a professional and the medium. A story or a T.V program is worth a million workshops. 'Taare Jameen Par' has done more than all the professionals creating awareness in Learning Disabilities. Dr Avdesh Sharma's pioneering series on mental illness is a shining example of the magic of the media. Years ago a sensitive news editor in the 660 Psychiatry in India : Training & training centres country carried one article every day during the mental health week against the view of his colleagues for many years. This was replicated by other media houses later. It was a hit.

Build Allies in the Media

A sensitive journalist in 1998 fought her way in the edit meeting of the biggest newspaper for a special feature during the mental health week. 'Mark Talwalkar' was one of the first patients who shared about his major mental illness with the world. In the same year a major advertising company put many big hoardings on Depression free of cost in Mumbai. Last year Aamir Khan joined hands with Prasoon Joshi and us for a free suicide prevention campaign in the Times of India, FM Radio and hoardings. He continues supporting mental health issues. A yearly calendar has been published by a Mumbai psychiatrist Dr Fabian Almieda with twelve first person stories of those suffering from mental illness this year. Many experiments across the country prove that mental health professionals have contributed immensely towards promoting awareness.

Advocacy and the media

Some years ago a Government centre certifying Learning Disabilities lost their funding. A front page article in a newspaper helped it find a new funder. Half a decade ago we realized that school children were disturbed in many schools as they were segregated by virtue of their performance in various divisions of a class[ those who scored high marks in one division and those with lower marks in the next] causing discrimination, low self esteem and violence. Our petition against these schools with the State Human Right Commission got a lot of publicity creating awareness. The Maharashtra Government passed an order asking schools to mingle children irrespective of their performances. Last year the oldest girls' school in Mumbai attempted to throw a child with muscular dystrophy out. The media took it up and that caught the attention of the Supreme Court and what happened is any one's guess. Scores of children have been included in schools in Mumbai inspite of insensitive managements only because of the media. In all these cases the mental health professional lead from the front. The media though capitalistic in nature loves the Mental Health Activist. Old school journalism where stories heralding change is loved. When the media finds that some mental health professionals are found wanting when mental health issues need fuel and energy it gets disappointed with the field. An interesting case is of a senior mental health professional who went ranting to all journalists in a metro complaining against withdrawal of facilities to his department funded by the Government but failed to garner support. Why? 'Do not quote me please' he said. He never found it necessary to lead from front and wanted to fire the Harish Shetty: Media and Mental Health 661 bullets from other shoulders.

Choosing the right medium

Years ago a mental health professional told me to associate only with good brands. He added that he works only with ‘THE HINDU' and 'FRONTLINE'. I seriously differ and would mind allying with all forms of media big and small depending on the availability of my time and energy. This I do for two reasons, the first one being journalists from the small brands migrate to the bigger brands as they grow. Secondly many brands have different constituencies and they are important. I have written columns in English, Hindi, Marathi, Gujarati and other languages. Ideas can always be translated to any languages

Media and Money

In all my experience I have not focused on earnings from the media. Though many pay me it is not the primary objective. This is an era where mental health professionals need to be missionaries and may sell ideas that would bear fruit to the next generation of mental health professionals. News channels have always sent cheques and articles always fetch a small amount but that is not the deal we are looking for.

Bad Apples

Some years ago a Psychiatrist was in trouble as a T.V channel kept their cameras and the mike on after a formal interview and the professional was unaware. As the Psychiatrist continued sharing ‘off the record’ the profession was embarrassed as this was publicly aired. Such bad apples in the media need to be avoided and one fact we all need to realize is that there nothing ‘off the record'. Everything is on the record. I was threatened by a tabloid who wanted me to comment on an issue where I felt confidentiality and restraint was more important. I stood by my guns and refused to be cowed down. A vernacular tabloid in western India carried a series of articles proclaiming the efficacy of hypnosis in treating all mental illness. A representation by a bunch of colleagues solved the issue.

Radio & the web

A two year continuous stint with a top FM channel helped me to understand the impact. God! It is cool and ossome [the misspelling is intentional] and so many people come back with feedback and referrals to everyone. I feel the e- groups run by Dr and the I.P.S are media arms. Many others are also revolutionizing the way we learn, share and argue. The latest debate on D.S.M 5 in these e groups is a shining example where the web has made life so easy for us. During my post graduate days access to information was dependent on 662 Psychiatry in India : Training & training centres affluent teachers or libraries that had very few books. And now with a click everything falls on our lap. The power game is over. The world is horizontal.

Our country is not a melting pot but a magic pot as shared by my educationist friend K.B.Kushal. The opportunities are so many. The time has come to close ranks and convert the half chances. The media space is more important than our designations, our visiting cards, our medallions that we wear during medical functions. Let us work towards magnification/multiplication of our ideas strategically as a team. It is a moment of reckoning and the future beckons us. The power of the 'whisper' is disappearing in a world infected by 'anomie'. The media compensates for this loss.

Let us exploit it.

Harish Shetty Psychiatrist Dr L.H. Hiranandani Hospital Powai, Mumbai. mindmoodsandmagic.blogspot.com 68 Good Psychiatric Practice: A primer for psychiatric trainees and professionals

Prathap Tharyan

ABSTRACT Psychiatrists are physicians who face additional challenges due to a number of factors inherent in their profession. They include the intimate nature of their relationship with their patients and the potential for boundary violations and to foster dependency; the distress and disability caused by mental illness; the blurred boundaries between normal and abnormal and the validity of psychiatric diagnoses and the appropriateness of interventions and procedures as perceived by the public and by other physician colleagues; limitations in current therapeutic options to cure many types of mental illness; the vulnerability of their patients and the confidential nature of their problems; their capacity to provide valid consent to procedures and interventions, and the use of overt and covert coercive treatments; the problems of co- morbid psychiatric and medical conditions; cultural differences in the approach to mental illness and disorder and their treatment; the special problems peculiar to research in vulnerable populations; the stigma attached to mental illness and all who provide care to those with mental illness; and the high potential for burnout and the development of psychiatric morbidity in mental health professionals. Added to these are the complexities of healthcare provision, out-of pocket payments, inducements for prescribing, and inequities in access to care that prevail in India This article outlines the principles of good psychiatric practice culled from national and international recommendations and guidelines, and from clinical experience, that every psychiatry trainee and professional need to be cognizant of, and incorporate into their professional lives in order to uphold the ideals of the profession; protect and enhance patient autonomy and their best interests, while ensuring public accountability and thus pave the way to a fulfilling career in psychiatry. 664 Psychiatry in India : Training & training centres Introduction

Psychiatrists are primarily physicians. This implies that they require sufficient medical knowledge and skills to diagnose, investigate and treat, or appropriately refer their patients, when medical conditions are thought to underlie or accompany psychiatric presentations. In addition, they need sufficient knowledge and skills to understand normal and abnormal behavior from a developmental, biological, psychological, behavioral, social, cultural, economic, and public health perspective. They are privy to the most intimate details of their patients' lives and that of their families; these often involve distressing moments, dynamics, and revelations of a confidential nature. These confidences need to be maintained in order to foster trust and uphold the ethical principles of the doctor-patient relationship; yet the nature of family dynamics, conflicting roles that psychiatrists may have to employers, third-party payers, and their responsibilities to protect others from harm and distress, may put this tenet to the test. Their patients are often demanding, vulnerable, may lack insight into their condition and the consequences of their actions, and consequently lack capacity to fully participate in decision making, often necessitating coercive treatments or surreptitious prescribing. The very nature of the relationship between psychiatrists and their patients opens up issues of transference and counter-transference, that if not adequately understood and addressed, lays open the possibility of blurring of boundaries between what is acceptable and what is unprofessional behavior. Psychiatry is also an inexact science with many criticisms of the validity of psychiatric diagnoses and theories; the appropriateness, efficacy, and safety of the interventions used; and the limitations in the amount of improvement they result in. Many physician colleagues and members of the public view the claims and practices of the profession as dubious, esoteric, unscientific and even unethical. Consequently, the stigma that cloaks mental illness also shrouds those that care for people with mental illness. The demanding nature of the profession and emotional toll it can place on empathetic professionals has the potential to lead to burnout, changing career options, mental ill- health and even suicide.[1]

However, psychiatry is the one branch of medicine that holds at its very essence the principles of holistic care that many other branches only aspire to, but rarely achieve, with perhaps the exception of and family medicine. One's attitudes and overall approach can turn the very challenges inherent in the profession into opportunities for reflection, research and audit, collaboration, community building, advocacy, and personal and spiritual growth that transcend what one normally can achieve in one's professional life, and that can improve the lives of our patients, families and the societies and communities within our sphere of influence. To facilitate this, it behooves every psychiatric trainee and profession to be familiar with, Tharyan: Good Psychiatric Practice 665 and to imbue their clinical practice with, the principles of ethical and scientific practice that are outlined in the reminder of this article. These are collated from international and national guidelines and recommendations and legal requirements that are referenced at the end of the article.

The basic principles of good psychiatric practice

At the heart of good psychiatric practice are the ethical principles that underpin medical ethics in general: Beneficence (acting always in the patient's best interest; Non-maleficence (doing no harm); Autonomy (respecting people's right to choose their treatments or refuse treatment); and Justice (ensuring fair and equitable distribution of healthcare resources, and balancing patient rights with the rights of others). These principles need to be contextualized in the problems that face psychiatrists when dealing with their patients and their families, particularly when the exercise of one principle seems to conflict with the exercise of one of the others.[1-6]

1. Respect for the dignity and autonomy of persons with mental illness: People with mental health problems are just that - people who have problems. They are not “schizophrenics” or “neurotics”, but people with problems that are given different names by mental health professionals to communicate information to other mental health professionals on their possible etiology, features and prognosis. These problems may range from the ordinary to the most complex and difficult; from non-existent ones to feigned ones; from acceptable and understandable behaviors and reactions, to unacceptable, dangerous, and downright bizarre and pathological behaviors. However, every person has the right to be treated with respect and dignity. Any limitation of their rights need to be within legally permissible means, documented appropriately, be undertaken with the consultation and approval of responsible family members or their legally appointed surrogates, professional peers and seniors; be enforced for as minimum a period of time as is necessary; and by using the least restrictive methods.[6]

2. Always act in the best interests of patients and their families: To do this effectively, a number of issues come into play:

a. Understanding the nature and extent of the problem from the perspectives of all concerned. The time spent in diligently eliciting a detailed history of the presenting complaints from the patient and their relatives, precipitating events, relevant past psychiatric and medical histories, developmental and educational histories, and current family and social circumstances, that can be combined with 666 Psychiatry in India : Training & training centres a diligent mental state examination to formulate a diagnosis based on a problem-based framework of troubling clinical symptoms, family dynamics, social and economic considerations, and the inherent strengths and challenges of each patient, forms the cornerstone of good psychiatric practice. This requires a good understanding of psychopathology and psychiatric diagnoses, good communication skills to elicit the concerns and beliefs of patients and their families; time spent in establishing a rapport with patients and their families that stems from an attitude of respect and politeness, and acknowledgement of their distress and despair, and personal attributes of verbal and non-verbal behaviors that instill confidence and respect. This also requires a questioning mind to seek congruence in the face of incongruity and seemingly vague or atypical presentations.

b. Seeking appropriate consultation and guidance: All trainees, and even experienced mental health professionals, will benefit from the experience and perspectives of others, be it colleagues, seniors, previous treating doctors or psychiatrists, family members or others who know the patient, and medical and surgical specialists. If the overall aim is to enhance the care of patients then enlisting the help of others can only aid this process.

c. Investigating appropriately: Many people with mental health problems need to be investigated for medical problems that are causative, contributory, or incidental to psychiatric symptoms. This includes a general and systemic examination. Many people on psychotropic medication need regular investigations to assess therapeutic blood levels, and monitor hematological, metabolic and endocrine parameters. People with mental health problems are at higher risk of developing physical problems that are often overlooked. Failure to investigate appropriately may lead to poor health outcomes in patients and is not in their best interests. Similarly, investigations that are done, only to yield patient's requests, stemming from inaccurate perceptions of risk and benefit, or inaccurate attributions, do not serve their interests; this requires patience, explanations and a shared perspective of a step- wise action plan to defer investigations while giving other approaches a chance to improve their condition.

d. Use interventions that are informed by reliable and relevant evidence. Evidence-Based Medicine (EBM) is an approach to healthcare that has many advocates and many critics. A proper understanding of its scope is to view it as an alliance between Tharyan: Good Psychiatric Practice 667 researchers, clinicians and patients, where reliable, relevant and timely evidence regarding diagnosis, prognosis and interventions are contextualized by skilled clinicians who assess the risks and benefits for their patients, who in turn expresses their preferences for treatment options. The term Evidence-informed Healthcare is preferable to EBM since all healthcare decisions cannot be based on evidence; the required evidence may not often be available, or it may be inadequate. Evidence in favor of an intervention may not necessarily be transferrable to clinical practice because it may not be affordable, practical, available, or appropriate in a particular context. However, if there is reliable evidence, not using it due to ignorance of its existence, or of how to interpret it and particularize it for one's patient is not in their best interest. Evidence informed guidelines for practice are available for many treatment conditions, but those from professional bodies overseas are actually meant for use in their local circumstances, and one needs to be cautious in blindly transferring them to Indian conditions, unless thought has been given to issues of applicability, cost, and patient values and preferences, and other more suitable alternatives with, perhaps, less convincing evidence from trials. e. Involving patients and families in decision making. Though India is a transitional society, with people moving from the joint to nuclear family structures rapidly, for most people the family is core unit of decision making. Understanding the family decision-making processes and involving key decision-makers, as well as the patient, in a shared decision-making alliance should be the ideal that one should strive for. While psychiatrists are the experts when it concerns diagnoses, investigations, and therapeutic options, patients (and their carers) are the experts when it comes to deciding whether they wish to pursue the suggested options. Patience, good communication skills, sensitivity, and persistence may be required if therapeutic suggestions are not immediately accepted. Understanding patient's and family views and preferences and seeking, if necessary, alternative, though less than optimal options, initially and following up with the psychiatrist's preferred options at a later date may be needed, in such instances. However, if the option preferred by the patient is likely to be harmful, either directly, or through worsening of the psychiatric condition due to withholding appropriate interventions, then the psychiatrist is not required to comply with the wishes of the patient or family and should explain the reasons for this decision. 668 Psychiatry in India : Training & training centres f. Providing sufficient information in a manner, timing, and form that enables shared-decision making. Informed consent, the implicit duty inherent in respecting patient autonomy, is not an isolated event but a process integral to shared-decision making. To achieve this effectively, one should discuss with patients, and their carers, their condition and treatment options in a way they can understand, and respect their right to make decisions about their care. One should see getting their consent as an important part of the process of discussion and decision-making, rather than as something that happens in isolation. In deciding how much information to share with one's patients one should be guided by their wishes. The information shared should be in proportion to the nature of their condition, the complexity of the proposed investigation or treatment, and the seriousness of any potential side effects, complications or other risks. The level of education, the normal process of decision making that the patient follows- whether it is autonomous or based on the decisions of others, will impact on how this is done, but does not obviate the need to provide relevant information. Sufficient time should be provided to ensure adequate comprehension and lack of coercion. If time is a limiting factor, then another member of the team may provide this information, provided they have the expertise to do so, but the psychiatrist has the responsibility to ensure that the information provided was adequate and was understood. The consent may be verbal, keeping with the spirit of informed consent but may need to be written for special procedures and for procedures involving substantial risks, or is a deviation from usual practice.

Ideally, the information that one should provide includes: a) the diagnosis and prognosis; (b) any uncertainties about the diagnosis or prognosis, including options for further investigations; (c) options for treating or managing the condition, including what would happen if one did not treat the condition; (d) the purpose of any proposed investigation or treatment and what it will involve; (e) the potential benefits, risks and burdens, and the likelihood of success, for each option; this should include information, if available, about whether the benefits or risks are affected by who provides this care; (f) whether a proposed investigation or treatment is part of a research programme or is an innovative treatment designed specifically for their benefit; (g) the people who will be mainly responsible for and involved in their care, what their roles are, and to what extent students may be involved (if in an academic set up; if you are a student, then who will supervise your work and how often); (h) their right to refuse to take part in teaching Tharyan: Good Psychiatric Practice 669 or research; (i) their right to seek a second opinion; (j) any bills they will have to pay; (k) any conflicts of interest that you, or your organization, may have; (l) any treatments that you believe have greater potential benefit for the patient than those you or your organization can offer. g. Following legally and ethically permissible methods when patients lack the capacity to consent. Every adult patient must be assumed to have the capacity to make decisions about their care, and to decide whether to agree to, or refuse, an examination, investigation or treatment. One must only regard a patient as lacking capacity once it is clear that, due to severe mental illness or intellectual handicap, having been given all appropriate help and support, they cannot understand, retain, use or weigh up the information needed to make that decision, or communicate their wishes. One must not assume that a patient lacks capacity to make a decision solely because of their age, disability, appearance, socio- economic status, educational status, behavior, medical condition (including mental illness), their beliefs, their apparent inability to communicate, or the fact that they make a decision that you disagree with.[7]

The Mental Health Act of 1987 in India permits involuntary hospitalization through a court order, or with the consent of relatives under special circumstances, provided two medical certificates from two independent psychiatrists support the application. The Act is silent on the issue of treatment in such situations and in the absence of legal doctrine, treatment with the consent of relatives is the norm in such situations.

Coercive measures such as involuntary admission and the use of seclusion, mechanical restraints and non-consensual medication, via short acting or depot injections, or covert oral medicines in crushed or liquid forms, are interventions used by psychiatric services worldwide that pose ethical controversies. There are opposing views to the ethics and legality of their use. If at all they are used, they should be used only as a necessary temporary measure, to prevent harm to others or to oneself, and to help people recover and regain their decisional capacity.[7,8]

Children are not legally permitted to provide consent, but parental consent should be supplemented by attempts to explain and involve children in decision making and in securing their consent to treatment. This may be possible with children above 7-8 years of 670 Psychiatry in India : Training & training centres age but needs to be individually assessed for younger and older children.

h. Providing more than just pharmacological care: Just as the experience of mental illness involves more than just clinical symptoms but a variety of effects that color a patient's life and that of their families and loved ones. So also should treatments for mental illness involve more than just a prescription for drugs. Psychiatrists form but a part of a multidisciplinary team who all have contributions to make towards ensuring recovery, rehabilitation and leading as normal a life as is possible. Supportive and more specialized psychological treatments, nursing care, occupational and rehabilitative services play an integral part in this process and a team approach serves the interests of good psychiatric practice better than if only one of the members of the team were to provide this. In order to do this effectively, one must make sure that patients and colleagues understand the roles and responsibilities of members in the team, and who is responsible for each aspect of patient care.

i. Enhancing patient autonomy and promoting positive mental health: Mental ill health can have devastating consequences on people with mental illness, and their families. The role of the psychiatrist should ideally extend beyond proving medication or talking therapies but also enhance the potential of the person with illness and their families to live productive and as full a life as is possible. Rehabilitation should form part of the ambit of services, patients and their families can access and one should be able to provide patients and their families' referrals to such services, if one does not provide them. Even if such services are not available, good psychiatric practice demands that the treating psychiatrist, or an appropriate member of the team, should provide patients the time and the opportunity to discuss what the mental illness means in terms of their overall life's goals, discuss potential limitations in their activities and life style modifications they should adopt to cope. In addition, one should attempt to identify strengths and talents that patients have, compliment them on their efforts to deal with difficult situations, and foster a sense of hope and renewed resolution to work within their limitations in order to lead a productive life. This includes their educational, vocational, recreational, romantic, sexual, marital, spiritual, and other aspirations that they, as people, have a right to expect, as much as people without their problems. Even in those who are unable to achieve their potential or even a minimal approximation of their Tharyan: Good Psychiatric Practice 671 potential, need affirmation of their inherent worth as people, and attempts to ensure that families and others involved in their lives see them in this light are important. Families also need the opportunity to grieve the events in the lives of their loved ones and the effects these have on their own lives and their hopes. These challenges are often more difficult to deal with than the actual treatment psychiatrists offer and dealing with them effectively, within the limitations of what can realistically be achieved, can spell the difference between optimal and suboptimal psychiatric care and serve as a source of renewal for patients, their families, and the mental health team.

3. Ensure that psychiatric interventions do no harm or use methods that minimize harm: Apart from assessing the individual risks and benefits of psychiatric interventions and procedures for each patient and ensuring the benefits exceed risks, and involving patients and their carers in discussions of these issues, additional issues need to be addressed:[9,10]

a. Communicating with sensitivity and compassion: The very nature of psychiatric diagnoses, and the prognosis and stigma many of these conditions carry, makes the disclosure of the diagnosis of serious mental disorder emotionally overwhelming for many people. Many psychiatric drugs carry substantial long term risks and may need to be taken life-long. Some psychiatric interventions are frightening to patients and to the public. Hence, while the doctrine of informed consent is an ethical imperative, the manner in which information is provided should be sensitive to the potential distress this could elicit in patients and their families. Empathy, sensitivity, and compassion are required in order that undue distress is not caused by the manner of disclosure. While one cannot prevent this distress, one should seek to help people cope with this information, and overloading them with too much information in an impersonal manner is not good psychiatric practice. Similarly, trivializing distress in people with common mental disorders, and in those with serious mental disorders with associated distress, or making sarcastic comments in order to re- assure, is also damaging to people and should be avoided. Treating people with respect means acknowledging their distress and offering to provide support, emotionally, and in pragmatic ways. Since informed consent is a process, ensuring that appropriate amounts of information, necessary to make informed decisions are provided in a timely manner is what is required, unless the patient seeks more information that what one thought they would want at 672 Psychiatry in India : Training & training centres that time.

b. Maintaining confidentiality: Confidentiality is central to the trust- based relationship between doctors and patients and is even more important in psychiatric practice. Without assurances about confidentiality, patients may be reluctant to provide the information needed in order to provide good care. Revealing confidential information has the potential to distress or otherwise damage patients and their families. Confidential information should not be revealed without the express consent of the patient or under court order, or in specific situations where confidential information may need to be disclosed for public interest. Psychiatric records, including even the identification of a person as a patient, must be protected with extreme care. The concept of shared confidentiality implies that confidential information regarding patients may be shared by others involved in their care but these others are also bound to protect the confidentiality of this information. Family members do not automatically have the right to information about patients and such disclosure requires the consent of patients. Even if information has to be divulged in a court of law or for other reasons dealt with under justice, only the information required for the purpose should be disclosed. This means that one should be circumspect in what notes in patents records, keeping in mind that these might be revealed to others. This is especially important if electronic medical records are being used. Confidentiality should also be preserved in academic discussions, presentations or case reports that are not integral to patient care and involve people who are not part of the treating team and under the obligations of shared confidentiality.

c. Avoiding boundary violations: The nature of psychiatric practice is such that violations of professional boundaries are especially important to avoid. One must be careful not to use one's professional position to betray the trust implicit in the psychiatrist- patient relationship, even if the patient appears to be consenting to this-due to their vulnerability and the unequal nature of the doctor- patient relationship. The boundary violations one needs to avoid include any form of sexualized behavior, or sexual relationships with one's current or former patients or their relatives, or the use of one's position to secure material favors or services from one's patients. While these practices are not uncommon, they are not therefore to be condoned. One needs to be particularly careful when performing physical examinations to have a chaperone present, especially for people of the opposite sex and with children Tharyan: Good Psychiatric Practice 673 or those with impaired capacity, and to be sensitive to patients' embarrassment or reluctance to be examined. Psychotherapies and long term therapy often invokes transference and counter- transference relationships that are often useful from a therapeutic standpoint, if used skillfully, but can be missed, misunderstood, and abused. Supervision from a sensitive and experienced colleague can help one learn how to deal with such situations. If patients appear to be seeking personal revelations from therapists that go beyond the natural curiosity inherent in our culture, or if they make overt suggestions or advances of a sexualized nature, and if these issues cannot be sensitively handled in therapy, then one should consider terminating therapy after ensuring continuity of care. Boundary violations also include inappropriate behaviors between seniors and junior colleagues, particularly students, where the nature of the professional relationship is exploited for material gain or for sexual favors. d. Avoid inflicting personal beliefs and discriminatory practices on patients: Since the duty of a psychiatrist is to treat one's patients with respect, whatever their life choices and beliefs are, one must not discriminate against patients by allowing one's personal views to affect adversely on one's professional relationship with them or the treatment one provides. This is particularly important in issues dealing with gender preferences, sexual lifestyles, use of substances of abuse, religious views, manner of dressing or speaking, the community they belong to, or other preferences that may conflict with the beliefs or values of the psychiatrist. If carrying out a particular procedure or giving advice about it conflicts with one's religious or moral beliefs and this conflict might affect the treatment or advice provided, one must explain this to the patient and ensure that arrangements are made for another suitably qualified colleague, who does not share your beliefs, to take over your role. Similarly, while one may seek to enhance patients' views and practices that can help them cope with their problems, such as seeking spiritual help, one must not express one's personal beliefs, including political, religious or moral beliefs, to patients in ways that exploit their vulnerability or that are likely to cause them distress. e. Avoiding unethical practices and conflicts of interest: One of the problems facing medical and psychiatric care in India is the provision of care largely in the context of private care that is mostly for profit. While reasonable charges depending on the ability of the patient to pay is not against any ethical principle, unfair or hidden 674 Psychiatry in India : Training & training centres charges, especially ones that are exorbitant, or for services that are either not provided, or are provided unnecessarily, are a serious cause for concern. These unethical practices include and are not limited to: exploiting patients' vulnerability or lack of medical knowledge when charging for treatment or services, encouraging patients to give, or lend money or gifts that will directly or indirectly benefit the psychiatrist, or putting pressure on patients or their families to make donations to people or organizations nominated by the psychiatrists, putting pressure on patients in government facilities to accept private treatment, ordering unnecessary investigations and getting a commission for this or doing this to meet targets set by others, or making patients buy drugs from pharmacies or undertake investigations in laboratories owned by the psychiatrists, fee splitting between professionals and laboratories or pharmacies, and prescribing certain products in exchange for monetary or other benefits from drug representatives or pharmaceutical companies. Again, the fact that this is commonly done does not make it right. These practices are against all professional codes of conduct, including Indian regulations.

4. Ensuring fair and equitable use of and access to resources and balancing individual rights with the rights of others

The principle of distributive justice encourages that psychiatrists should ensure that all people with mental health problems should have access to the best possible care that is practical and affordable, under the circumstances. Care in the community is the ideal and working with non-governmental agencies and in governmental primary care services to strengthen their services should be the goals of the profession. In secondary and tertiary care, this principle would suggest that using cheaper, traditional medicines judiciously, cheaper brands over costlier brands, using clinical skills and judgment in ordering investigations, and helping patients find resources if more expensive treatments are needed. There are other situations where the principle of distributive justice is invoked in clinical psychiatry:

a) Breaking confidentiality when a patient's behavior or statements may put others or themselves at risk, including the appropriate disclosure of mental illness in pre-marital discussions.

b) Reporting impaired patients who are in occupations or positions that their impairment may put others lives in danger.

c) Reporting or finding ways to deal with situations where patients are being physically, emotionally or sexually abused by significant Tharyan: Good Psychiatric Practice 675 others in their lives.

d) Reporting or finding ways to otherwise deal with other members of the treating them who might be impaired in ways that put patient’s safety at risk or who are abusing the trust placed by the patient in the treating team in material, emotional or sexual ways. These require sensitivity, discussions with responsible others trying all possible measures to prevent breaking confidentiality, in the first instance, but finally putting public good and the rights of others over maintaining confidentiality.

Duties of psychiatrists

In order to practice the principles of good psychiatric practice, psychiatric trainees and even those in professional roles, need to:[11-13] a) Keep abreast of scientific advances, understand how to critically appraise relevant evidence for the effects of interventions, particularly good quality systematic reviews, and learn how to assess them for validity of their methods and conclusions and their applicability one's clinical practice. b) Join a professional association and participate in and contribute to its activities. c) Read and have access to documents pertaining to the ethical and legal underpinnings of the profession d) Ensure that a personal programme of continuing professional development is developed and that appropriate credits are obtained and recorded e) Seek appraisal and feedback from colleagues and superiors on one's abilities and deficiencies and regularly audit one's performance in order to provide better care. f) Elicit feedback from patients about all aspects of care and use these constructively to improve one's practice g) Seek balance between one's work and family and other responsibilities, leisure activities and a healthy lifestyle, as these are ways one can avoid burnout and mental health problems. Be aware that psychiatrists have a higher than average risk for abuse of, and dependence to, prescription medications and alcohol. h) Seek personal growth by reflecting on your work and its challenges; the 676 Psychiatry in India : Training & training centres successes and difficulties of your patients and their families and on examples of resilience in the face of adversity. Use spiritual and religious insights, if one is so inclined, in order to understand your life and the lives of your patients. Literature and the arts have many examples and insights that can help one understand the difficulties people with mental illness have and how they deal with them. i) Consider joining or starting a formal or informal support group where difficult situations and ethical problems can be discussed with peers you respect and who can provide an objective opinion. j) Promote positive mental health. Psychiatrists have an important role in changing public perceptions of psychiatry and mental illness and reducing stigma. They serve this best by their personal conduct with their patients, other professionals, the pharmaceutical industry, the media and members of the public. They can also do this by ensuring ethical principles are followed in their professional practice and by considering and addressing the misconceptions and concerns people might have. They also have a role in educational awareness raising, and stigma reduction activities, and in promoting positive attitudes towards mental illness and fostering preventive mental health.

REFERENCES:

1. American Psychiatric Association. The Principles of Medical Ethics with Annotations Especially Applicable to Psychiatry. 2009 edition (revised). American Psychiatric Association. Arlington Virginia, USA. 2. Beauchamp T.L. & Childress J.F. Principles of Biomedical Ethics. 3rd edition. New York N.Y: Oxford University Press. 1989. 3. Dunn LB, Candilis PJ, Roberts LW. Emerging empirical evidence on the ethics of Schizophrenia research. Schizophrenia Bulletin 2006 32: 47-68. 4. General Medical Council. Good medical practice. Regulating doctors. Ensuring good medical practice. 2006, updated 2009. [Internet]. London, UK. [Accessed November 18, 2010]. [Available from: http://www.gmc-uk.org/guidance/good_medical_practice.asp] 5. Indian Council of Medical Research. Ethical guidelines for medical research on human participants. 2006. [Internet] Indian Council of Medical Research. New Delhi. October 2006. {Accessed June 18 2010]. [Available from: http://www.icmr.nic.in/ethical_ guidelines.pdf]. 6. Indian Psychiatric Society. Clinical Practice Guidelines. 2009. [Internet]. Indian Psychiatric Society. 2009. [Accessed august 10 2010]. [Available from: http://www.indianjpsychiatry. org/cpg2009.asp] 7. Latha KS. The non-compliant patient in psychiatry: The case for and against covert/surreptitious medication. In: Psychopharmacology Today: some issues. Singh AR & Singh SA (eds). 2010; 8: 96-102. 8. Medical Council of India. Indian Medical Council (Professional Conduct, Etiquette and Ethics) Regulations, 2002. (Amendment) Regulations, 2009 - Part-I. [Internet]. New Delhi; 2009 Dec 10. [Accessed 2010 April 18]. [Available from: http://www.mciindia.org/know/ rules/ethics.htm]. Tharyan: Good Psychiatric Practice 677 9. Fiona Subotsky, Susan Bewley and Michael Crowe (Eds). Abuse of the Doctor-Patient Relationship. 2010. [Internet]. Royal College of Psychiatrists. [Accessed 10 December 2010]. [Available from: www.rcpsych.ac.uk/publications]. 10. Singh AR. Covert Treatment in Psychiatry: Do no harm, true, but also dare to care. In: Medicine, Mental Health, Science, Religion and Well-being. Singh AR. & Singh SA (eds); Mens Sana Monographs 2008; 6: 81-109. 11. World Medical Association. Medical ethics manual. 2nd edition. Ethics Unit of the World Medical Association. 2009. [Internet]. [Accessed June 18 2010]. [Available from: http://www.wma.net/en/30publications/30ethicsmanual/index.html] 12. World Medical Association. Declaration of Helsinki. Ethical principles for research involving human subjects. 2008. [Internet]. October 2008. {Accessed 18 January 2010]. [Available from: http://www.wma.net/en/30publications/10policies/b3/17c.pdf]. 13. World Psychiatric Association. Madrid Declaration on Ethical Standards for Psychiatric Practice. 1996. [Internet] Madrid, Spain. August 25, 1996. [Accessed 19 August 2010]. [Available at: http://www.wpanet.org/detail.php?section_id=5&content_id=48]

Prathap Tharyan Professor of Psychiatry Christian Medical College, Vellore 632002 Tamil Nadu, India [email protected]

69 Good Clinical Practice - Key ethical issues in clinical trials in psychiatry in India

Sudipto Chatterjee & Vikram Patel

ABSTRACT

The protection of the rights of research participants is a central feature of Good Clinical Practice (GCP) guidelines governing clinical trials in psychiatry. Current GCP guidelines have evolved through several landmark declarations defining and enshrining these rights. Clinical trials need to meet ethical standards in the design, conduct and reporting of results while making all efforts to uphold and protect these rights. The most important requirement is that participants must provide informed consent prior to participation. The informed consent procedure needs to adequately address key dimensions of the decision making process and be approved by an appropriate regulatory authority. These concerns are especially relevant in trials in psychiatry that may involve participants with compromised decision making abilities. In addition, there are special challenges in ensuring that fully informed and voluntary consent is obtained, which may pose unique challenges in countries like India due to several contextual factors such as the large power differentials between medical practitioners and patients. These factors place special responsibilities on researchers to meet the requirements of ethical and regulatory approval in letter and spirit. The use of placebo controlled group in clinical trials, although an invaluable resource for estimating the 'true' effects of a new treatment, needs careful scrutiny and is acceptable only in situations where there is no existing effective treatment which, if denied, could lead to serious harm to the participant. Awareness about these diverse dimensions of the ethical conduct of clinical trials is an essential element of training for research in psychiatry. Key Words: Psychiatry in Nepal, Training centre, Relevance to India 680 Psychiatry in India : Training & training centres Introduction

Research, in particular clinical trials, is an essential requirement for the development, evaluation and adoption of treatments in psychiatry. Trials can be utilized not only to evaluate new treatments but also establish treatments for new indications, delivery systems for established treatments and interventions to prevent mental disorders and promote mental health. The growing emphasis on evidence based practice, where treatment decisions are influenced by research, has made the conduct of high quality clinical trials even more important. In parallel with the increasing number and widening scope of clinical trials, there has been recognition of the importance of ensuring that all research involving human participants has to be conducted in an ethical manner to protect the rights, safety and well-being of subjects participating in such trials. Key ethical considerations and guidelines governing clinical research and trials are described in more detail below. In writing this article, we borrow heavily on our own experiences of leading major clinical trials for a wide range of evaluation questions, from the efficacy of specific treatments for mental disorders to the effectiveness of lay health worker delivery systems .[1-5]

Good Clinical Practice (GCP)

The ICH-GCP guideline, developed by the International Conference on Harmonization (ICH) of technical requirements for the registration of pharmaceutical agents for human use, is the consensus international ethical and scientific quality standard for designing, conducting, recording and reporting trials that involve the participation of human subjects. These guidelines provide the requirements for the standards of the protocol, ethical safeguards and data management required of clinical trials to be ethically acceptable. Though designed initially with drug trials in mind, the GCP guidelines have informed the ethical framework for a wider range of clinical research studies and trials of non-pharmacological interventions. The guidelines stress on:

l considering the need for risks and benefits analysis before initiating a trial

l that the rights, safety, and well-being of the trial participants are the most important considerations and should prevail over interests of science and society

l that informed consent is the basis for participation,

l the need for standards of the protocol and systems for conducting the trial Chatterjee & Patel: Ethical issues in clinical trials 681

l that data collected in the trial is to be managed securely to ensure confidentiality.

It is important to remember that the ICH-GCP guidelines were built on key milestones governing the safety and well being of subjects participating in scientific research that have been progressively shaped since the Second World war. Three important milestones are notable in this regard. The Nuremberg Code[7] was issued by the Nuremberg Military Tribunal in 1947; in the aftermath of the second World War, this ten-point statement was intended to prevent future abuse of human subjects and unequivocally states that, above all, participation in research must be voluntary. The second influential document is the Declaration of Helsinki[8] adopted by the 18th World Medical Association in Helsinki, Finland, in June 1964 (and subsequently revised further till 2008), that provides further guidance to physicians and other participants in medical research involving human subjects. Finally, In 1974, the 'Ethical Principles and Guidelines for the Protection of Human Subjects of Research' (1979) or the Belmont report,[9] commissioned by the US government, also concluded that the primary principles underlying ethical research with human participants are respect for person's autonomy, beneficence, and justice. These guidelines form the basis for exploring the subsequent sections of the article.

Ethical issues in conducting research involving human participants

Any research involving human participants needs to be reviewed for ethical considerations on the following considerations:

l Is the study necessary and justifiable? For example, is there a genuine uncertainty or equipoise about the potential benefits of a new treatment compared to an existing one? In other words, is the study justified scientifically in the light of available evidence?

l Is the study designed in a manner to provide a clear answer to the question being asked? Has the study been designed appropriately to answer the research question and is the study adequately powered to provide a clear answer to the research question?

l Do the potential benefits to subjects outweigh the risks? Is the risk benefit ratio (of taking part in the study) of an acceptable magnitude? This is particularly important for investigational and novel treatments where adverse events (known and unknown) are anticipated as being highly likely. This question is also important in the context of placebo-controlled trials in the context of the risk that participants may be harmed because, if allocated to a placebo, they may be denied a known effective treatment. 682 Psychiatry in India : Training & training centres

l Do all subjects provide informed consent prior to participation? This is fundamental to any research study and is elaborated in the next section.

l Are the rights of research subjects protected during the study? For example, how will the study ensure the confidentiality of the data collected is protected? Does the study protocol ensure that subjects who have decided to drop out during the course of the study continue to receive adequate care without prejudice?

l Has the study been cleared by appropriate regulatory authorities? This refers to the need for studies to be reviewed for ethical standards by an independent Institutional Review Board (IRB)/ institutional ethics committee and other relevant regulatory bodies; formal institutional approval is essential prior to the commencement of any study involving human subjects.

l In the case of randomized trials, is the study being monitored by an independent Data Management and Ethics Committee (DMEC)? For randomized controlled trials, an independent DMEC or similar Trial Monitoring Committee that can review the trial progress, monitor adverse events and advise discontinuation of the study if adverse events in one arm are unacceptably large is an additional safeguard for ensuring the ethical conduct of trials.

l Is the trial registered appropriately and has a unique ID? It has become mandatory for clinical trials to be registered with an open access registry for controlled clinical trials. There are several such international registries like the ClinicalTrials.gov registry in the US, the ISCTRN registry and the Clinical Trials Registry- India (CTRI) that has been set up by the ICMR. All of these are based on the recommendations of the WHO International Clinical Trials Registry Platform that require trials to describe 20 key questions to ensure GCP guidelines are adequately followed. In addition, such trial registration and ID are becoming essential for scientific publications, as described by the International Committee of Medical Journals Editors (ICMJE) initiative. These measures ensure that the design and analysis of the data is specified prior to initiating the data collection and prevents the post hoc manipulation and 'cherry picking' of the data. Informed consent As noted earlier, a mandatory requirement for all clinical trials is that participants need to provide informed consent to participate; this is central to good practice requirements for research and clinical trials. The GCP Chatterjee & Patel: Ethical issues in clinical trials 683 guidelines further state that:

l consent must be obtained prior to participation, must be voluntary and free of any overt or covert coercion

l information provided to influence consenting must be readily available, acceptable, accessible, easily understandable and of certain quality

l that the final choice about whether to take part or not made by the person must be respected

There are multiple dimensions to the process of research participants providing informed consent to participate in the study. The most important elements that comprise the person's ability to exercise their choice are:

l understanding information relevant to the decision (purpose, procedures, risks and potential benefits of the study)

l appreciating the information (e.g. recognizing the voluntary nature of research participation)

l using the information rationally (such as being able to describe potential consequences of participation in the study)

l expressing a choice (i.e. being able to state clearly whether he/she is willing to participate in the study)

Thus, the onus is very clearly on the investigators to design the consent procedure around these universal principles of informed consent and comply with all ethical and regulatory requirements. This requires the investigators to provide simple language information sheets (in the participant's own language) that outline the purpose, risks, benefits, data collection procedures, the fact that participation in the study is voluntary, that non participation will not affect care in any manner, data confidentiality assurance, the key persons involved, the sponsors of the study, the names of regulatory bodies that have cleared the study and a contact person for further clarification. The consent form needs to have five essential elements to be in compliance with GCP guidelines:

l that participation in a study is involved (and that the study is not 'usual care')

l that there are requirements of participating in the study

l that information from the assessments is confidential

l that there are possible benefits and risks of participating; and 684 Psychiatry in India : Training & training centres

l that participation is voluntary and non participation will not compromise usual care

In addition, as noted earlier, the informed consent procedure, the information sheets and all consent forms need to be reviewed and cleared by an independent IRB/ Ethics committee before any subject is recruited. These guidelines are designed to help enforce a system of ethical recruitment of subjects in research based on a carefully designed consent procedure that has the subject's rights and concerns at the heart of the matter.

Obtaining informed consent in psychiatric research is sometimes challenging since the subjects chosen for potential participation are vulnerable and need special protection. A central assumption of the informed consent process is the implicit understanding that the person possesses the cognitive faculties for understanding and processing the information provided to make a rational choice. However, in planning research with persons with psychotic disorders, dementias and intellectual disabilities, the central issue is whether the subject has an adequate decisional capacity to provide an informed choice. In such circumstances, the most pragmatic position is to start with the assumption that any subject has the capacity to make an informed choice, unless proved otherwise. The consequence of this position is that the onus is on the study investigators to make all reasonable and feasible attempts (such as using simplified language for communicating information, providing information in small parcels, having an interactive process with built in revision and discussion/further clarification and the use of interactive multimedia and computerized learning aids) before opting for options like proxy consent or a legal guardian who is empowered to make the choice on the person's behalf.

Translating these universal principles into practice is challenging in most contexts, but the problems are more obvious in countries like India. Some of these are:

l Different cultural understanding of autonomy and the informed choice being an alien concept in daily life decision making

l Weak regulatory framework for vulnerable persons

l Many participants are non-literate and cannot read the information brochure

l Large power differential between doctors and potential participants thus there is a risk of coercion to participate if the treating doctor is also responsible for obtaining consent to participate

l That decisions about consenting to treatments are often taken Chatterjee & Patel: Ethical issues in clinical trials 685 collectively along with family caregivers rather than the subject alone

l Financial/care incentive to participate

Again, the onus is on the investigators to satisfy themselves and the independent regulatory authorities that these challenges have been acknowledged and addressed to the extent possible in the study design. Clearly, this is an area with many grey areas and in need of urgent attention in India where there has been a proliferation of clinical trials in recent times with some concerns about their ethical standards .[10]

Placebo controlled trials

Controlled clinical trials that compare two or more treatments by definition employ a control or comparison group. Control groups have one major purpose: to allow discrimination of patient outcomes (for example, changes in symptoms, signs, or other morbidity) caused by the experimental treatment from outcomes caused by other factors, such as the natural progression of the disease, observer or patient expectations, or other treatment. In other words, the control group experience tells us what would have happened to patients if they had not received the experimental treatment or if they had received a different treatment known to be effective.

Typically, a control group is chosen from the same population as the experimental group and treated in a defined way as part of the same trial that studies the experimental treatment, and over the same period of time. The experimental and control groups should be similar with regard to all baseline data and on treatment variables that could influence outcome, except for the study treatment. Failure to achieve this similarity can introduce a bias into the study to make the estimate of a treatment effect deviate from its true value. Randomization and blinding are the two techniques usually used to minimize the chance of such bias and to ensure that the experimental and control groups are similar at the start of the study and are treated similarly in the course of the study. Whether a trial design includes these features is a critical determinant of its compliance with GCP standards, quality and persuasiveness.

When testing the effectiveness of an experimental treatment, the choice of the type of control group depends on the purpose of the trial. In a placebo- controlled trial, subjects are randomly assigned to the experimental treatment or to an identical-appearing treatment that does not contain the active ingredient of the experimental treatment. Such trials are almost always double-blind. The name of the control suggests that its purpose is to control for placebo effect (improvement in a subject resulting from thinking that he or she is taking a drug), but that is not its only or major benefit. Rather, the 686 Psychiatry in India : Training & training centres placebo control design, by allowing more comprehensive blinding and randomization and including a group that receives an inert treatment, controls for all potential influences on the course of the illness other than those arising from the specific action of the experimental treatment. These influences include spontaneous change (e.g. natural history and regression to the mean), subject or investigator expectations, the effect of being in a trial, use of other therapy, and subjective elements of diagnosis or assessment.

However, the scientific advantages of the placebo controlled trial (which are needed for certain regulatory authorities like the FDA in the US prior to licensing a drug for use in a certain disorder) need to be tempered with the need to protect the rights of subjects, as emphasized in the Helsinki declaration. If there is an existing treatment for the particular condition that is demonstrated to be more effective than placebo, there is little justification for a placebo controlled trial. In this case, the comparison should be between the experimental treatment and a standard treatment, in other words, an "active" control group. In technical terms, trials with active control groups can either be superiority trials or, in most cases, non-inferiority trials intended to establish the efficacy of a new treatment against an existing one.

Thus, the routine use of the placebo controlled trial is not recommended unless there are compelling reasons for doing so. This is especially true for psychotic disorders where withholding standard treatment is seldom acceptable due to the suffering that would be expected if participants receive an inert treatment. However, in trials involving people with depression, placebo controlled comparison groups may be more acceptable given the consistent reports of large placebo responses and the relatively weaker side effect of existing treatments.[11] Thus to summarize, placebo controlled trials are justified when:

l There is no known effective therapy

l The best standard therapy is no better, or only marginally better, than placebo

l There are doubts regarding the net therapeutic advantage of standard therapy

l The standard treatment is unavailable or inaccessible (for example, due to high cost or low supply)

l In special circumstances, like trials involving add on treatments or for treatment resistant patients CONCLUSIONS The conduct of clinical research and trials is increasingly being governed by Chatterjee & Patel: Ethical issues in clinical trials 687 universal GCP guidelines to ensure that the rights of participants are adequately protected. Understanding these guidelines is an essential element of psychiatric training to ensure that psychiatrists adhere to these standards while conducting research. REFERENCES 1. Patel V, Chisholm D, Rabe-Hesketh S, Dias-Saxena F, Andrew G, Mann A. The efficacy and cost-effectiveness of a drug and psychological treatment for common mental disorders in general health care in Goa, India: a randomised controlled trial. Lancet 2003;361:33-9. 2. Dias A, Dewey ME, D’Souza J, et al. The effectiveness of a home care program for supporting caregivers of persons with dementia in developing countries: a randomised controlled trial from Goa, India. PLoS ONE 2008;3:e2333. 3. Patel V, Weiss H, Chowdhary N, et al. The effectiveness of a lay health worker led intervention for depressive and anxiety disorders in primary care: the MANAS cluster randomized controlled trial in Goa, India. Lancet 2010; 376: 2086–95. 4. Balaji M, Andrew T, Andrew G, Patel V. The Acceptability, Feasibility and Effectiveness of a Population-based Intervention for Promoting Youth Health: An exploratory study in Goa, India. Journal of Adolescent Health May 2011;48(5):453-60. 5. Chatterjee S, Leese M, Koschorke M, et al. Collaborative community based care for people and their families living with schizophrenia in India: protocol for a randomised controlled trial. Trials 2011, 12:12 http://www.trialsjournal.com/content/12/1/12. 6. ICH Harmonized Tripartite Guideline for Good Clinical Practice E6(R1) In: International Conference on Harmonization of Technical Requirements for Registration of Pharmaceuticals for human use 1996; 1996. 7. Annas GJ, Grodin MA. The Nazi doctors and the Nuremberg code. New York: Oxford University Press; 1992. 8. World Medical Association Declaration of Helsinki. Bulletin of the World Health Organization 2001;79. 9. Ethical Principles and Guidelines for the Protection of Human Subjects of Research (aka the Belmont Report). 1979. 10. Annas GJ. Globalized clinical trials and informed consent. N Engl J Med 2009;360:2050-3. 11. Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, Johnson BT. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Med 2008;5:e45.

Sudipto Chatterjee Consultant Psychiatrist Sangath, Goa.

Vikram Patel Professor of International Mental Health & Wellcome Trust Senior Research Fellow in Tropical Medicine, London School of Hygiene & Tropical Medicine and Sangath, Goa, India [email protected]

70 ‘Four Principles’ approach to medical ethics

Nicholas A. Deakin, Dinesh Bhugra

ABSTRACT

Doctors and psychiatrists increasingly rely on the four principles of autonomy, beneficence, non-maleficence and justice as aspects of decision-making in treating their patients. The ‘four principles’ approach has much to offer medical professionals when they are faced with ethical dilemmas in clinical and non-clinical practice. In this paper, we outline the basis of these principles and consider the key strengths of using this theory. These include the historical basis, appreciation for modern values in healthcare and the fact that the outcomes often match those that would be reached through alternative ethical theories. These are countered against key weaknesses, including difficulties with whom the principles apply to and, most importantly, the potential for conflict within the principles. The merits of the ‘four principles’ mean that all psychiatrists’ and doctors’ dilemmas should consider them when making ethical decisions, but they do not alone offer the tools to come to definite conclusions: they should be used in conjunction with professional judgement and wider ethical frameworks to ensure that the profession maintains the respect of those who we serve.

Key words: ethics; principles; practice

Introduction

Medical ethics have been at the core of professionalism in medicine and in psychiatry in particular for several millennia. ‘First, do no harm’ has long been the watchword principle of taking care of patients. As the practice of medicine has become increasingly complex, newer ethical issues may have emerged, but the core principles remain the same. In addition, with newer interventions, specific challenges have emerged. These principles are at the heart of medical professionalism. In this brief paper we comment on these 690 Psychiatry in India : Training & training centres principles and indicate their role in the practice of psychiatry in the 21st century. In the past decade, medical professionalism has become of major interest to practitioners and public alike. The professionalism relies on technical knowledge, care of the patient, compassion, integrity, honesty, high moral standards and working with colleagues along with accountability to self and others.[1]

Beauchamp and Childress [2] have propositioned and subsequently gone on to refine a system for ethics which can be used across medicine and psychiatry. This approach is constituted of ‘four principles’ which are: respect for autonomy, non-maleficence, beneficence and justice. There is little doubt that such a way of thinking is related to engagement with considered moral judgments and professional values. Autonomy means an individual is an independent moral agent, and in this context it will be the clinician who is to be seen as an independent agent allowed to make decisions based on technical expertise and knowledge. Equally important, the patient too has to be seen as an autonomous agent though this is not always possible, especially in paediatrics and psychiatry. Furthermore, cultural values will play a key role. For example, in India when a patient is brought to see a psychiatrist there is every likelihood that they will be accompanied by several friends and relatives. Under those circumstances, autonomy, confidentiality and freedom to be an independent agent need to be redefined. The other three principles are non-maleficence, not causing harm; beneficence, benefiting others; and justice, acting to treat everyone in a fair and equal manner.[2,3] The normative ‘four principles’ guide, and justify, clinical and non-clinical actions and can generate general rules about such actions[2]. Each principle is ‘prima facie’ so carries equal weight until the situation leads to inter-principle conflicts. In the latter situation, the principle(s) with the most weight would have supremacy when reaching a clinical decision.[2] This raises critical questions for further discussion among clinicians and ethicists so as to determine what the clinical needs and priorities are for the patient.

Theories of principles and medical ethics

The application of the ‘four principles’ allows justification and explanation of all universalisable norms of medical ethics and combines traditional with more modern values in healthcare. These principles have been described as

‘moral DNA’.[4] The results of Beauchamp & Childress’ approach very often concur with the results of other normative theories, as most theories applied to medical ethics somehow encompass these principles[2] even if their individual processes are distinct. Whether developed by ethicists, such as virtue ethics,[5] or by professional associations (for example, the British

Medical Association (BMA) approach),[6] and even if the theories contain many more principles, this remains true. The four principles fuse contemporary Nicholas A Deakin, Dinesh Bhugra: Four Principles’ approach 691 patient values including justice and respect for autonomy with the ancient principles of beneficence and non-maleficence set out by Hippocrates.[2] The strengths of this approach mean that even critics accept that the ‘four principles’ are virtually always involved in any ethical discussion.[7] It is problematic to think of examples where healthcare professionals should ignore these key principles, though there are some notable exceptions in paediatrics and psychiatry.

Establishing the ‘common morality’ shared by all

The ‘prima facie’ moral principles embedded in various ethical theories can be applied to medical ethics cases across cultural and geographical boundaries. Beauchamp concludes that the ‘four principles’ offer potential for moral norms that are universally valid.[8]

The universal application of ‘four principles’ is, according to Gillon, a cause for great celebration and a key strength of the theory.[4] Legitimate moral diversity as defined by Beauchamp and Childress[2] means that ‘many moral norms may be binding in one culture but not in another’.[9] For example, where there are strong societal barriers in terms of the stigma of mental illness, responses may be different from areas where other social systems predominate.

Thus, even if there were a common set of principles which transcend cultures[1] these may yet lead to different conclusions across different cultures. There is no doubt that social imperatives will affect morals across societies and cultures and sometimes within the same culture. Also important here is the influence of the relative size of the population who holds a view on the common morality, with the majority view almost always likely to predominate.[10] It is important to remember that any civilised society has an obligation to look after the interests and views of the minority. Gillon holds the view that the ‘four principles’ are distanced from full moral relativism,[4] where the assessment of moral acts would take place exclusively within the moral framework of the culture, society or grouping within which the decision is to apply[11] without going as far as moral objectivism, where the theory would hold that there is only one way of making ethical decisions regardless of cultural differences.

Whilst it may seem appealing, especially in psychiatry where the social and cultural context is central to each consultation, this ‘middle ground’ view has been suggested to be ‘inherently unstable’.[11] There is an argument that the theory must either embrace relativism (where any one society cannot comment on the judgements of another) or accept that the principles should be applied regardless of culture. Some ethicists believe that whilst it may be acceptable for judgements to differ because of situational differences, it is 692 Psychiatry in India : Training & training centres not acceptable to have universal features of morality that do not apply, or apply to different extents everywhere.

A debate is urgently needed to determine whether the theory should be either completely relative or aim for moral objectivism, but there is no room to discuss this here in the depth that it deserves (see Gillon,[4] Dawson &

Garrard,[11] Sokol[9] and Lee[10] for detailed discussion).

The claim that the four principles are not enough to encompass the ‘common morality’ throughout the world damages this approach. Whilst many hold that ‘it will be difficult to find the black swan [cases required] needed to invalidate the [framework’s] sufficiency’[9], if we claim that it universally expresses ‘common morality’ we cannot rely on any moral norms that are not encompassed by the approach.[12] However, Shweder and colleagues argue that societies actually use three basic ‘ethics’ at once: those of autonomy (incorporating harm and justice), community (incorporating duty, respect and interdependency) and divinity (incorporating tradition and purity).[13] Walker[11] challenges the idea that all moral rules can be linked back to the ‘four principles’ by using examples from outside medical ethics to invalidate the claim. He acknowledges that whilst the ‘four principles’ may be enough in healthcare, it would be odd for narrower moral consideration to apply in the healthcare setting than more generally.[12] Thus there needs to be further exploration of ethics within psychiatric practice, health care and in general society to explore these divergences.

Dealing with conflict

The main weaknesses of the ‘four principles’ approach concern conflicts between principles and issues of scope. Some, such as Gillon,[4] go as far as to claim that this approach does not provide a method for dealing with irresolubly dilemmatic conflict of the principles or many specific moral obligations encompassed by them.

Because the principles are ‘prima facie’, decision makers are bound by each principle and the moral demands they place on the situation unless they conflict with another principle, when we must decide which is most compelling.[14] Significantly, Strong[15] holds that, to be coherent, principles must be logically harmonious and there must be internal support within and between them. Ideally, principles should help to explain the others and the moral rules derived from them.[16,17] There are many examples in the literature and in professional practice where this conflict occurs; particularly pertinent one in psychiatry concerns involuntary treatment. Here, this occurs between the principles of respect for autonomy with nonmaleficence and beneficence. The following moral rules (amongst others) can be established: Nicholas A Deakin, Dinesh Bhugra: Four Principles’ approach 693 1. To respect a patient’s autonomy, and freedom to choose for themselves whether to undergo treatment

2. Where appropriate treatment is available to a critically ill patient, it is not morally acceptable to risk further deterioration by not treating them

3. It is always morally right to maximise benefit (including function and capacity) and minimise patient harm – treatment can be an important way to decrease risk to the patient and those around them.

This obviously causes issues for the ‘four principles’ - inner conflict is a major disadvantage leading to incoherent results. The strengths of the status of the principles, however, remain intact. Thus, proponents argue both that theories should allow for more than just following rules, and that ‘speciation’ can help resolve such conflicts if they arise.[8] These issues are explored below.

Is there room for ‘speciation?’

‘Speciation’ refers to refining the ‘four principles’ to enhance utility when analysing specific cases. If this was fully successful, it could mediate the weakness posed by internal conflict, improve efficacy and foster ethical deliberation whilst preserving the key moral obligations that the principles place on decision-making.[8] This is acceptable to those who accept the theory providing it maintains or improves the mutual agreement among the principles and the moral obligations that come from these.[16,18] Richardson described this as specifying ‘where, when, why, how, by what means, to whom, or by whom’.[16]

‘Speciation’ tries to tackle the disadvantageous inability of the ‘four principles’ to yield rational, morally acceptable answers. However, this is notoriously difficult with many traditional theories, from Bentham’s utilitasrianism to Kantian deontological ethics, sharing this deficiency.[19]

Speciation would deem it appropriate to amalgamate them to form a general rule such as: It is always morally right to maximise benefit to the patient, as well as minimising potential harm, when appropriate treatment is available, if the patient is not competent. In doing this, however, autonomy has been superseded by the other principles – an issue when all four are equal in worth and ‘prima facie’. The legal systems in various countries would permit this in some cases, but the law is often complex and differs across national boundaries.

In practical terms, ‘speciation’ does not then offer the great counter to the weakness in the ‘four principles’ approach based on internal conflict. 694 Psychiatry in India : Training & training centres Imprecision is not necessarily removed, and moral answers may not always be rationally accountable even if discourses are smoothed. Furthermore, focusing just on the ‘four principles’ may not be enough to encompass the universal ‘common morality.’ Thus, speciation is not the great answer to the weakness around inner conflict; it actually compounds it.

Scope of application:

Whilst ‘speciation’ may not resolve the potential conflicts in practice, it does go some way to countering another weakness in the ‘four principles’ approach in terms of who or what they apply to. Even proponents such as

Gillon[4] have raised the question of who are we obligated to and to what degree. This is particularly pronounced with the principles of beneficence and justice, and issues such as resource allocation in psychiatry. Obligations must fit with the principles, and whether they extend to the patient, their family, the healthcare team, wider hospital, health service or society more generally. This is somewhat weakened by Gillon’s claim that the principles apply to the professional-patient relationship[14] but it is not clear to what extent the family, religious leaders or society should be involved, which raises key questions about clinical practice in countries such as India, where family may play a bigger role in managing patients.

Where budgets are limited, accommodating autonomous choice may restrict resources for other areas of care. Whether we should take this into consideration is not clear. This weakness means the ‘four principles’ approach is thus caught between two unappealing scenarios. If the scope of the principles is too wide, utility is minimised and conflict maximised. If it is too narrow, important moral considerations may be missed.

Moving beyond the individual doctor-patient relationship

There are key differences in justifying individual acts and policies.[2] Therefore, acts that can be morally justified according to the principles cannot necessarily become policies to be applied to all patients. For example, where a patient would benefit from very expensive psychiatric treatment, a fourth consideration is required to consider the wider societal consequences of using higher cost drugs. Whilst the individual cost increase may be negligible, standard policy implementation may be tremendously expensive and prohibit wider societal healthcare needs. This weakness with standardisation decreases the usefulness of the ‘four principles’.

Public health can be defined as ‘what we, as a society, do collectively to assure the conditions in which people can be healthy’.[20] This may reflect a clear focus on greater good and not necessarily on a single patient. Instead of looking at the needs of individual patients, it requires wider considerations considering Nicholas A Deakin, Dinesh Bhugra: Four Principles’ approach 695 the whole, or specific sectors of society. Childress, Faden et al[21] articulate this as deciding whether to spend finite resources on vaccination or the treatment of conditions as and when they present. Not only the condition we are vaccinating against must be considered, but also other conditions which may not be treatable using vaccinations, if resources have been diverted to vaccination programmes. In the Indian context, as Agarwal [22,23,24,25] has very cogently described ethics though not popular among psychiatrists carry an extra importance and urges that in addition to common ethical principles for all doctors, speciality based ethical considerations must be developed and considerable amount of work is being carried out in India [see 25].

Furthermore ethical rules published by the Medical Council of India [26] deal with not only diagnosis but doctor-patient interactions must be taken into account. Recent exposes on the Indian television have once again brought the spotlight on medical profession and ethical dimensions. Desai [27] points out that the responsibilities of the psychiatrists include not only competence but also ethical behaviour and accountability along with advocacy for their patients. Chaturvedi and Somasekhar [28] highlight that at the time of their study in 2009 only 51% research papers published in the Indian Journal of Psychiatry explicitly mentioned informed consent which raises serious ethical questions and it is also important to understand that with low literacy rates different methods of consent may be required. However that should not, indeed must not take away from the principles discussed in this paper.

In contrast to recent, individual ‘Western’ medical ethics where great emphasis is put on autonomy,[4] in public health considerations, individual autonomy is often limited to maximise public benefit. For example, if all individuals in an area are forced to have fluoride in their water, the potential benefits around preventing harm and maximising health benefits may allow the curtailment of autonomy.

Childress, Faden et al[21] have proposed general moral considerations required for public health decision making which extend beyond rules linking to the ‘four principles.’ They also include ensuring distributive and procedural justice, protecting privacy, confidentiality, keeping commitments, disclosing information, being truthful and building trust. Whilst public health may require this different approach to individual ethics, justifying these extra considerations, given that even one of the founders of the ‘four principles’ approach cannot justify which morally relevant units to consider, the weakness with scope is only further enhanced.

Disadvantages of the approach

There are both disadvantages and clear advantages with using the ‘four principles’ in medicine and psychiatry; they attract widespread praise from 696 Psychiatry in India : Training & training centres critics and proponents alike for being ‘thick in status’.[10] Most theories that can be applied to medical ethics somehow include the ‘four principles’[2] – so much so that they ‘constitute moral DNA’,[4] and they should therefore be utilised in psychiatric practice. No doubt thanks to their combination of contemporary and more historical ethical considerations, their findings often concur with those of theories that work in different ways with different considerations.[5,6] However, as discussed above, some philosophers, including Sokol, have argued that we need more principles to encompass the ‘common morality’.[9] Whether or not you agree with this, the most damaging disadvantages with the theory come to light only when we begin to apply the ‘four principles’ in practice.

The theory is seriously undermined by the inner conflict that can occur between different principles. Solutions such as ‘speciation’ as proposed by Beauchamp and Childress and others do not address this in a coherent or standardised way. The problems regarding the lack of clarity as to who the relevant moral units that must be considered in ethical decision-making are only exemplified when we move beyond the individual doctor-patient interaction. This is true whether we are considering limited budgets or strategies to improve public health.

When we summate these disadvantages with the real advantages already discussed, we have a theory that ‘can be used with astounding ineptitude or dazzling virtuosity’.[9] Particularly when we consider medical students, junior doctors and new psychiatrists, it encourages what Harris calls a ‘checklist approach’ to ethics.[7] In being like a pro forma, the ‘four principles,’ if quickly considered, could be used to yield answers lacking the deeper understanding required in complex cases of psychiatric ethics. So whilst they laudably encourage us to consider key aspects of situations, the ‘four principles’ do not form a conclusive method for health professionals to apply in all cases of medical ethics. The other major disadvantages that come with the practical application of the ‘four principles’ mean that, instead, they should be used only to highlight the ethical questions and moral factors upon which we have to reflect. The interesting moral work occurs once these ethical considerations have been identified, when the ‘four principles’ should be used in conjunction with established professional judgement and wider frameworks such as utilitarianism, deontological theories and virtue ethics in order to yield moral conclusions in psychiatric and wider medical ethics.

Conclusions

‘Four principles’ are the heart of good and ethical clinical practice. A key challenge for psychiatry is whether these can be used across cultures when issues like rights and resources may play a role. Clinicians across all Nicholas A Deakin, Dinesh Bhugra: Four Principles’ approach 697 specialities must have ethical values inculcated in them from an early stage of training and these values should also be part of ongoing training.

REFERENCES

1. Bhugra D. Medical leadership in changing times. Asian Journal of Psychiatry 2011;4;3;162-164 2. Beauchamp T, Childress J. Principles of Biomedical Ethics. 6th edition. New York: Oxford University Press; 2009. p. 1-15, 25, 383-4 3. Mason J, Laurie G. Mason and McCall Smith’s Law and Medical Ethics. 8th edition. Oxford: Oxford University Press. p5 4. Gillon R. Ethics needs principles – four can encompass the rest – and respect for autonomy should be “first among equals”. J Med Ethics 2003;29;307-312 5. Campbell A. The virtues (and vices) of the four principles. J Med Ethics 2003;29;292-296 6. Sommerville A. Juggling law, ethics and intuition: practical answers to awkward answers. J Med Ethics 2003;29;281-287 7. Harris J. In praise of unprincipled ethics. J Med Ethics 2003;29;303-306 8. Beauchamp T. Methods and principles in biomedical ethics. J Med Ethics 2003;29;269- 274 9. Sokol D. Sweetening the scent: commentary on “What principlism misses”. J Med Ethics 2009;35;232-233 10. Lee M. The problem of ‘thick in status, thin in content’ in Beauchamp and Childress’ principlism’. J Med Ethics 2010;36;525-528 11. Dawson A, Garrard E. In defence of moral imperialism: four equal and universal prima facie principles. J Med Ethics;2006;32;200-204 12. Walker T. What principlism misses. J Med Ethics 2009;35;229-231 13. Shweder N, Much N, Mahapatra M. The ‘big three’ of morality (autonomy, community, divinity) and the ‘big three’ explanations of suffering. In: Brand A, Rozin E, editors. Morality and Health. New York: Routledge; 1997. pp.119-172 14. Gillon R. Medical ethics: four principles plus attention to scope. BMJ 1994; 309;184 15. Strong C. Specified Principlism: What is it and does it really solve cases better than casuistry? Journal of Medicine and Philosophy 2000;25;323-341. 16. Richardson H. Specifying norms as a way to resolve concrete ethical problems. Philos Public Aff 1990;19;279-310. 17. Rawls J. A Theory of Justice. Cambridge: Harvard University Press; 1971. pp.21, 579. 18. DeGrazia D. Moving forward in bioethical theory: Theories, cases and specified principlism. Journal of Medicine and Philosophy 1992;529. 19. Strong C. Justification in ethics. In: Brody B, editor. Moral Theory and Moral Judgements in Medical Ethics. Dordrecht, The Netherlands: Kluwer Academic Publishers; 1988. pp.193-211. 20. Institute of Medicine. The Future of Public Health. Committee for the study of the future of Public Health. Washington, D.C.: National Academy Press; 1988. pp. 1. 21. Childress J, Faden R, Gaare R, Gostin L, Kahn J. Bonnie R et al. Public Health Ethics: Mapping the terrain. Journal of Law, Medicine and Ethics 2002;30;170-178. 22. Agarwal A K. Ethics in Psychiatry. Indian Journal of Psychiatry 1994;36, 5-11. 23. Agarwal A K. Ethical issues in the practice of psychiatry. Indian Journal of Psychiatry2001;43,16-21. 24. Agarwal A K. Proceedings of the workshop on Ethics in psychiatry. Lucknow: Dept of 698 Psychiatry in India : Training & training centres Psychiatry. KG Medical College. 25. Agarwal A K. Ethics in Psychiatry. In TSS Rao(ed): Indian Research in Psychiatry: a journey of six decades. Mumbai: Indian Journal of Psychiatry Publications 2010. 26. Medical Council of India: Professional conduct and ethics regulations. New Delhi: MCI. 27. Desai N G: Responsibilities of psychiatrists: need for pragmatic idealism. Indian Journal of Psychiatry 2006, 48:211-214. 28. Chaturvedi SK, Somashekar BS: reporting ethical aspects of in published research articles in the Indian Journal of Psychiatry. Indian Journal of Psychiatry 2009, 51, 34-37.

Nicholas A. Deakin Medical Student University of Bristol Senate House Bristol BS8 1TH, UK

Dinesh Bhugra Professor of Mental Health and Cultural Diversity Health Service and Population Research Department Institute of Psychiatry, King’s College London London SE5 8AF, UK [email protected] Trainee Perspectives 71 Expectations from a training program in psychiatry: A trainee's viewpoint

K.R. Aarya

When one pictures an MBBS-trained doctor standing baggage-in hand at the archway welcoming him/her into Psychiatry, one wonders… 'What would his/her expectations be…what does he/ she think the field will involve?”. Romanticized depictions of the field encourage people to assume that it chiefly involves having to deal with exotic patients and listening to mysterious, exquisitely entertaining tales. But the expectations and experience of most entrants end there. This is understandable since the methods of our existing system of undergraduate medical education are such. Investing largely on acquisition of a theoretical base through bookish knowledge and laying relatively lesser emphasis on acquiring clinical skills, it thoroughly fails to familiarize a MBBS student with even the absolutely preliminary tenets of a psycho-behavioral science like Psychiatry. The 'exposure' to Psychiatry includes a few paragraphs sprinkled with Psychiatric jargon crammed last-minute for the final MBBS exams, a few days' namesake posting in a psychiatry outpatient and no more.

Leave alone the postgraduate aspirant and his/her expectations, how does the system of post-graduate education itself operates? It so happens that in most parts of the country, Psychiatry as a branch is embraced in the blanket mode and the method of postgraduate education is as practiced with other divisions. The postgraduate student is dealt with like someone who has experience enough to be left on his/her own and is hardly bestowed the attention and supervision that is his/her due. He/she is barely 'taught', 'corrected', 'trained'. He/she is not taken through an organized academic schedule nor is due seriousness accorded to his/her research training.

Will this system do for psychiatry? One doesn't need a moment to answer in the negative. Psychiatry, though also a clinical discipline, needs skills that stand apart from those required with most other medical fields. Here is a stream where one has to learn to communicate, listen, empathize, to be non-judgmental and non-critical. Problems cannot be handled solely going by 700 Psychiatry in India : Training & training centres diagnostic criteria nor can management blindly follow guidelines like instructions out of a cookbook. The terrain is much broader and much more nuanced. Problems of the patients will not make sense if the clinician doesn't make efforts at understanding the person as he/she is, in the context of where he/she comes from, his/her ideals, morals and culture-dictated norms. The skills involved in doing so cannot be completely acquired by reading textbooks but rather require close clinical observation and supervision as to how to elicit and label the same. What needs to be understood is that the postgraduate student in Psychiatry needs to be held by the hand, taught, watched and corrected. These years of training in Psychiatry perform the distinctive role of serving both as kinder-garten years and the highest level of learning; hence the need for intensive training cannot be under-estimated.

Rigorous, elaborate and wholesome training in Psychiatry would expand as teaching clinical skills, allocating adequate time and attention to academic activities AND providing at least a basis for research skill acquisition.

'Clinical teaching' undisputedly tops the priority list as irrespective of the career direction one is headed, what eventually matter are the skills possessed as a doctor of Psychiatry. Yes, clinical acumen grows and strengthens with practice and experience, but it would not do for the training program to quote this and take a passive stand with respect to teaching. Honing of clinical skills would start from teaching students to interview, to take a good history, to formulate and present it in a meaningful manner. Though, the sequential steps of inspection, palpation, percussion and auscultation would not apply to mental status examination in psychiatry, the value of observational and interviewing skills as a part of examination of a client need guidance and emphasis. Besides theoretical discourses on the same, these skills should be actually taught by exposing the students to regularly observe the manner of interviewing of experienced faculty. Students themselves should be encouraged to interview in the presence of faculty and seniors so as to permit essential criticism and facilitate learning. It is crucial that at this stage of learning the student is encouraged to expend time to elicit detailed histories and present exhaustive mental status examination instead of taking recourse to 3-line histories and cursory examinations.

Approach to diagnosis is an area that needs to be consistently worked on as diagnoses cannot be reduced to a sum total of diagnostic criteria. Irrespective of the faculty's own staunch theoretical beliefs it would merit the training postgraduates if they gained sufficient exposure to the various schools of thought (Behavioral, biological, psychodynamic).This would in turn allow the student to at least sport a broader perspective when attempting to understand his/her patient and his/her problems. Aarya KR : Training program in psychiatry: A trainee's viewpoint 701 Doctors who merely scribble a prescription for pills and scream 'Next!' are far from the kind of therapists a teaching program should churn out. The pertinence of non-pharmacological methods in patient management and how they stand as significant as pharmacological means should be a message that rings out loud and clear. But instead of just mindlessly chanting this slogan, actual training in this avenue is of paramount importance. 'Psychotherapy' calls for allocation of separate time and training. Starting off with clarifying that words of advice and counseling are not and cannot masquerade as psychotherapy, trainees should be persuaded to employ psychotherapeutic aid to patients wherever suitable and required. More importantly special psychotherapy forums can provide a platform for students to present their sessions so that they could be supervised and bettered.

Academic activities as a part of training in Psychiatry hardly exist in most institutions or so I've heard. But a well-organized academic program greatly enhances the value of a postgraduate program. A systematic schedule of lectures delivered by the department's faculty attempting to provide an overview of the broad areas of Psychiatric interest is the first requirement. But it would be aplaudable if Guest lectures of faculty from elsewhere in the country and if possible overseas could be organized from time – to – time to permit an exposure to varying approaches and perspectives.

Besides these didactic lectures by faculty, regular seminars and case presentations by the trainees would serve more than one purpose. Starting with providing an opportunity for an in-depth foray into the topic allotted, to a platform for learning and rehearsing skills of making formal presentations, to a means for acquiring the confidence to boldly address a knowledgeable audience, to a medium that permits discussion and exchange of diverse views on selected topics – the advantages of these academic events are multifold.

For those who are academically inclined and even otherwise, it would do well if the program were to encourage students to write, publish alongside learning and to train the student in the basic rules of the game.

Submitting an MD thesis, figures amongst the requirements of a candidate to be eligible for MD degree. But the tendency to view the thesis as something that must be merely rushed through, done with and quickly forgotten is also rampant. A reasonable approach would be one that encourages simple projects that in the process impart fundamental research skills instead of pushing the student into elaborate, over-ambitious projects that borrow heavily from his time and energy at this crucial period of learning.

Perched at the close of 2 years of learning as a PG student, I realize how indispensable it is that one is actually taught and supervised in a manner that 702 Psychiatry in India : Training & training centres a fresh undergraduate student would be and unlike the scant attention that a postgraduate student would otherwise be accorded. A program that hence strives to blend the pursuit of clinical, academic and research skills would have done its bit in ensuring that for this fascinating and challenging subject, learning is at its best!

K.R. Aarya Junior Resident Department of Psychiatry PGIMER, Chandigarh [email protected] 72 Trainee Perspectives of Psychiatry: Training at NIMHANS

Santosh K. Chaturvedi, Prabha S. Chandra, Nishanth Jayarajan, G.S. Ramkumar, Smita Manjunath, Satish Kumar Budania

ABSTRACT This article summarises the perspectives of four trainees at different levels of training, discussing their experience with the training program at NIMHANS. Such perspectives of psychiatric trainees are useful in planning the training programmes for the trainees. These views are also like a feedback on the training programme. The views and opinions of trainees and trainers differ in certain aspects of postgraduate training. Key words: Psychiatry trainees, training programmes, trainee perspectives, feedback, postgraduates.

How do psychiatry trainees evaluate their training? What elements do they value and what more are they looking for? Are there any major areas that are being missed out in the training? Is the program catering more to the students or to the convenience and interest of the teachers? How can the training program be made enriching and also focus on training PGs in basic skills of psychiatry.

In order to identify some of these aspects we invited four students at different levels of training to critically discuss their experience with the training program at NIMHANS. They were asked to focus on the following aspects

1. To what extent were your expectations met? 2. What were the areas not adequately covered? 3. What more can be done to enhance the quality? 4. What are the limitations of the training?

The views expressed here are of four trainees and may not necessarily reflect that of all the students. 704 Psychiatry in India : Training & training centres 1. A first year trainee's perspectives–

I have been a psychiatry trainee at the institute for slightly more than 6 months and have had the opportunity to attend all the Lectures, Seminars, Journal reviews, Book reviews, Case conferences, OSCEs, Role-playing, Modules, Work-shops, Group-discussions, supervised Psychotherapy sessions, feedbacks to trainees by supervisors and feedbacks to supervisors by trainees at the end of 3 months of posting. I had not expected such well planned academic programmes, well informed trainees and such involvement of trainees and consultants in the academic programmes. I am also impressed by the fact that the faculty is open to suggestions, approachable and there is not much hierarchy between first year, second year and third year residents. Some other positives have been the feedbacks to supervisors by trainees, rotation in all units to get exposure of approaches of all consultants, cultural and gender sensitivity during patient interviews, timely written and practical examinations, Objective Structured Clinical Assessment with Feedback (OSCAF), clinical audit, on stage model clinical examination/viva of exam going trainees by the consultants (which is open for all other trainees to attend), and the hi-speed internet facility in hostel.

Within a period of a month of training I felt confident in management of psychiatric emergencies & electroconvulsive therapy. Within a period of another 2 months I felt confident in making diagnosis of commonly encountered mental health problems, treatment of the same with drug dosages. After 3 months I realized that lectures by the senior professors could have been more in number because their lectures are never overloaded with information but are simple, concept making and could be grasped fully.

Adequate time is given before any departmental presentation by trainee and it is evaluated by a number of faculty members who award marks considering all aspects of a presentation. The concept of awards for the best presentations is also motivating for trainees.

Some issues of concern - Many a times the content of the Journal clubs and Seminars is just a “copy & paste” from soft text materials and the presenter reads it very fast, often omitting some of the lines. I feel, the trainees should be given a brief workshop on presentation skills; how to read a slide, make eye to eye contact with the audience, use a pointer and summarise with take home messages.

While it is understandable that there is no prescribed course or syllabus for MD curriculum and it is extensive; there could still be a minimum level which should be achieved by students. Once this minimum is achieved , a trainee may automatically extend himself/herself to more learning. Chaturvedi et al: Trainee Perspectives at NIMHANS 705 I also feel that most of the departmental seminars and the following discussions focus more on research ideas and they do not always fulfil the requirements of beginners. I expect departmental seminars on topics like, differences in ICD-10 & DSM-IV classificatory system of all disorders in a Tabular form, definitions in psychiatry, side effects of psychopharmacological agents (common to rare with exact prevalence), management of side effects of psychopharmacological agents (only the maximum evidence based treatment strategies be included), involuntary movements (overall idea, concepts and facts), scales in psychiatry – an understanding and application, neuroanatomy for psychiatry and clinical applications, book review of Strub and Black etc.

I find it extremely difficult to reproduce the definitions because I am not explained why each word in the definition was incorporated and how important it is. At this stage I also do not feel confident in the management of psychiatric disorders with co-morbidities or of side effects of pharmaceutical agents and am not confident in applying rating scales.

We have not had any interdepartmental meets for case discussions i.e. between psychiatry, neurology, neuroradiology, endocrinology. It would be useful to have such discussions for example in management of non epileptic seizures, antipsychotic induced amennorhoea or lithium induced hypothyroidism.

OSCAF is a wonderful tool however, this academic exercise is limited to a particular psychiatry unit. I feel it should be a part of academic exercises of all the units.

I realize for most of the trainees the 3 years of MD course may pass without satisfactory conceptual & factual knowledge. To overcome this, each faculty should be given a task to prepare a seminar on a topic (according to their interest); and this way all the topics should be covered. These seminars should be made with extreme caution, extreme simplicity, highlighting important facts, excluding unnecessary text and including Indian aspect also. On this scaffolding a multi-storeyed building can be made and should not be considered as “spoon feeding”.

Every trainee should also be given an opportunity to prepare a question paper and conduct a model examination for other trainees. It indirectly makes the trainee responsible to learn the subject by heart.

Many doubts or curiosities of new students are not adequately addressed. To overcome this there should be a forum or blog (owned by the institute) where any trainee from the institute can ask his doubts. The senior faculties should respond to it. 706 Psychiatry in India : Training & training centres I am still not sure how to incorporate both empathic listening and a documented detailed work up (including physical examination) in a limited time duration (i.e. 1 hour). I wish a senior resident or a consultant could demonstrate me a timely detailed work up combined with empathic listening.

Moreover, the trainee has to spend enormous time in psychoeducating the patient and relatives again and again about the disease, its course, early warning symptoms, compliance, side effects and duration of medications because it is difficult for them to remember the information. To overcome it and to save the time of trainee a printed material in regional languages should also be made available to them (which can be prepared with consensus).

2. A second year MD resident’s perspective (post DPM)

Specifically from a Diploma trainee's perspective, I have worked through this topic in a retrospective manner. I wish to recount some of my experiences after I finished DPM to see where the Diploma training had left me.

I have had the opportunity of working at two other psychiatry departments elsewhere for very brief periods of time before joining back for my MD. My Diploma training was no different in terms of quality from that of my contemporary MD trainees. In a way, the difference is only of the course duration and absence of dissertation. Working outside NIMHANS, I realised my training did ensure I was as competent as other trainees as far as history taking, observation, mental status examination, diagnostic issues and plan of management was concerned. But what strikes me as an important asset I had gained from my diploma days was the work ethic – diligence, empathy, regularity, punctuality, professionalism, a sense of priority and scientific curiosity. These qualities, perhaps, we all imbibe to variable extents from our seniors, consultants and role models. This reflects that needs of the diploma trainees are well met as also the bonuses of what the training had imparted. One area I did not feel confident to handle was consultation-liaison. This is perhaps because my training had been in a tertiary institute.

In the interviews I attended after my diploma, one question that kept coming up was if I had done a thesis. This, I now realise, is because some institutes do ask their DPM residents to do a dissertation.

A tough quandary that diploma psychiatry trainees face is where lies the way ahead. Is it private practice that one must opt for? Prospects overseas? DNB? Attempt to get an MD? Of course, it has not been as murky for a number of my colleagues. Perhaps it is a function of merely the tag of the title of Diploma. But the general opinion that floats around unqualified and perhaps unjustified is that diploma does not guarantee progressive academic careers. Chaturvedi et al: Trainee Perspectives at NIMHANS 707 Hence, it boils down to DNB or MD. Though Senior Resident/ Tutor/ Lecturer jobs are open to DPM candidates, is it the lure/greed of higher positions or more learning that pushes us to try for MD's? I can only answer that on a personal level. The two years of Diploma whet my appetite for more psychiatry, to say the least. This is also a reflection of how the training exceeded my expectations.

Coming back to do my MD, it is a welcome change to have postings in Consultation-Liaison Psychiatry. The introductory modules, especially in research methodology, ensure that all residents proceed from a common footing.

Needless to say, what I have documented is merely a personal sojourn, its generalisability can be questioned. However, it may still be representative of the large majority of diploma psychiatry trainees.

3. Perspectives of a Final year MD student

At the end of 3 years of psychiatric training my expectations have largely been met especially with regarding to training in child psychiatry. Learning about Deaddiction and geriatric psychiatry has been a bonus as it was not expected at the time of joining. The availability of internet round the clock was not expected but has become an addiction both for information and entertainment! There was, of course, the rather romantic expectation of learning psychoanalysis which remained unfulfilled! Modular teaching programs and small group discussions have become salient, though transiently I had been exposed to them in community medicine department during MBBS. Journal club programs stand out for their excellent discussions. Case discussions during consultant rounds have been the backbone of the learning process.

The general perception that lecture mode of teaching is outmoded has resulted largely from misuse or disuse of such technique by unimaginative and lazy hands. This probably has resulted in most of current teaching programs becoming student driven with the faculty taking the chairperson role. However, nothing can replace a well informed lecture by the senior faculty and hence it does have its role in the teaching program. While this aspect is being felt as a deficiency in house teaching programs, the senior faculty are often noted to generously offer such lectures in extramural PG training programs.

Thesis definitely was a learning process however but it definitely eats into the trainee's reading time as it is being done concurrently. Allotting one month exclusive for thesis during the 3 year program should not be a bad idea. Some people do also suggest that literature review alone should suffice in PG 708 Psychiatry in India : Training & training centres dissertations when separate time is not allotted because they feel asking the student to do a full research with out giving time will force them to adopt unethical practices! Regarding use of micro teaching methods such as the OSCE or OSCAF, I am not sure of the cross cultural validity of these methods. In a pluralistic multilingual society it becomes difficult for the trainee to form and to express ideas in English concurrent with the need to display interpersonal niceties. The modular programs can be preserved using a web log (blog) which will have the twin advantage of real time communication while the program is being run and as a ready reckoner for the trainee at the time of examinations. The department is expanding with ~70 trainees and ~50 staff. A twitter account of the department would be trendy and would facilitate real time communication about various academic programmes, special lectures by visiting faculty and other departments. I am happy with the clinical skills acquired especially with respect to children with mental health problems, drug and substance use, dementia. I have also developed the ability to critically appraise journal articles, present seminar topics, to work in a team and to write a research paper. Psychotherapy training, case conferences and OSCE have helped me in developing communicating skills, establishing rapport with patients and taking a non judgemental attitude.

4. A senior resident who just completed MD In India, psychiatry training at the postgraduate level is for all practical purposes the only training in psychiatry that one receives. The foundation courses present in some countries like the UK [1] are conspicuous by their absence in India, and generally a young MBBS graduate enters into post graduation in psychiatry with little guidance on what to expect. In addition to this, many colleges in India have a lack of faculty members to impart adequate training to residents. With regard to the above, I consider myself fortunate to have undergone psychiatry training which has been quite intensive and instructive in many respects. The vast number of patients which one comes to see in NIMHANS gives good exposure to a wide range of cases. The high load of patients also ensures that in time we develop skills to elicit specific points relevant to each patient without wasting much time on redundant details. The multidisciplinary approach present here also helps in understanding the roles of psychologists and psychiatric social workers for specific cases. There is also good exposure to various recent trends in psychiatry e.g.; opportunities to administer TMS sessions during our training. The psychotherapy programme Chaturvedi et al: Trainee Perspectives at NIMHANS 709 imparts training in communication skills as well as giving exposure in various types of therapies. In addition, interacting with and listening to visiting faculty from across the world gives a relative idea about facilities and practices in other places. The assessments for seminars, journal clubs and case conferences provide a framework to improve the quality of presentations. There is excellent exposure to child psychiatry and de- addiction services and some exposure to geriatric and forensic sub- specialities. The community psychiatry posting also helps in gauging the needs of people in the community. Over time one becomes sensitive to the socio-cultural aspects of psychiatric illnesses. In addition, one gets opportunities to dabble in good quality research and pursue it more seriously if inclined. Despite all these good points there are a few lacunae in the training here. The patient profile is not too representative of the general population as NIMHANS is a tertiary referral centre. Hence, we inevitably tend to miss out on the common cases which are present in the community e.g.; cases of sleep disorders and sexual dysfunction are relatively less frequently seen. This is a shortcoming especially for those who want to enter into private practice after their course. Another issue is that as the residents change units frequently, one doesn't get a longitudinal picture of the course of an illness over time. More importantly the exposure to consultation liaison psychiatry is quite minimal. In the absence of undergraduate students and interns, teaching opportunities for junior residents are also scarce. Hence in view of these lacunae one would expect some changes in the teaching programme here. More exposure to Consultation Liaison Psychiatry is essential. Also longitudinal follow ups of a few patients over the training period would help residents in improving their concepts about the course of an illness. Giving teaching opportunities to final year residents will be useful to reinforce their learning and confidence. All in all, at the end of the training one feels confident as a clinician in handling a wide range of cases as well as dealing with psychological reactions of relatives. Having worked outside for a brief period while after my post graduation, I did not feel any problems in adjusting to another setting as a good foundation had been laid.

Needs and satisfaction about supervision among post graduate psychiatry residents in India Supervision and feedback are important part of any training, and one expects that this is done systematically in all postgraduate psychiatry training centers. 710 Psychiatry in India : Training & training centres Every year in the department of psychiatry at NIMHANS, 20 post-graduate psychiatric trainees enter the mainstream course as junior residents (JR) and finish their training at the end of 3 years. There are 6 adult psychiatry units and speciality units of child psychiatry, addiction psychiatry, family psychiatry and behavioural medicine units. The rotation of JRs occurs every 3 months. In each posting, the JR is directly supervised by a senior resident (SR) and two consultants. Each SR and consultant will supervise 2-3 residents at a time. In addition, the JRs are also provided with a research supervisor (thesis guide) and a psychotherapy supervisor. The trainees are given individual feedback by the supervisors. In addition, individual assessments and feedback are given at the end of each clinical posting (3 monthly). Psychotherapy supervision occurs every fortnightly on a group basis (5 per group) for an hour or more.

Needs and satisfaction about supervision among 47 psychiatry residents in the academic year 2009-2010 were surveyed. A questionnaire to assess needs and satisfaction in areas of educational supervision, clinical supervision and personal/research supervision was used. Scoring system used was: 1- unsatisfied, 2-satisfied, and 3-excellent. Educational supervision during unit case conferences and departmental seminars were identified as most satisfying, whereas majority of residents identified supervision during external postings and exam clinics as inadequate. Clinical supervision in general was deemed adequate by most residents, but supervision regarding psychosocial management was considered inadequate. In the area of personal/research supervision, the availability of supervisors for personal/ health problems was considered the best. However, many areas of need were identified in this subsection which included the following: 1. Development of specific area of interest, 2. Involvement in leisure activities, 3. Social and administrative skills supervision and 4. Help in liaison with other disciplines.

What are the highlights and what more needs to be done?

Positive aspects of the training

1. Wide exposure to a variety of patients and large numbers 2. Well planned and regularly conducted academic program 3. Variety of teaching methods 4. Useful speciality postings- Child psychiatry, Deaddiction and Community psychiatry 5. Learning to work in a multidisciplinary team 6. Formal two way feedback methods ( student to teacher and the other way round) 7. Focus on research methods Chaturvedi et al: Trainee Perspectives at NIMHANS 711 Ways to improve the training program

1. Enhance Consultation Liaison Psychiatry training 2. Faculty lectures 3. Seminars to focus on basic aspects of psychiatry in addition to controversies and complexities 4. The need for a blog for information sharing and academic support 5. More emphasis on presentation skills, communication skills 6. Dedicated time for thesis or modifications in the thesis requirements. 7. Have more interdepartmental case conferences and meetings 8. Dissertation for DPM students

Conclusion: The perspectives of psychiatric trainees are useful in planning the training programmes for the trainees. The views are also like a feedback on the training programme. The views and opinions of trainees and trainers differ in certain aspects of postgraduate training [2]. The views expressed here are based on differing duration of exposure to the training programmes – one, two, three years and recently qualified. The trainees sent their perspectives, had second thoughts, modified, and reconsidered. It seems like an adaptation process. When they are new to the course, they expect undergraduate like teaching, ready made material [not really spoon feeding, but a plate of food !] Seeing there is no 'chalk and talk' [a phrase used by a trainee], rather self directed learning, modelling and peer teaching and learning. Views and opinions of those who trained 5, 10, or more years would also be useful, and give an idea about the long term impact and effects of the postgraduate psychiatric training at any centre. Those who were trained years ago and later working in centres overseas, often point out, difficulties in appropriate communication skills. On the other hand, they were considered as over informed, strong in arriving at diagnosis, confident in decision making, and aware of most theoretical aspects. Those working within the country expected some career counselling and more knowledge about neuropsychiatric aspects. The training, syllabus, dissertations, examinations are based on guidelines of the Medical Council of India, which also need to be reviewed and revised periodically. There is no one perfect way, and there should not be one – it would take away the charm and fun out of learning and teaching

REFERENCES

1. Javed MA, Ramji MA, Jackson R. The changing face of psychiatric training in the UK. Indian J 712 Psychiatry in India : Training & training centres Psychiatry 2010;52:60-5. 2. Murthy P, Chaturvedi SK, Rao S. Learner centred learning or teacher led teaching: a study at a psychiatric centre. Indian Journal of Psychiatry, 1996; 38, 133-6.

Santosh K. Chaturvedi Professor & Head Department of Psychiatry NIMHANS Bangalore 560029 [email protected]

Prabha S. Chandra Professor & Chairperson, Academic Programmes

Nishanth Jayarajan Senior Resident

G.S. Ramkumar Final year Junior Resident

Smita Manjunath Junior Resident

Satish Kumar Budania

1st year Junior Resident Department of Psychiatry National Institute of Mental Health & Neurosciences Bangalore, India 73 Expectations of a psychiatry resident

Anoop Raveendran

I completed my Diploma in Psychological Medicine from the Christian Medical College, Vellore in March 2007. I then worked for two years at the Department of Psychiatry at the Dr. SMCSI Medical College, Thiruvananthapuram. I joined the MD Psychiatry program at the Christian Medical College, Vellore, in March 2009. As a final year postgraduate in psychiatry, I reflect on what the training course should ideally provide us with, in order to equip us to face the variety of situations that exist outside the safety and structure of an academic institution.

Being a psychiatrist often involves a heavy demand on one's emotional resources. Many a time an individual embarks on a career in psychiatry without being aware of this fact, often influenced by myth, media and fantasy. The selection process focuses entirely on the amount the individual has read and does not assess the aptitude or potential for psychiatry. Once in the course, the student needs to be guided on how to cope with the emotional demands of the profession.

The diploma course in psychiatry is growing obsolete with the post-DPM student finding him or herself trapped between the MBBS and the MD, with few options. Diploma holders are not treated on par in hospitals and teaching institutions. There is a need to seriously consider abolishing the DPM and converting these PGs seats to MD.

The methods of assessment and evaluation in psychiatry are completely different from other specialties. As the training at the undergraduate level does not prepare one adequately for this, the new entrant often finds concepts difficult to understand and practice. Ambiguity and vagueness in conceptual issues combined with rigidity and a lack of flexibility in diagnosis leaves the post-graduate confused, with a poor sense of mastery and confidence. A special emphasis during the initial part of the training period to make the concepts in psychiatry clear and understandable would benefit postgraduates immensely. 714 Psychiatry in India : Training & training centres New students in psychiatry often neglect contextual issues and focus solely on symptom checklists, or they may make diagnoses based on personal biases rather than established guidelines. Learning to make diagnoses according to established criteria, while appreciating the context of the patient's problems is something that I wish I had learnt early on. Teachers sometimes make diagnoses on the basis of their experience; communicating their thoughts to us students and helping us understand the rationale is useful.

While we are often reminded about the importance of psychological intervention, formal training in psychotherapy is limited. A greater emphasis on this is ideal. Helping the student learn to deal with difficult and neurotic patients is essential. Often students develop an attitude of therapeutic nihilism and helplessness towards such patients, as they do not receive adequate support and guidance.

Students require adequate teaching about the principles of drug management, management of emergencies in psychiatry and an understanding of the basis of important policies in the care of the mentally ill. Periodic demonstration of the skills to translate theory into actual practice by senior consultants is helpful for students. Such demonstration and discussion will empower students.

Carrying out research, writing a paper and taking it through to publication are often seen as herculean tasks for the postgraduate, who is more comfortable in the role of clinician. More training in these areas and a familiarity with these issues is essential so that the student has the confidence and skill to critically read and evaluate published literature, as well as carry out investigations on his/her own.

As postgraduates, we are often complacent about the learning process and find it easier to passively absorb information rather than make active efforts to improve knowledge and skill. An insistence on excellence and a refusal to accept mediocrity by our teachers helps to stimulate our learning and the quest for quality. In addition, nurturing a sense of belonging in the postgraduate- to the subject, profession and institution- is something that we look up to our teachers for.

My training in the Department of Psychiatry at the Christian Medical College, Vellore has been special to me in many ways. I have learnt the importance of accepting patients in a non-judgmental and empathetic manner, as individuals with their own needs and rights. The opportunity to work with patients from a variety of language, social and cultural backgrounds helped me appreciate the relevance of culture, and to tailor therapy to suit the Raveendran: Expectations of a psychiatry resident 715 individual. Working as part of a multidisciplinary team helped me understand the essential role of colleagues from the nursing, psychology, social work and occupational therapy departments in providing holistic care to the mentally ill. The opportunity to take up responsibilities and work with large numbers of patients has given me the confidence that I will be able to care for patients with pharmacological and psychological interventions as appropriate.

I learnt many lessons while observing my seniors and over the course of time. However, formally addressing these issues early in the training program would empower and benefit postgraduates.

Anoop Raveendran Resident Department of Psychiatry Christian Medical College, Vellore 632002 India [email protected]

74 Trainee Perspectives of Psychiatry

R.J. Bishnoi

Deva Institute of Healthcare & Research Pvt. Ltd. is a major teaching hospital in private sector in this part of country. The psychiatry residency program provides educational excellence, providing access to expert educators, and exposure to a wide variety of Psychiatric care facilities. Residents can expect a broad range of both inpatient and outpatient experiences in multiple settings. This includes wide experience on the Consultation/Liaison service across various multi-specialty hospitals. Residents gain the experience and knowledge not only to pass the exams, but also to be ready for psychiatric practice and teaching.

With an emphasis on education, it provides sufficient hours of education each week. This is protected time, free from any other duties or distractions. With regular classes varying from faculties (psychiatrist & psychologists), residents are provided a wide breadth of education. In addition to education, this institute provides extensive exposure to research involving pharmacological and non-pharmacological trials, basic and advanced cognitive research projects and self initiated research projects.

I feel lucky to have Dr M R Jhanwar as a director of institute and Dr Venu Gopal Jhanwar as my mentor during my stint at this centre in religiously important city of Kashi. Wherever my career takes me as a psychiatrist I know I will be prepared thanks to my training at the Deva Institute of Healthcare & Research Pvt. Ltd., Varanasi.

R. J. Bishnoi DNB – Secondary Candidate Deva Institute of Healthcare & Research Pvt. Ltd., Varanasi. [email protected]

75 Of all the dreams- 'I chose this'

M.S. Darshan

“If you have a gift for critical conceptual reasoning, then you are certainly likely to be suited to psychiatry because in psychiatry you have to be able to deal with and explore abstract concepts and notions” – Dr. Femi Oyebode[1]

I am six months old in this speciality which I dreamt of for over 8 years. Here I pen a few words as to why I love psychiatry, what my related experiences were and what my expectations are as a postgraduate student.

To start with, my liking towards psychiatry spurred during high school, triggered by columns on mind and psychology in newspapers and magazines. What started as a liking, crystallised into a passion over a period of time. I wanted to be a doctor since school days. Though earlier this idea was mainly a result of 'thought insertion' from my parents, it was later on my own interest in psychiatry that made me take up MBBS.

I did my under-graduation from the very Medical College where I am pursuing my PG, that is JSS Medical College and Hospital, Mysore, my exposure to psychiatry department during those days had a huge impact on me. An interesting incident happened during my three weeks of clinical postings in second year MBBS. During rounds a recently admitted manic patient started spitting all of a sudden and for some unknown reason I became his primary target. Though I tried to dodge it, I wasn't successful in doing so. A couple of days following pharmacotherapy he himself came and apologized and said that he did not know what he was doing and he felt very bad when his relatives told him what had happened. He was so well behaved and such a contrasting change just after a couple of days of pharmacotherapy was fascinating. I always found the clinical discussions and cases intriguing. Psychiatry was an optional posting of 15 days during internship. Fortunately I had the opportunity to attend the postings twice and had a firsthand experience interviewing and following up psychiatric patients, attending seminars and case conferences which was a helpful exposure before I joined the same department as a post graduate. 720 Psychiatry in India : Training & training centres When I spoke of my interest in psychiatry, most of my friends showed a positive attitude and felt that treating the mentally ill and making them better is a noble deed. It probably reflects a better attitude towards the mentally ill. But, few others looked at me with disdain and asked “Are you sure? ...You want to be a shrink?” A few others tried ‘counselling’ to change my views. Though my mother had palpitations initially, as she had some 'notions' that psychiatrists have high chances of going insane, she settled down later and my parents have always been supportive of me pursuing psychiatry.

It was not only my fascination but my likings and beliefs were well synchronised with psychiatry. My interests of interacting with people and understanding human behaviour were attainable through this field. I feel that people choose to live, but when that living becomes unbearable, they become suicidal rather than continuing to live. Psychiatry solely aims at 'making living better' in various aspects of life again. I believe improving quality of life is as important as saving a life at that moment and sending home. Due to associated stigmas and the need for supportive care, mental health problems impose a heavy burden on the entire family. Treating one patient successfully will not only make him/her better but it will also have a positive cascading effect on the lives of all family members. Although there is no long list of diagnoses, the presentation of each case will be different and the excitement of eliciting history always lingers around. Also Psychiatry carries a lot of scope for research and opportunities are plenty.

I expect my training to be:

1. Learning in a well established and recognised hospital with a good exposure to a variety of cases. 2. Adequate guidance from the teaching faculty. 3. Adequate number of clinical discussions, classes and seminars. 4. Provision and support for research activities which will help improve my research skills and 5. A comfortable and friendly learning environment that helps my personal growth.

At present, there is no opportunity for getting speciality training in any of the specialized areas of psychiatry after post graduate training. If one has to get trained in areas like sexual medicine, child psychiatry, addiction psychiatry, forensic psychiatry, geriatric mental health, psychotherapy or behavioural medicine, one has to go abroad. Therefore the postgraduates may be allowed to undergo focussed training in the speciality area in the third year of the three years master's program. The centres of excellence in the country may offer Diploma/Degree programs in the speciality fields after the post graduate Darshan: Of all the dreams- 'I chose this' 721 training in psychiatry.

I feel nowhere do people touch us so close, let us in with such trust, get better may be due to pharmacotherapy or psychotherapy or both but when they do get better they are effusive with their appreciation about how it helped change their lives which I find very satisfying and motivating.

Stigma around psychiatry is common. But I believe or rather I would like to believe that compared with the olden days, it has come down significantly with improving education and economy. Fortunately it is continuing to do so. More patients are coming during the early phases of illness on their own compared to being brought in forcibly. From the notion of finding and treating the invisible, psychiatry is moving towards evidence based medicine and is fast becoming more of a first choice for PG aspirants rather than a last option. I am proud of my decision and I intend to maintain this zeal towards psychiatry for the years to come.

REFERENCES

1 http://www.usmletomd.com/mdinter views/2007/01/why-did-you-choose- psychiatry.html, obtained on 21/12/2010.

M.S. Darshan Director & Consultant Psychiatrist Prerana Hospital Mysore [email protected].

Reminiscences 76 The All India Institute of Mental Health, Bangalore in the 1950s

O. Somasundaram

After the independence of India in 1947 from the imperialists the Indian Psychiatric Society was formally inaugurated. The existing psychiatric centres were service-oriented and almost all the senior psychiatrists were trained in the UK, mostly at London (DPM of the conjoined board of the Royal College of Physicians and the University of London) and also at the Royal College of Physicians of Edinburgh. I could recall here the names of some of the superintendents of the mental hospitals of the time trained in England - L.P. Verma and R.V. Davies of Ranchi, K.C. Dube of Agra, Vidyasagar of Amritsar, Mujawar of Nagpur, N.S. Vahia, Shanti Seth, M.R. Masani and V.N. Bagadia of Bombay, R. Master of Pune, Hakeem of Ahmedabad, M.V. Govindaswamy of Bangalore, A.S. Johnson of Madras and N.N. De of Calcutta.

David Satyanand of Delhi, Ajita Chakraborty of Calcutta, D.L.N. Murthy Rao of Bangalore, Natarajan of Hyderabad, Shantakumar of Kerala and G.R. Parasuram of Madras were amongst those who studied at Edinburgh.

Gurushantappa of Bangalore and Bhaskaran of Ranchi were alumni of the McGill University of Canada.

P.K. Vyas of Jaipur did his M.S. Psychiatry in the USA.

The WHO wanted to select a suitable location to establish a centre for training of post-graduates in psychiatry, psychiatric nursing, clinical psychology and psychiatric social work for the S.E. Asian region. Dr. Willi Mayer-Gross, who had emigrated to the U.K. during the Nazi holocaust, was deputed for this purpose and he visited the mental hospitals at Madras and Bangalore . The erudition and pleasant manners of Dr. M.V. Govindaswamy and the salubrious climate were the deciding factors in locating the WHO centre here. Dr. Meyer-Gross became a Visiting Professor for the initial 3 to 4 years after inception.

I was deputed by the Health Department of the then Madras State (minus 724 Psychiatry in India : Training & training centres Andhra Pradesh) along with Dr. K.S. Bushanam to undergo postgraduate training of 2 years duration leading to the DPM, affiliated to the Mysore University. We were in the second batch of students to enter this institution. Along with those of the first batch, we were comprised of people from various states - there were 3 from Andhra Pradesh, one each from Mysore, Nagpur, Jaipur and Punjab and 2 each from West Bengal and Tamil Nadu and a very senior doctor Saleh Khan from Jakarta, Indonesia. Students were also recruited for the Diploma in Medical Psychology (DMP) a 2-year course for M.A. Psychology graduates and Diploma in Psychiatric Nursing - a one-year course for certified nurses. Training in psychiatric social work had not yet begun at that time.

It is extremely illuminating to note how one man Dr. M.V. Govindaswamy created the first centre for premier post-graduate training in mental health from an old mental hospital of a princely state. Though trained in the U.K., he was a widely-travelled person, Europe and the U.S.A. and imbibed with wide and differing aspects of the subject of mental health and served on many of the Expert Committees of Mental Health of the WHO held at Geneva in the 1950s. This was reflected in his teaching of general psychiatry and child psychiatry - his teaching reflected not only the Mapotherian ideas but also Meyerian theories. His child psychiatry leaned heavily on the Kannerian views. The classical textbook in psychiatry - Clinical Psychiatry by Willi Meyer- Gross, Eliot Slater and Martin Roth was published in 1954 and became the Bible of the institute. Dr. MVG presided over the weekly clinical meetings conducted on the Maudslean style allowing all the students to participate and express their views freely. Many a time he would invite visiting eminent foreign dignitaries in the field to give lectures. One of the notables was R.M. Varma, Senior Registrar in Neurosurgery at the Bristol Neurological Institute.

Dr. MVG was a strict disciplinarian and was very particular that the students remained in the wards during working hours and took active interest in the various activities involved. He teamed-up a psychiatry trainee with a psychologist trainee and a psychiatric nursing trainee. He insisted that the students wear a loosely-fitting full-length (reaching below the knees) white doctor's coat with full sleeves. Women trainees were forbidden to adorn themselves with flowers. He established a photography department, a full- time canteen became functional on campus so that students need not waste time going to the city. Dr. MVG organised the annual meeting of the IPS for the year 1956 at Bangalore in the hospital campus with the students participating in all the seminars.

Dr. D.L.N. Murthy Rao, the Deputy Medical Superintendent of the hospital, was an active administrator and organised the psychiatric services of the two wings, male and female, of the hospital (admissions were regulated under the Somasundaram: AIIMH, Bangalore in 1950s 725 Indian Lunacy Act of 1912) and also taught the students, taking lecture classes in organic psychiatry, addiction and mental deficiency. Dr. Murthy Rao followed his masters textbook: Textbook of Psychological Medicine by Henderson and Gillespie. He was a great enthusiast of the field of mental deficiency (he was one of the earliest pioneers in organising community services for the mentally retarded in Bangalore) and his lectures were based on Tredgold's Mental Deficiency. The maximum clinical teaching was done at his afternoon outpatient clinic which on most occasions ran on till 8 pm. Students were posted to this clinic for a month - a posting they relished.

Another Senior Medical Officer Dr. Gurushantappa, a most likeable person, kept a low profile in academic activities.

It must be remembered that the Department of Psychology of the Maharaja's College of Mysore at Mysore was one of the earliest and finest departments in the subject in India. When Dr. M.A. Gopalaswamy retired from the professorship there, he came to Bangalore and was responsible for the inception of the Department of Psychology here. He took classes in general and social psychology. Mr. Vasudeva Rao, the clinical psychologist of the hospital, was in charge of classes in mental testing and we learnt the Stanford- Binet from him. A member of the psychology department gave a special course of lectures in medical statistics - an innovation a that time. Other aspects of clinical psychology especially psychodynamic, psychoanalytic and behavioural were handled by Prof. Sen, an alumnus of the Maudsley hospital. A special mention must be made of Dr. Ramachandra Rao who took classes in various aspects of Indian psychology particularly that of the Buddhist and Sankhya schools, another innovation of our training. Dr. H. N. Murthy, a member of the psychology department, took introductory lecture classes in medical genetics, which was to play a dominant role in the following decade.

Another burgeoning subject was neurochemistry. The retired professor of chemistry from the IISC gave us the basic aspects and I'm afraid most of it went over our heads. The clinical aspects and biochemistry were ably imparted by Dr. Balakrishnan, another IISC alumnus. The earliest EEG Departent attached to a mental hospital probably functioned here and the Professor of Physics of the local Govt. college made periodic visits and reported on the EEG records (his work was ably taken up by Dr. J. Hoenig who served as a Visiting Professor here from 1955 for a couple of years).

Dr. Hoenig played a significant role in establishing clinical psychiatry in the institute. Trained in psychiatry in Germany where he had worked during the Nazi regime he had later emigrated to the UK with Dr. Meyer-Gross and other notables in the late 1930s. He was a methodical teacher and took classes in neuroanatomy and put the services of clinical psychiatry on a firm footing. 726 Psychiatry in India : Training & training centres There were regular ward rounds in both wings of the hospital with all the medical and non-medical trainees. It is not a matter of surprise that the future translator of Jaspers' General Psychopathology shed so much light on phenomenology. The EEG department came under his able guidance and he regularly reported on the EEGs along with us; his departure to the UK in 1957 was a great loss to the students. To his credit, he continued to correspond with his former students here, initially from Britain and subsequently from Canada where he'd moved to. His old students were very much pleased to receive him at the Annual Convention of the IPS held at Bombay in 1983. Dr. Gundu Rao became a full-time member of the EEG department and then underwent further training in this area at Aberdeen.

Dr. D.M. Lieberman followed Dr. Hoenig in 1957 as his successor. He organised the Insulin Coma Unit and the modified ECT for the first time here. He was a staunch believer on the physical methods of treatment and prided himself being a follower of Kalinowski - the famous author of Somatic Treatments in Psychiatry. Dr. Lieberman started a modest unit to admit neurological cases. Dr. K.S. Mani who had just then been recruited as Asst. Prof. of Neurology joined him, both of them taking classes in academic neurology.

Considering the importance of the history of psychiatry and the stature of Dr. Meyer-Gross in this field, he gave us a course of lectures at the behest of Dr. MVG. He also presided over some of the weekly clinical meetings and shared his knowledge with us.

Dr. MVG also arranged for neuroanatomy classes to be given by Prof. Appaji, the Professor of Anatomy at Mysore Medical College. Dr. Venkatta Subba Rao, the Director of Medical Services of Mysore demonstrated neurological cases at the Victoria and Bowring hospitals.

A special course in forensic psychiatry was organised to be taught by a senior retired judge of the Mysore High Court. A valuable handbook on this subject was distributed by him, which was a source of inspiration in furthering my interests in forensic psychiatry to this date.

A remarkable innovation was the introduction of literature to psychiatrists. The knowledgeable Professor of English of Maharaja's College of Mysore visited us once a week to talk about the Greek tragedies of Sophocles and Aeschylus and the Shakespearean tragedies especially Hamlet, Macbeth and King Lear. Needless to mention most of the Indian mythologies were interspersed throughout the lectures of Dr. MVG.

Dr. G.N. Reddy, the future Director of the institute, joined as a Junior Medical Officer in 1956; Dr. N.N. Wig, the future researcher and postgraduate teacher, Somasundaram: AIIMH, Bangalore in 1950s 727 came here to get trained before he proceeded to the UK for further studies. A very senior Ayurvedic psychiatric physician Dr. A.B. Dutt of Calcutta organised the ANCIPS 1960. It is very heartening to recall that 3 of us - batch-mates Deb Sikdar, J.S. Neki and myself, became presidents of the IPS.

With much pleasure I reminisce (drawing from my remote memories with omissions and commissions, probably without confabulations) on the great role played by Dr. Govindaswamy and his team in establishing the premier post-graduate training centre for . Standing on the shores of Mammallapuram in Tamil Nadu the splendours of the reign of Narasimhapallava of the 7th Century A.D. dazzles us. Similarly, at the great temple of Thanjavur we recollect the marvellous achievements of Rajaraja Chola. Upon entering the environs of the present-day NIMHANS one cannot but be amazed at the manner in which Dr. M. V. Govindaswamy built this edifice of psychiatry.

O. Somasundaram, (Old#:30) New#:17 23rd cross Street, Besant Nagar, Tamilnadu - 600 090 [email protected]

77 Post graduate training in Psychiatry in sixties - Reminiscences

A.K. Agarwal

The editor of our journal requested me to write an article on psychiatric training during our time nearly forty seven years back. I had certain misgivings, whether one could recall events of that long past, would there be errors of omission and commission due to memory distortions. Yet I thought that the task is worth attempting in spite of the reservations. I was fortunate to study in two of the best institutions of that time; All India Institute of Mental Health, Bangalore from 1963 to 1965 where I pursued DPM, and All India Institute of Medical Sciences New Delhi from 1965 to 1968 where I joined M.D. Both had a contrasting set-up, while the first was based in a Mental Hospital the second was mainly General hospital based in a tertiary care institute of excellence.

Psychiatric post graduation facilities in India in 1963

Presidential address1 of IPS in 1962 stated that D.P.M. courses have already started in Calcutta, Bangalore and Bombay and Ranchi may start it soon. M.D. Psychiatry was not available anywhere in 1962The facilities for psychiatry post graduation were very minimal at that time, yet there were not many takers as it was neither a very well known specialty nor highly financially rewarding.

After passing M.B.B.S in 1961, I started looking for the options of the places where one could do post graduation in psychiatry. One obvious choice was to go abroad either to U.S.A or U.K. Meanwhile I also started looking for psychiatric training facilities in India .I found that there was such facility in Bangalore at All India Institute of Mental Health (AIIMH).

All India Institute of Mental Health

I saw the advertisement for admission in AIIMH in a news paper and applied for the same. I was called for an interview in the directorate of Health at New Delhi. The interview venue must have been kept at Delhi so that students 730 Psychiatry in India : Training & training centres from north could conveniently attend. They asked few questions which I can hardly recall but I do remember it was a very poor performance. Yet I was selected as there were very few takers for such courses. There were only five students in DPM course in that year and seven seats were vacant.

I joined the AIIMH in January 1963.When I reached the office of the Institute I was told that the Director of the Institute breathed his last the previous day; therefore the Institute was closed for the day. Later I learned that I had missed the opportunity of meeting one of the most charismatic psychiatrists of that time Dr. D.L.N. Murthy Rao. First few months of our stay at the institute were spent in listening to fond stories of his greatness as well scientific tenor. I have described this in some detail because his passing away also meant that psychiatric teaching program of the institute took a severe beating as there were not many other teachers of that stature. Teaching staff in psychiatry were few and after the death of the director there was hardly anyone available. Two assistant professors were appointed but they were quite fresh and could not take load of teaching. We had a series of visiting teachers starting from Dr. S. S. Jairam, who provided teaching input whenever required. He was a lovable person and had great sympathy and understanding for the students. Later we were taught by Dr E.M.Hoch. She was trained in Jungian tradition. She was a very unassuming person and was great help. We had short visit from G.M Carstairs a professor from Edinburgh who was very closely connected to Indian psychiatry. All these visitors provided us with different perspectives in psychiatry.

Ultimately Dr M.R.Masani was appointed the director of the institute. He was a very outgoing person and the students could connect well with him. He was dynamically oriented. He was sacked by the government after short time. We as students could not understand the reasons for the same. But the way he informed about this event to the students is worth recalling. He took our lecture for one hour in his usual manner. At the end of the lecture he told us that this was his last lecture as his services have been terminated and his salary for three months had been sent to him by telegraphic money order. All of us were shell shocked and we asked him why did this happen. His reply was completely in harmony with his style .He said that one can not predict the behavior of women (the health minister was a woman) she must have got annoyed with him for some reason. He took his termination with grace and equanimity.

Diploma in psychological Medicine was a 26 month course divided into two parts. Part one constituted basic sciences that included neuro-anatomy, neurophysiology, Indian psychology and abnormal psychology while part two consisted of psychiatry and neurology. A.K. Agarwal: PG training in sixties 731 The structure of the program provided a very sound foundation of basic sciences as related to psychiatry. The practical involved direct administration of various tests required in psychological assessment. The greatest strength of the Institute was its multidisciplinary approach where both programs of psychiatry as well as psychology were conducted together and most lectures and conferences were attended jointly.

I have been involved with psychiatric teaching all through my active service and worked at two of the well run institutes All India Institute of Medical Sciences New Delhi and K. G's. Medical College Lucknow. I have visited most psychiatric training centers in one capacity or the other but I can still appreciate the strength of the DPM training program. All other institutes did not pay any emphasis on basic sciences. Clinical psychology training at most centers was minimal or totally missing. Neurology training was nearly nonexistent.

Psychiatry in sixties

Psychiatry in early sixties was in a transition phase. The influence of psycho- analysis was very evident both on theory and practice of psychiatry. All most all psychiatric disorders were considered to be a product of childhood psychological experiences as well as other stressors of life. Biological factors were not given much importance. Consequently right treatment was psychological and psychoanalysis was considered ideal. Though real life efficacy of psycho-analysis did raise doubts on its usefulness yet the purists felt that the lack of efficacy was a result of improper implementation of the treatment rather than the inadequacy of the theory. Most textbooks of psychiatry devoted major portion on psycho-analytic theory and practice. Every disorder had a psychoanalytic explanation for its development. Schizophrenia was thought to be a result of weakening of ego resulting in direct expression of unconscious. One therapy that was recommended for its treatment was Rosen's direct analysis.

Even treatment like Electro Convulsive Therapy was provided with psychological explanations. The post graduates were usually discussing among themselves as to which school is more suited to Indian needs and most of us preferred the eclectic option. Fortunately the AIIMH had strong influence of Meyer Gross and most our teachers in psychiatry were British trained so there was a better balance between biological versus psychological theories.

No psychiatric classification had found any acceptance by that time .Different text books described the names of illnesses according to the etiological models they followed. Meyer-gross Slater and Roth's Clinical Psychiatry was more biologically inclined and describe disorders by there names as anxiety 732 Psychiatry in India : Training & training centres disorders schizophrenia and depression while Henderson and Gillespie Text book of Psychiatry used the word reaction indicating the disease was a reaction to some psychosocial stressors.

Diagnosis-There were no research criteria for diagnosis. The only viable approach to confirm the diagnosis was independent diagnosis by two similarly trained psychiatrists. Many clinicians felt that there was no need to make a diagnosis.

Psychiatric training in the AIIMH was largely inpatient based as there were very few out patients coming to the OPD those days.

Child psychiatry was largely limited to mental retardation and associated behavioral disorders.

We mostly worked with psychotic patients as there were very few patients with neurotic disorders coming to the institute. Training program revolved around didactic lectures, case conferences and journal club. The lectures covered almost all aspects of the subject. These lectures helped most of us to develop basic knowledge of all aspects of various subjects.

The development of psychiatry at that time was very limited. There were very few drugs available .Amongst the antipsychotic chlorpromazine, thioridazine, prochlorperazine, and trifluoperazine were available. Haloperidol came soon after. Amongst the antidepressant amitriptyline and imipramine were available. MAO inhibitors were available but were not much in use.

Electrical Convulsive Treatment was considered to be a safe and useful treatment option for schizophrenia, depression and manic illnesses.

We had a very unusual teacher in the form of Dr.N.C.Surya. Few words about his approach to teaching would not be out of place. The first lecture he took was to introduce him as well as the way he would like to teach .He said that post graduates are not provided information on a platter, but they should search hard to obtain information from various sources. He told us that he would think loudly on the topic of the day, would raise certain questions and issues, would like to provide answers if possible otherwise it would be the task of the students to search for the answers. His lectures were of a very different quality where he taught us to think systematically and take nothing for granted .He changed the format of the case conferences and decided to invite local medical practioners specially those whose case was to be discussed. The chairperson of the conferences was one of the students and he would sit in the back another great innovation. He was an astute clinician and his clinics were an experience on entirely different dimension. Even as a A.K. Agarwal: PG training in sixties 733 researcher his advices were very unusual. One of the students gave him his research paper for comments before he sent it for publication. Dr Surya studied it for a couple of days and then advised the student to keep the paper in his table drawer and read it after a year. Thereafter, if he felt that the paper was fit for publication than he may proceed.

The strength of the AIIMH was a committed staff and a very committed group of students who have traveled thousands of miles to fulfill their love of psychiatry.

I shifted to All India Institute of Medical Sciences (AIIMS) New Delhi in1965 after obtaining D.P.M from Bangalore. This was entirely a new set up. This institution ran a M.D. program which was mainly OPD based. There were only ten psychiatric beds. The patients were mainly coming to a tertiary level hospital from all over the country. The head of the department at that time was Prof.D.Satyanand who was dynamically oriented and was considered near to Melanie Klein in his thinking. He had evolved a new school of analysis called total analysis. In spite of his leaning towards analysis he encouraged other approaches towards psychiatry. It being M.D. program didactic lectures were very few. The teaching was mainly through seminars, conferences and journal club. There was an active psychotherapy program with provision of personal analysis and guidance. Each student and teacher had a placard in his room which stated that psychotherapy was in progress and nobody violated the sanctity of the psychotherapy sessions. OPD had large number of posters emphasizing body mind relationship. These were the early days when psychiatry had not found great acceptance and only those joined psychiatry that had great interest in the subject and they transcended the limitations of teachers' books and expertise. Most of them emerged as leaders in psychiatry later.

REFERENCES

1. Saha, CC Presidential address Indian J.Psychiatry. Vol 4(1) 1962

Note-The author requests the indulgence of the readers as there could be some errors in the names and dates due to difficulty of recall and non availability of old text books due to paucity of time.

A.K. Agarwal Past President, Indian Psychiatric Society B104/2 Nirala Nagar, Lucknow. [email protected]

78 Changing Perspectives in Psychiatric Practice

James T. Antony In early nineteen-sixties, when this scribe joined as a post-graduate trainee at Ranchi, Psychiatry was quite different from what it is today. Its priority areas, theoretical positions and even the very philosophy prompting a medical graduate to take up psychiatry were all different. The emphasis, during clinical training used to be on early detection of disorders, as well as on making a 'psycho-dynamic formulation'. Such a formulation, which made use of every important finding about the patient, used to be the platform to launch various strategies of management. A psychiatrist's primary job was to understand more and more about his patient, in the context of their relationship. He was to gather everything about the patient's predicament, including subjective experiences. He was required, to even look for cues, which would 'reveal' the un-conscious mind, as such insights were considered to be extremely useful for understanding, the true nature of the disorder. The teaching used to be that only when patients' subjective experiences also were considered along with standard clinical signs, an early diagnosis would be possible. Besides being exposed to various dynamic schools, trainees were also taught about “Phenomenology” of Carl Jaspers. This was to empower them with a method to study subjective experiences of patients. They were also encouraged to evaluate their own subjective experiences, as an exercise to sharpen one's own sensitivity as clinicians! If for example, the task at hand was to detect or rule out a schizophrenic illness, a trainee is to ask the following questions to himself: is my rapport with the patient all right, satisfactory? Do I have a 'precox-feeling'? Is a “glass- wall” separating the patient from me? The ability, on the part of the doctor to introspect and analyze his own subjective experiences, along with that of his patient, was the one most essential quality, to become a clinical psychiatrist. All other clinical skills, including the gathering of some of those minute details from history, or eliciting some difficult-to-elicit non-tangible clinical signs, would come only 736 Psychiatry in India : Training & training centres next! When a clinician has a hunch regarding Schizophrenia, let us say, on the basis of his 'poor rapport', he is expected to keep his 'index of suspicion', deliberately high. This was to make sure that he would proceed to scan the history and conduct clinical examination, with painstaking thoroughness; and chances are he would end-up picking some subtle, but clinching signs, leading eventually, to a diagnosis of schizophrenia! Such an approach was required, to make an 'early diagnosis', which would ensure that treatment would yield the best results. Those days, the treatment approach of early schizophrenia used to be known by a special term, “total- push”! This special package, 'total-push', was an approach in therapeutics, where all available modalities of treatment were administered, in a focused, concerted and optimally vigorous manner, so that the patient would derive maximum possible benefits. Along with making 'early diagnosis' and having a 'total-push- approach” in therapeutics, another point emphasized those days was that a psychiatrist must have a 'psychotherapeutic attitude'. It was often mentioned that 'clinical acumen' in a psychiatrist was his very special ability, to reach out to patients with empathy and informed concern. In our present times, all these have changed. For the modern psychiatrist who is all the time looking for solid evidence, paying attention to subjective experiences of patients is un-fashionable! Even 'phenomenology' of Jaspers is abandoned by present-day psychiatrists! Many authorities [1] use the word giving it a different meaning, namely to denote 'symptamatology'! When it comes to treating patients vigorously, nobody seems to have even heard about the phrase, 'total-push'! And with regards to 'psychodynamic formulations', it has ceased to find a place in the case records of even prestigious training centers! Today we have many new molecules, as well as novel non-pharmacological interventions. And one could legitimately expect a better outcome for the old scourge, schizophrenia, if these were used optimally, along with traditional strategies, such as 'early diagnosis' and 'total-push'. But what is our real situation? The profession is too preoccupied about various rigid diagnostic criteria, algorithms and so on! Diagnostic manuals convey an impression that by just following them strictly, clinical practice would be hassle-free! [2]. It is as though by merely eliciting the required minimum number of criteria, from a given list, no one could make any mistakes! There is no hurry either, as the Manual has laid down a handsome duration criteria! You have all the time in the world to make your diagnosis! Antony: Changing Perspectives in Psychiatric Practice 737 In this scenario, our new-generation psychiatrists take comfort in the thought that everything is honky-dory! There is hardly any emphasis about various pit- falls that one would encounter, while eliciting a good lot of elusive signs in Clinical Psychiatry. Manuals, with their 'whip', are prompting everyone to make diagnosis with acceptable 'stability'. The teaching of Rene Descartes, “believe nothing till there is evidence to prove it”, continues to have its profound influence on the “scientist” in every new-millennium psychiatrist! And currently, with 'evidence-based-psychiatry', becoming the new 'mantra', things have only worsened! While a scientific-temper is a very desirable attribute, the problem is that in Psychiatry is that we do not always have tangible signs. After all, even most common 'symptoms' of psychiatric illnesses [or for that matter any illness!], such as 'depression' and 'anxiety' are subjective experiences of patients, not 'objective' signs! And if we are too insistent about having 'scientific evidence' or 'proof' in all our clinical work, we may miss all such common symptoms! In psychiatry many times, it is not just enough for us to fix diagnostic labels as per Manuals. For one thing, Manuals do not persuade the clinician to have enough 'sensitivity' in his clinical drill! Our reasoning power and science may not by themselves, be enough to give us the kind of insights needed to understand many complex human predicaments! Merely fixing a diagnosis does not mean anything, unless it improves our ability to understand our patients! When patients with all sorts of presentations meet a doctor, he could understand them in the true sense, only if subjective experiences are known and analyzed. And in doing so, the doctor has to be reconciled to the situation that he may sometimes, even make 'mistakes'! Even though feeble protestations are occasionally made, like “our clinical practice should consider patients' experiences” [3], in practice, nobody seems to be bothered much about subjective experiences. Everybody appears to be obsessed about avoiding mistakes, by rigidly following Manuals! In this context a motto of Akio Morita, the famous Japanese business tycoon, “do not be afraid to make a mistake; just make sure you do not make the same mistake twice” [4], seems to be quite sensible in many of our clinical situations. After all, despite keeping all senses and also 'sixth-sense' wide open, mistakes are bound to happen to any sensitive clinician! During nineteen sixties, a second important thing that a trainee-psychiatrist was required to learn was to be 'dynamically oriented' and 'psychoanalytically informed'. The ability to craft a well-knit 'psychodynamic formulation' was the bench-mark of his clinical sensitivity and diagnostic ability. Also, a psychiatrist was always required to be wedded to an idea that 738 Psychiatry in India : Training & training centres psychotherapy is the central treatment modality in his armamentarium. A further basic requirement for a well-rounded psychiatrist used to be that he must have a bio-psycho-social approach, in his clinical thinking. But all these have changed, imperceptibly, over a period of time. Today it is as though, the profession getting totally medicalized, and is going-back completely, to the 'pre-dynamic era'. With psychiatrists getting quite hardened in their biological orientation, the question that most psychiatrists have is this: “Is it necessary at all, for Psychiatry to be Dynamic?” This turn-around became pronounced, with the arrival of DSM-III, which was approved by American Psychiatric Association in 1979. [2] When this new version of classification was drafted, its authors saw to it that the theoretical underpinning of dynamic theories, which its previous version, DSM-II had, was no more there. Obviously their objective was to banish 'dynamic psychiatry' and have in its place a simple, '', which would be exactly similar to the approach in mainstream Medicine! They wanted to ensure that Psychiatry became “theory-neutral”, or rather “a- theoretical” [5]! But the point missed by the creators of DSM-III is that without a theory to back him up, a clinician would just be bewildered and shattered when the patient comes out with his most delicate and often closely guarded thoughts, feelings, fears, jealousies, humiliations, insults, pains and much else [6]! In this context, we must be conscious of the fact that human thinking process always works in a 'deterministic' manner. We humans could take-in data from the world around us, only when we are able to interconnect all materials in a kind of deterministic sequencing, on the basis of a theory. Or else we would feel threatened! Doctors in general keep away from mundane day-to-day concerns of their patients, because, during their medical education, they did not learn a 'theory' to explain those kinds of things. A psychiatrist too, when he is 'a- theoretical', would want to distance himself from his patient, like all other medical professionals. Otherwise, when the patient comes out with a whole lot of bizarre data during clinical interview the turmoil would affect the doctor as well! Here, the doctor's defense mechanisms would be working quite unconsciously, to 'rescue' him. He would simply 'be made to shut-off', and in the process, would fail to pick many subtle, non-tangible clinical signs! The doctor's 'distancing' would be reciprocated by his patient as well! He would conceal many odd ideas and feelings, which ought to come out, through the contend of his talk. The net result would be even a common disorder like Schizophrenia would be missed! Antony: Changing Perspectives in Psychiatric Practice 739 Here lies the importance of psychiatrists having a theory. Only a comprehensive theory, which has a 'Schema', like we have in psychoanalysis, would enable us to 'explain' and 'understand' whatever a patient may bring- out. Weissman has mentioned about ten psychoanalytical concepts which will continue to be useful for psychiatrists in the next century [7]. Only then, a psychiatrist could relate with his patient with warm concern and empathy that is expected of him. “Ultimately”, as Sabshin [1999] has put it succinctly, “the current absence of theory will stultify psychiatry, rather than protect it” [8]. There is a popular notion that a good theory must always have 'solid-data' to support it. This is rather naive. While having solid data to support is a good attribute, a theory needs to have many other important qualities, too. It must aid in our understanding; it must stimulate helpful questions; and, most importantly, it must open possibilities for experiments that would improve our understanding, further [9]. When the above attributes are fulfilled, even in the absence of solid data to support, a theory could be extremely useful. This precisely, is the logic behind making a plea, to continue using dynamic theories. They are very useful to practicing psychiatrists, when it comes to improving their ability to relate to, understand, and also, manage their patients, in a much better way. But what the present powerful forces want to do is to make psychiatry totally a theoretical and just one more medical specialty, perusing the narrow reductionistic track! And psychiatrists are getting somewhat dazzled or seduced by new sciences. And many are proudly displaying their 'techno- savvy-image', even while they fail to integrate the present 'knowledge surge' into the 'corpus-proper' of Psychiatry! Statements like “…although integration is necessary as an attitude, reductionism is necessary as an approach. Both must co-exist in an individual psychiatrist, as much as the branch itself ” [10] would only re-enforce reductionism further. Even from the times they were pejoratively referred to as 'alienists', psychiatrist had a legacy of combining the humanism of Philip Pinel, with inclusive approaches of Sigmund Freud and Adolf Meyer. It is this very special identity of psychiatrists, among medical professionals that is threatened today. It is as though the profession is loosing its very moorings!

Among mental health professionals, the lack of clarity on basic concepts is sometimes bewildering. We have, for example, a 'threat' from some clinical psychologists, who think that they have a professional 'territory', namely the 'Mind', which as they see it, is totally distinct from the 'area of operation' of psychiatrists. For them it is as though Mind is a material organ, which can be repaired by specially trained 'mind-mechanics', or 'clinical psychologists', who 740 Psychiatry in India : Training & training centres would pursue a reductionistic approach, just the way many 'super-specialist' doctors do! What we lose in this kind of fragmented thinking is a holistic perception of all kinds of human predicaments. What we miss in a totally biological, narrow approach to health and disease, in our patients, is an integrated understanding about human existence. Inputs from the streams of biology, psychology as well as various social sciences, is slowly disappearing from the present-day Medicare scenario. And this precisely is the reason why psychiatry must re-discover many of its traditional approaches to clinical practice. As Eric Kandel, the Nobel Prize winning researcher in biological psychiatry stated elegantly, “…we do not have an intellectually satisfactory biological understanding of any complex mental processes”. “…Psychoanalysis still represents the most coherent and intellectually satisfying view of the Mind that we have” [9]..

REFERENCES

1. Gelder M.G. et. al. [2009] New Oxford Textbook of Psychiatry: Oxford University Press. London. 2. American Psychiatric Association: diagnostic and Statistical Manuel of Mental disorders, 3rd Edition. Washington, DC. 3. Kallivayalil, R. A. [2008] “Are we over-dependent on pharmacotherapy?” Indian J Psychiatry. Jan–Mar; 50(1): 7–9. 4. Morita, A. [1986] “Made in Japan”. Dutton, New York. 5. Wallerstein R. S. [1994] Introduction; Psychodynamic Psychiatry in clinical Practice: ed. Glen Gabbard, American Psychiatric Press. Washington. 6. Glen Gabbard [1994] Psychodynamic Psychiatry in clinical Practice: ed. Glen Gabbard, American Psychiatric Press. Washington. 7. Weissman S. [1999] Psychoanalysis; Psychiatry in the New Millennium: Weissman Sidney et.al. American Psychiatric Press. Washington 8. Sabshin Melvin [1999] Psychiatry in the Twenty-first Century: New Beginnings; Psychiatry in the New Millennium: Weissman Sidney et.al. American Psychiatric Press. Washington 9. Kandel ER. [1999] Biology and the future of psychoanalysis: A new intellectual framework for psychiatry revisited. Am J Psychiatry. 156:505–24. 10. Singh A. R. [2007] The task before psychiatry today. Indian J Psychiatry. Jan–Mar; 49(1): 60–65.

James T. Anthony TC – 38 – 1375, Poothole Road, Thissur – 680004, Kerala Mob: 9847898998 [email protected] 79 Reminiscences on Psychiatric Training: Then and Now

J.W. Sabhaney

Introduction

Psychiatric training in India of yesterday is not the same as it is today. Everything has changed and so has psychiatric training. It has been modified to suit the current requirement and expectations of the present clientage. It has therefore been tailored to transform as innovative psychiatric teaching and training programmes, both for the undergraduate and post-graduate scholars. Therefore there has been a great revolution in the psychiatric teaching and training programmes in India, what it was then and what it is now.

Since I am a Medical Officer belonging to the Army Medical Corps (AMC) of the Armed Force Medical Services (AFMS), I had the good fortune of receiving psychiatric training in 1960, under the able guidance of stalwart and Father of Military Psychiatry, late Colonel Kirpal Singh and others. I will therefore narrate in this article my long personal experiences:

(i) Both in the past and present; and

(ii) Different perspectives of military and civil psychiatry, under the following three headings:

a) Teachers b) Students & Gurus c) Psychiatric training modules & methodology. a) Teachers: The teachers of yesterday were the real gurus. They had strong, stable and mature personality. They always were the “Role models”. They were elderly, experienced and more clinical oriented physicians. There was hardly any scope for post-graduate degree training in psychiatry in India, and therefore majority of the teachers during our times were diploma in psychological medical (DPM) holders, from the western universities like UK, USA, Canada, Australia & NewZealand. But, the 742 Psychiatry in India : Training & training centres

teachers of today are young, dynamic, well-read, knowledgeable and holding more than one post-graduate degree, either from India or abroad or both. They are widely travelled and therefore have greater exposure and faith in modern psychiatry.

Military psychiatrists had their limitations because of not dealing with normal population, as compared to their colleagues and counterparts in civil. But, in military set-up, in addition to regimental and disciplined approach, the structured , systemic and scientific application was equally followed as in civil. b) Students & Gurus: They were the real shishyas having full faith in their gurus. I remember as a post-graduate student while taking a class for the nurses on “ECT”, I had become nervous, where my guru, guide and renowned teacher, Doctor Colonel Kirpal Singh was present. After the class, he called me and counseled me by saying that when you speak to any audience, you are the boss and master of the subject. These young girls know nothing about ECT and you are the authority on this subject. So, there is nothing to feel nervous. It helped me in building my self-esteem and self-confidence, along with my total personality development. Because of strong and severe stigma towards psychiatry those days, the competition for selection for post-graduate scholars was not stiff or difficult. Therefore the quality of professional status and standard of post- graduates was entirely different than what it is today. These days, the competition is very tough and the selection is strictly and purely on merit on all India level. Moreover, the scholars are categorized and accordingly offered post-graduate degree MD (Psychological medicine) or DPM(Diploma in Psychological medicine) or recently DNB (Diplomate in National Board) in Psychiatry has also been introduced. The number of post-graduates those days were far and few because of non-availability of adequate number of post-graduate teachers. But these days more number of students are admitted every year, because of more availability of post- graduate teachers. The quality of psychiatric training both for the under- graduate and post-graduate scholars has tremendously improved in various government and private Medical Colleges, Institutions and Hospitals all over India. c) Psychiatric modules & methodology: Psychological medicine was considered more to be an art, rather than a science in the past. Today, it is more of a science than of course an art. It was an abstract subject in the older days. It is now a concrete and scientific discipline. Psychiatry of today is an evidence based specialty. The diagnosis in the olden days was mostly clinical and a lot of importance and emphasis was given to the detailed case-work and history taking. There were not many diagnostic Sabhaney: Psychiatric Training; then and Now 743 tools available in the past. Most of the cases diagnosed were labeled as “Schizophrenia” without any categorization, admitted to the hospital, given direct ECT and injections or tablets of chlorpromazine or Largactil. Not many psychiatric drugs were available then. Psychopharmacology was absolutely limited, counseling and psychotherapy had limited role because of psychotic behavior of patients. Recovery was slow and relapse rates were high. Rehabilitation facilities were poor. The availability of Para-medical staff like trained and qualified Clinical Psychologists, Social workers, Occupational therapists, Counsellors and Psychiatric Nurses were limited. There were no separate specialties like child and adolescent psychiatry, social psychiatry, biological psychiatry, community psychiatry, geriatric psychiatry etc. Today, the scenario is totally different. Research and drug-trial facilities are adequate. The diagnosis and treatment criteria are more specific and scientific, due to better diagnostic facilities and modern psychopharmacology. Modified ECT is only selectively prescribed, whereas direct ECT was the main method of management earlier. A full team consisting of qualified trained Psychiatrists, Clinical Psychologists, Social workers, Counsellors, Special educators, Occupational therapists and Psychiatric Nurses are available these days. In the olden days most of the patients were from urban population because the rural patients believed more in Faith-healing, Tantrics, Black-magic and there was no awareness education and information programmes about psychiatric diseases and disorders. Today, the patients are coming for treatment both from urban and rural background. The follow-up and maintenance therapy is adequate. And therefore relapse rate has come down. Stigma today is not as high as before. Rehabilitation facilities today are of very high standard and that has greatly helped the modern and sophisticated patients in their return to society and community with dignity, hope and honour because of resocialization and resettlement.

Conclusion: The journey of psychiatric training in India has made a tremendous progress and positive growth thanks to all the stalwarts and modern Psychiatrists. The best beneficiaries are the psychiatric patients because the Intelligentia of the young and dynamic psychiatrists has been matched and married with the experience and ideas of the elderly psychiatrists.

Acknowledgements:

(1) I am extremely grateful to Professor Dr. T.S. Sathyanarayana Rao, Editor, Indian Journal of Psychiatry, for his kind invitation and encouragement for writing this article.

(2) I am also obliged to Dr. P. Kasthuri, Secretary, Indian Psychiatric Society, 744 Psychiatry in India : Training & training centres

Karnataka State Branch (IPS-KSB) for her sincere interest and valuable assistance offered to me.

(3) My thanks to Mrs. Lata Jacob, Clinical Manager, MPA and Mr. Kumaran, Warden & Counsellor, MPA, Bangalore for their technical assistance.

J.W. Sabhaney MBBS, MD (Psych.Nimhans); FIPS; FIAPP; FAIPI Wing Commander AMC IAF (Retd) Senior Consultant Neuro-Psychiatrist Advisor, Psycho-analyst, Psycho Therapist & Sexologist; Bangalore (Karnataka) India 80 Psychiatric Training - Then and now

P.C. Shastri

Psychiatry as a specialty is comparatively a recent phenomenon in India. In the early years, it was primarily restricted to Mental Hospital Psychiatry. Most of these hospitals also did not have staff qualified for teaching and training in mental health. These institutions due to various restrictions including lack of adequate infrastructure and resources, were not recognised for training psychiatrists or teaching undergraduates the subject of psychiatry. There was no effective therapy that existed for mentally ill before 1940 and this resulted in custodial care and/or sedation as two prevalent forms of treatment. All these aspects played vital role in medical fraternity choosing other specialties and it is for this obvious reason that psychiatry as a subject did not attract any attention in teaching and training either by under-graduates or post- graduates.

From 1950 to 1960, significant beginnings were made resulting in considerable influence in psychiatry in general hospital and in medical colleges. This included the establishment of the earliest psychiatry departments all over the country during this period. This was the phase when psychiatry as a specialty found its desired existence and came out of mental hospitals.

The beginning however was quite primitive, as the psychiatry department was in one remote corner of the hospital with small Out-Patient-Department services. Undergraduates were not actively involved in clinical experience building and training. To add to the lack of support structure, absence of indoor patient facilities made these hospitals and colleges not recognised by any state/national bodies or even universities.

I started my undergraduate training in 1962 and we had 10 lectures in psychology and 12 lectures in psychiatry. As the hospital did not have indoor facility for mentally ill, there was no placement in wards or OPD. Most of my teachers on the subject were trained in England and some in the US with no experience on Indian scenario in mental health and its social and cultural dimensions. Our interactions with them in person, made us aware that they too had no required facilities available to them when they were students to 746 Psychiatry in India : Training & training centres train them as professionals in the field of mental health. Understanding this need and its importance, when they returned to India, they played instrumental role in establishing psychiatry departments/facilities. In Bombay University, MD in psychological medicine started only in 1965. Prior to that there was Diploma in Psychological Medicine (DPM) which was recognised by Bombay University and there was DPM by College of Physicians and Surgeons. The post-graduate teaching and training program was primarily running as a one-on-one model, hence this was also the student- teacher ratio. Post Graduation had considerable personal touch, but it lacked experience in theory and clinical exposure as part of the training.

In 1968, when I joined the Indian Psychiatric Society, my membership number was 168. Psychiatry as a specialty has evolved a lot since then and growth of psychiatrists has been exponential as today we have more than 4000 practising psychiatrists in the country. This in spite of a large number of psychiatrists from India migrating to foreign countries like US, UK, Australia, etc. Number of medical colleges and institutions (hospitals) who have developed their psychiatry departments has also grown in our country as its inclusion became mandatory for them to be recognised as centre for teaching and training. In spite of rigid principles of rewarding recognition to these institutions by national bodies, shortage of recognised teaching staff at various centres still exists with transcending implications in quality of training imparted.

Progress and development in undergraduate teaching and training structure over the last 3 decades has been both qualitative and quantitative in nature. Importance of 'Psychiatry' as a subject has been recognised by all the syllabi committees at all Universities across the country. Teaching modules of the subject at MBBS, DPM and MD levels have been periodically reviewed and revised to match with all developments and recent updates. The academic programs in psychiatry include lecture programmes scheduled round the year and periodical psychiatry exams as well as annual exams in Psychiatry as a separate subject. Intensive exposure to psychiatry as an integral subject during training also took place in occupational therapy, physiotherapy, speech therapy and dental colleges. In these paramedical specialties, role played by mental health in improving overall therapy outcomes was taught and psychiatry was given specialty status in teaching and training.

Syllabus at present has focus on basic sciences. Neuroanatomy, Neurophysiology, Neurobiochemistry, Genetics, Pharmacogenetics, Research etc. has been included in U.G. as well as P.G. teaching and training. Awareness of recent developments and research became basic to teaching and training. Recently speciality sections like Child and Adolescent Psychiatry and Geriatric Psychiatry has gained considerable attention and importance. Ethics in day to Shastri: Psychiatric Training; then and Now 747 day practice and research also has been part of regular teaching

Community Psychiatry and Child Psychiatry as important subjects in Psychiatry had a slow start in the 50's, however there has been accelerated growth since then. School mental health movement has been implemented over the years. Psychiatry in various disability groups like deaf, blind, cerebral palsy has been included and now is an integral part of the syllabi as well as supportive institutions. Infant psychiatry and development clinics have also got desired attention and evolved as essential building blocks of preventive psychiatry.

Psychiatry in India is mainly practised privately by individuals. Number of private medical colleges with teaching and training in DPM, DNB and MD has seen tremendous growth in this past decade. DNB program needs a special mention, as many hospitals in India which are not attached to teaching colleges have been running these programs successfully. Increase in number of private and public colleges/ hospitals with psychiatric program have further intensified the shortage of qualified teaching staff. Promising overseas opportunities play villainous role in taking away senior teachers from India which leads to a sudden void in teaching staff. This leaves the institutions with limited to no staff in the short term, directly affecting the under-graduate and post-graduate students.

Interest and popularity of psychiatry as a subject and its importance as a speciality is now picking up. Quiz competitions on the subject are held regularly in a large number of colleges and institutions across states, zonal and national level, sometimes being an annual event both at under-graduate and post-graduate level. Quality of this interactive and challenging platform along with involvement of the participants has been nothing but progressive and improvement is notable over the years.

Teaching and training has been part of various CMEs at city, state, zonal and national level. Here again the quality of programs held has been increasingly progressive with time showing increasing and excellent participation of post- graduate students. Number of experts and guest lecturers travelling across the country has also been steadily increasing to the extent that such CMEs are now held almost every weekend and sometimes at multiple cities simultaneously.

The Pharmaceutical industry has been taking active interest in Psychiatry for now more than a decade. Apart from National and International CME programs for post graduates, they also run intensive teaching and training programs at various zones, some of them being an annual event. There is a phenomenal growth and increase in interest in the field of neuropsychiatry from both students and industry alike. This has benefitted one and all, 748 Psychiatry in India : Training & training centres resulting in the number of teaching and training programs growing in quantity, frequency and of course quality.

Given the progress till date and the current outlook, the future and prospects of education are promising. The avenues look bright and inviting for both the under-graduate and post-graduate teaching and training program in Psychiatry.

Author is the Past President of IPS, SAARC Psychiatric Federation and Chairman WPA Section on Developing Countries, Child Psychiatry.

P.C. Shastri Professor of Psychiatry T.N. Medical College Hon. Psychiatrist B.Y.L. Nair Hospital, Mumbai [email protected]

Influential Teachers 81 Girindrasekhar Bose and Psychiatric Education

Arabinda Brahma & Gautam Bandhopadhyay

ABSTRACT

Girindrasekhar Bose was not only one of the eminent psychiatrists and psychologists of India, but also the first psychoanalyst outside the western world. He was a versatile genius and had built a strong foundation of psychology in India and the world at large. His view on the 'concept of repression' was somehow different from that of Freud's view; though Freud ultimately recognized his new theory on psychoanalysis in a positive manner. He was the founder-President of Indian Psychoanalytical Society and Lumbini Park Mental Hospital.

Key words: Girindrasekhar Bose, psychoanalysis, psychiatric education

Introduction:

Dr. Girindrasekhar Bose was born on 30th January 1886 at Darbhanga in Bihar. The Bose family had the reputation for cultural excellence. Girindrasekhar's father Chandrasekhar Bose, a very learned and pious man, was the Dewan of the Darbhanga Raj Estate. Girindrasekhar's second brother Rajsekhar Bose was a renowned writer of Bengali literature. Girindrasekhar was the youngest of the four sons and five daughters.

Amiable in his behavior, inquisitive by nature, the fair-complexioned and good- looking boy, Girindrasekhar was much liked by his school friends and teachers. He was not very studious in his early life, 750 Psychiatry in India : Training & training centres but his high intelligence and strong common sense always earned him good marks in the examination.

Academic Career:

Throughout his academic career Girindrasekhar showed his brilliance. He stood first in the first year in B.Sc exam from Presidency College of Calcutta University in 1905, passed MBBS exam in 1910 from Calcutta Medical College, got special permission for appearing in the M.Sc exam in Experimental Psychiatry in 1917 and stood first in the first class. In 1921 University of Calcutta conferred on him D.Sc Degree for his thesis entitled 'Concept of Repression' which also attracted the attention of Freud , Jones and many other foremost psychoanalysts of that time. He was asked to be on the editorial board of the International Journal of Psychoanalysis.

Professional Career:

Just after passing the M.Sc in Psychology, Bose joined at Calcutta University as a part time lecturer in abnormal psychology in 1917; twelve years after joining he took upon the charge of the department, following the persuasion of Dr. Sarvepally Radhakrishnan, who was the then President of Board of higher studies.

After taking the charge on 29th June 1929, Bose paid attention on many aspects of functioning of the department which proved his administrative brilliance and ability as a teacher. Thousands of followers of psychology blossomed through this route. Over a period of thirty years ( 1917 – 1949 ) Bose had a galaxy of students, who helped him to spread the 'Psychology movement in India' through opening of departments in different colleges and universities to teach psychology at Undergraduate and Postgraduate levels and applying psychology for solution at individual and at group level. One interesting and rarely discussed topic was that Subhash Chandra Bose (Netaji) was a student of experimental psychology for a few months (before his departure to England for ICS examination), and during this period he came under Girindrasekhar's psychoanalytic influences.[1]

Bose in Psychiatric Education:

Being the first student of psychology in India, Girindrasekhar Bose was duty bound to build a strong foundation of psychology in India and world at large. He had the vision and mission to do that job. There are many examples which prove his multi-dimensional contributions regarding this. During his leadership in the psychology department of Calcutta University there were several new approaches, which include – Brahma & Bandhopadhyay: Girindrasekhar Bose and Psychiatric Education 751 a. Modernization of post graduate syllabus b. Introduction of psychology as a subject at the undergraduate level c. Making psychology as a subject of study in faculty of Science at Calcutta university d. Introduction of Ph. D programme in psychology.

In the revision of Postgraduate syllabus Bose introduced one elective paper. Newer branches of Psychology, Like Educational Psychology, Industrial Psychology, Social Psychology and Indian Psychology came through this route. New introduction of dissertation paper helped students to be acquainted with methodology of research.

Besides lecturing in the class, Bose also spent many hours in laboratory to devise apparatus and conducting research. Sand-Motor and exposure apparatus, Big Muscle Ergo-graph, Group Pass along test, Group Matching test and Dotting test are few examples of Bose's innovative ideas.

In fact, Applied Psychology section would not have gained a footing in Calcutta University without support of Girindrasekhar Bose. He made arrangements for clinical examination of the abnormal and retarded children along with the vocational guidance for normal ones.

Bose in Psychiatric Social Work:

Bose held the view that a psychologist should work in social field for the benefit of the society at large. He persuaded the authority of Carmichael Medical College (now, R.G. Kar Medical College) to start a psychiatric outdoor clinic in the year 1933, which was also the first of its kind in the whole of Asia. Later, he proceeded to start a non-government mental hospital with 3 beds in Calcutta in 1940, known as 'Lumbini Park Mental Hospital'. It gradually grew into an 80 bed hospital and became a strong platform for research work and practical training for budding psychologists, psychoanalysts and psychiatrists.

He also started a small school named 'Bodhayana' in 1949 for educating normal and abnormal children on Psychoanalytical principles. In this connection a residential home for mentally retarded children was established in 1951, known as 'Bodhipith'.

Establishment of Indian Psychoanalytical Society:

Girindrasekhar Bose was not only one of the eminent psychiatrists and psychologists but also the father of psychoanalysis in India. Bose's innovative ideas and foresight are evident from the establishments of different 752 Psychiatry in India : Training & training centres organizations for different purpose. Indian Psychoanalytical Society (1922), Indian Association for Mental Hygiene (1928), Indian Psychoanalytical Institute (1936) etc. were few such examples. The Indian Psychoanalytical Society was accepted as a constituent member of the International Psychoanalytical Association since its inception. In appreciation of Bose's original contribution to psychoanalysis Sigmund Freud provided direct patronage and support for the affiliation of Indian Psychoanalytical Society, the first of its kind in entire Asia. The Indian Psychoanalytical Institute, the teaching wing of the society was established to train up psychoanalysts and psychologists. The Institute is still functioning at 14 Parsi Bagan Lane, Kolkata -700009 and provides training in various categories of Health Professional including that of psychiatry. It also provides Postgraduate Training & Research in Psychiatry and Psychology.

View of Bose and Freud in Psychoanalysis:

As an academic psychologist Bose's view was a bit different from that of Freud's view. In his D.Sc. thesis, entitled 'The concept of repression' Bose put forwarded a new theory on Psychoanalysis and ultimately Freud commented on this in a positive way - “The contradictions within our current psychoanalytic theory are many and deep-going, and I reproach myself for not having given attention to your ideas before”. Unfortunately Bose's important concept on 'Opposite wish' is neglected even today. [2]

Bose a versatile genius:

Bose's academic brilliance went beyond the field of mainstream Psychology which is evident from his list of publications. Purana Prabesh, Patanjali's Yoga Sutra, Bhagwad Gita, Andhra Chronology indicate his vast knowledge and also extended psychoanalytic field in contemporary literature.

REFERENCES

1. Dev M. Girindrasekhar Bose's glowing brilliance in the realm of Psychology. Psychologic Research J 2003; 27 (1&2). 2. Mallik A. Bose - The forgotten genius in Psychology. Bengal J Psychiat 2008; 15 (1).

Arabinda Brahma Gautam Bandhopadhyay 14, Parsi Bagan Lane Kolkata 700009, India [email protected] 82 Prof. Narendra Nath Wig - a man ahead of his time

R. Srinivasa Murthy

ABSTRACT

Indian psychiatrists have made important contributions to the development of the various aspects of psychiatry in the country and to international psychiatry. Prof. Wig has played a pivotal role in a number developments in India and other developing countries. His initiatives led to the inclusion of acute psychoses in the international classification. The studies of course and outcome of schizophrenia, obsessive compulsive disorder, hysteria increased the understanding of these disorders. He made it his mission to make general hospital psychiatry as centres for mental health care, training of professionals and research. The leadership provided by him in the area of community mental health and the National Mental Health Programme has changed the service scenario in the country. Studies of psychiatric aspects of family planning provided support to public health programmes of the country.He addressed the need for development of the psychological assessment tools for use in India; the PGI Health Questionnaire and PGI Memory Scale are important national level contributions. His understanding and interpretation of religion and culture as applicable to mental health was special. He also recognised the importance of public mental health education and continuously shared information through mass media. His contributions to international mental health is widely respected by the mental health community. His thoughts, choice of areas for research and public health action were ahead of his time.

Key words: Psychiatric classification, phenomenology, general hospital psychiatric unit, family planning, community mental health, National Mental Health Programme, psychological tests, drug dependence, religion and mental health, public mental health education, developing countries, suicide. 754 Psychiatry in India : Training & training centres

Introduction

Six decades of psychiatry from the 1950 to 2010, represents the history of Indian psychiatry in Independent India. Starting with a handful of trained professionals and almost no centre for training of mental health professionals and very limited mental health services, six decades back, now the country has a National Mental Health Programme formulated in 1982, a revised Mental Health Act in 1987, Persons with Disabilities Act in 1995, National Trust Act in 1999,improvement of mental hospitals, a vibrant private sector psychiatry and wide range of voluntary organisations working with mental health issues. This point in time allows us to review the developments and one of the important personalities who contributed to the developments and guided the profession. In this developing story of the development of psychiatry in India, Prof. Wig has played a pivotal role. The present attempt is to present the highlights of his career and review his professional contributions.

Career

Prof. Wig was born on October 1,1930, in undivided India, in what is now Pakistan. He completed his undergraduate and postgraduate medical education (medicine) from Lucknow. Following this, he trained in psychiatry at a number of centres in U.K. and India. Following this, he started the Department of Psychiatry at the Postgraduate Institute of Medical Education and Research, Chandigarh in 1963. In a few years the Department became one of the leading centres of psychiatry in India. In 1976, the Department got international recognition as WHO Collaborating Centre for Training and Research in Mental Health. In 1980, Professor Wig moved to All India Institute of Medical Sciences, New Delhi, as Professor and Head of the Department. In 1984, he joined World Health Organisation as the Regional Advisor for Mental Health and remained at Alexandria, Egypt, till 1992. In this capacity, he was responsible for developing mental health programmes in 22 countries, from Pakistan to Morocco in the Middle East and North Africa. Following retirement he devoted part of his time to provide free psychiatric care at the Lajpat Bhavan, Chandigarh and towards public mental health education. It is typical of him to choose to address the unmet needs of the mentally ill persons of Chandigarh, by providing voluntary services to this population. It is a recognition of national and international contributions that the Royal College of Psychiatrists conferred on him the unique honour of the Fellowship of the College. He is the first Indian psychiatrist to receive this honour. He has received a number of national and international awards for his professional contributions.

Reviewing the professional contributions of Prof. Wig is a challenging task. Murthy: N.N. Wig - a man ahead of his time 755

His research contributions are significant in a wide range of subjects (from classification, phenomenology, general hospital psychiatry, family planning, community psychiatry, drug dependence, psychological toll development, religion and mental health and public mental health education). He has published more than 250 articles/chapters in books/books and contributed to major breakthroughs in mental health. About 10 years back, on his completing 70 years, while editing the book of essays in his honour, I was impressed both by his contributions as well as the pioneering nature of many of his initiatives. Over two dozen contributors, reviewed his contributions against the background of the national and international developments and recognised his innovative approach in research and mental health service development in India and other developing countries, as his most important and lasting contributions.[1]

Learning from routine work

One of the unique aspect of Prof.Wig’s approach to research is, what I would like to call as, ‘learning from the reality of day to day work’. He believed that much can be learned from examining the routine clinic work. This reflected in the annual review of the case records in the Department of Psychiatry, Postgraduate Institute of Medical Education and Research (PGIMER) Chandigarh. This annual effort, reviewing of the analysis of the records of different services of the department, provided both students and staff, an opportunity to learn from simple analysis as well as to take decisions on data of the day to day work. This approach is evident in many of his publications throughout his career and even after retirement [2-14]. I can recall a number of service initiatives that came up from this annual review and analysis of routine data. For example, the analysis of two years data [8] laid the foundation for reaching out to the community, based on the finding of significant drop- outs from the outpatient services. Another was to reserve one day a week for follow up of the patients. Another aspect of his approach is to periodically review the field of interest for trends [7,13,14].

Psychiatric Classification

The area of work in which Prof. Wig has been a pioneer and consistently contributed is the area of ‘Psychiatric Classification and Phenomenology’. The choice of both of these areas is important to understand the characteristics of mental disorders as they occur in India; his concept was way ahead of the thinking of the other professionals of the time. He recognised that for building Indian psychiatry, there is need for examining the way mental disorders express on the course of the disorders and their outcome over time. Further, he believed that the international classification of mental disorders can be influenced by these efforts. 756 Psychiatry in India : Training & training centres

His first article, along with Prof. Gurmeet Singh, in this area was in 1967, ‘A proposed classification of psychiatric disorders for use in India’[15]. In this article they noted: “ In the present state of knowledge it is not possible to have one common and universal classification for the simple reason that we do not possess enough knowledge about the aetiology of mental illness. Transcultural variations in symptomatology of psychiatric disorders is now well known”. This article is important for two reasons. Firstly, the attempt to share the Indian approach to classification of mental disorders. Secondly, this was a serious effort to influence the categories to be included in the international classification of psychiatric disorders. It is remarkable that Wig and Singh [15] presented an Indian psychiatric classification, calling the attention to psychiatric conditions like hysterical psychosis [16]. Prof. Wig continued this interest in influencing international psychiatry over the next four decades. In the area of influencing international classification, the example of acute psychosis stands out as very significant. They noted “acute psychosis of uncertain etiology as one of the main innovation of our classification of psychiatric disorders” . In the ICD-8 and earlier classifications, there was no direct recognition of acute psychosis as a separate clinical entity. They were either classified as reactive psychosis or as other psychoses. It is the persistent efforts of Indian psychiatrists [26], and the generation of research data [17-25] to support the separate clinic entity that led to the inclusion of acute psychosis as a separate category in the international classification. Prof. Wig has been part of the psychiatric classification efforts nationally and internationally during the last 40 years. He was an important part of the ICD-9 and ICD-10 revisions of ICD system of World Health Organisation. In a way he has been the Indian and developing country voice in the psychiatric classification efforts at the international level[27-36] (Box 1). He considered that ‘good research work done in developing countries can provide a framework for better classification than available at present’ [36] Box1: Short comings of current classificatory systems [36] 1. Shortcomings related to cultural differences(eg.somatic expressions, differential distribution of personality disorders anorexia nervosa, sexual disorders) 2. Shortcomings on health service grounds( eg. mental health care at the level of primary care, classification for use by non-specialist care providers) 3. Shortcomings on cultural grounds(diffuse boundaries of disorders) Murthy: N.N. Wig - a man ahead of his time 757

Understanding mental disorders

The other side of the coin of classification was his interest and contribution in the area of phenomenology. At the Department of Psychiatry in 1970s, the staff and students were engaged in a historic effort to understand the nature of mental disorders in India [16]. The long term follow up study of Dr. Kulhara on schizophrenia [37] was the second study to examine the differing course and outcome of schizophrenia in developing countries, reaffirming the better outcome of schizophrenia in a developing country. Similar was the study of obsessional neurosis by Dr. Salman Akthar [39-41]. This study suggesting a new approach to the classification of obsessions and compulsions received international recognition. There were other follow up studies of hysteria [42] and protein calorie malnutrition[43]

He continued his interest in describing the nature of mental disorders, by leading the ICMR multi-centric collaborative studies in India . The two most important national studies are the ‘Factors associated with the course and outcome of schizophrenia[17, 44-46] and ‘Onset of acute psychotic states in India: a study of socio-demographic, seasonal and biological factors’[17]. The schizophrenia study provided further support to the earlier international finding of a better outcome of schizophrenia in developing countries. More importantly, this study along with that of acute psychosis established the methodology and mechanisms for collaborative studies across different centres in the country.

His collaboration with international researchers is equally important. Notable of this collaboration are the studies of acute psychosis[18-25] and studies of the role of expressed emotion in schizophrenia[47-49].This set of publications demonstrated that there are lower levels of expressed emotions as well as the distribution of the components of expressed emotion is different in India as compared to European centres.

‘56% of Chandigarh relatives made no critical comments at all, compared with 29% of Aarhus relatives and 28% of British relatives. While 16% of the British relatives scored 15 or more, no Chandigarh relative made more than 14 critical comments. The mean number of critical comments made by urban relatives was 2.42 compared with only 0.58 for rural relatives, as compared to 8.4 for British sample. In the Indian sample warmth is likely to be associated with high criticism as with low criticism, whereas in the English and Danish samples warmth is much more likely to accompany low criticism. The proportion of families categorised as high-EE was 54% in English and Danish samples as compared to 30% in urban and 8% in the rural samples... During the one year follow-up of the above group of patients at Chandigarh, only 14% had a relapse, as compared to 29% in the British sample. The same association between the individual components of EE and relapse in previous Anglo-American studies 758 Psychiatry in India : Training & training centres was found in Chandigarh, but only the association between hostility and relapse was statistically significant. The overall findings of this set of cross- cultural comparison of EE studies are that (i) there were far fewer critical comments made by Indian families than by British relatives and within the Indian families’ rural relatives were significantly less critical than urban relatives, (ii) Over involvement was virtually absent in the Indian sample, (iii) city dwellers show a shift towards western patterns of EE, (iv) in the west hostility is closely linked with critical comments, but in Chandigarh, relatives expressed hostility at relatively low level of criticism; and (v) the relationship between critical comments and warmth was different in the Indian sample. Western relatives are unlikely to express warmth if they are highly critical, while Chandigarh relatives can often be warm and critical at the same time”[47- 49]

This set of research studies provided support to the better prognosis of schizophrenia.

Prof. Wig stimulated research in phenomenology among his students like Dr. A. Kala[50,51] who studied the content of delusions manifested by Indian paranoid patients and the role of social factors on delusional elaboration. One of his important contribution is the description and categorisation of sexual problem in young people, which he named as ‘Dhat Syndrome’ [52,53.54] The problems of translation of psychiatric interview tools developed in western countries and the need for adaptation was an area of continuing interest to him. An example of this is the “Hindi version of present state examination: Problems of translation and application in Indian setting[55]”. This effort demonstrated the absence of certain concepts (eg: brooding), the need for modification of certain terms during translation. The other systematic efforts to develop psychological tools for use in India is considered elsewhere.

General hospital psychiatry Units (GHPU)

The setting up of one of the early units of general hospital psychiatry(GHPU) in the country was his passion[56]. He viewed the movement of psychiatry outside the confines of the mental hospitals as essential for the development of mental health services in the country. He demonstrated the value of the GHPU in a number ways. First of these is the feasibility of providing mental health care in a general hospital setting and the characteristics of the patients seeking care and their treatment utilisation patterns [57-66], demonstrated by him. Secondly, he demonstrated the importance of psychiatry in medicine and surgery through research in matters of body and mind. An illustration of this was his long collaboration with Prof. P. L. Wahi, in relation to cardiology, examined the psychiatric symptoms following mitral surgery, measures of Murthy: N.N. Wig - a man ahead of his time 759 neuroticism and prediction of psychiatric disturbances in patients awaiting cardiac surgery; disturbance of body image in patients awaiting surgery, and problems of rehabilitation in patients undergoing cardiac surgery[67-69]. He collaborated with Prof. Chugh of nephrology to understand the psychiatric aspects of hemodialysis and chronic uremia[70,71]. There was active collaboration with Prof. Chopra of Neurology on cerebral cysticercosis presenting in a psychiatric clinic [72] and other departments[73,74]. Following his move to AIIMS, New Delhi, he continued research on issues of the prevalence of mental disorders in general medical wards and the different aspects of psychiatric problems in emergency room[75-83]. The monthly joint case conferences with the departments of medicine and neurology were an excellent demonstration of the importance of the collaborative effort and recognition of the integrated approach to health issues.

There is one area in which Prof. Wig did not get directly involved, namely the mental hospital psychiatry. During the last 50 years, there have been many issues relating to the mental hospitals and human rights of the mentally ill persons, starting with the scandals of Trivandrum, Ranchi, Pune and Shahadra mental hospitals, to the initiatives of the National Human Rights Commission reviews of mental hospitals in 1998 and 2009. It is significant that Prof. Wig, a leader of a number of mental health care initiatives was not directly involved with them, possibly because of his exclusive experience in general hospital psychiatry units at Lucknow, Chandigarh and New Delhi. His insight in this area could have been important to the country.

Family planning

In the late 1960’s and early years of 1970’s family planning was an important national level public health priority[84,85]. Prof. Wig was one of the limited number of psychiatrists who recognised the importance of the mental health aspects of family planning in India. Working with colleagues like Prof. P.K. Devi and Prof. A.K. Gupta (another illustration of his collaborative approach to mental health issues) he initiated a series of studies in this area relating to the impact of family planning measures like psychosomatic symptoms following male sterilization[86-88], prospective study of psychiatric and menstrual disturbances following tubal ligation, usefulness of preoperative assessment in the prediction of psychiatric disturbances following tubal ligation, perspective study of psychiatric and menstrual disturbances following tubal ligation, comparative study of rural and urban population undergoing tubal ligation[89-93] and psychological sequelae of medical termination of pregnancy; why women drop out of a medical termination of pregnancy clinic?[94,95]. He also addressed the larger issues of women and mental health [96-101]. One of the important observations Prof. Wig offered for the understanding of the psychological sequelae of family planning measures was the model similar to 760 Psychiatry in India : Training & training centres grief. It is unfortunate that this body of work, especially relevant to India, has not continued after 1980 and no other centre has taken up this work. One of the reasons could be the negative impact as a result of the political controversies of the late 1970’s (during emergency) about all family planning measures in the country.

Community Mental Health

The most important contribution of Prof. Wig is the leadership he has provided for community mental health movement in India and other developing countries. This contribution is important as it was the most important need of the country in the 1970’s, as it occurred at a time in India when there were only about 500 psychiatrists and it required taking professional positions often not supported by others in the profession. It is significant to recall that one of his first papers in 1959 was titled ‘Problems of Mental Health in India’[102] and his setting up of the department of psychiatry at the newly coming PGIMER, Chandigarh was reflection of his belief of taking psychiatry to the people[56]. In this area, the thesis of Dr.B.C.Khanna[8] on the two year analysis of the patients seen in the department laid the foundation. This research, as noted earlier, illustrated Prof.Wig’s approach to ‘learning from the data’. The findings of the analysis was multifold. The one I want to refer to, relevant to the current context, is the observation of the large numbers of patients not fully utilizing the treatment from the outpatient services. This study of Dr.Khanna was followed by a small series of focussed studies about characteristics of patients and their treatment utilization [103-105] and the general public attitude towards mental disorders and psychiatric treatment [106-109]. Following these studies, which were small in nature but significant, most professionals would have been satisfied with their work and considered the issues of ‘drop-out’ as not important. In fact, I still recall, the way some of the senior psychiatrists called it the ‘Chandigarh syndrome’ when I presented the first paper at the Trivandrum conference in 1976 and claimed they have no such drop out problems at their centres. However, in the coming years studies from Bangalore and other centres showed that this is a problem in all of the psychiatric centres.

What followed is a remarkable development of interest in India and other developing countries. Coincidentally, Chandigarh was one of the 7 centres of the WHO multicentric project ‘Strategies For Extending Mental health Care’[1975-1982]. Prof. Wig led the team to a series of efforts to understand the needs of the mentally ill persons in the rural areas and measures to address the unmet mental health needs in the rural population. The setting up of a rural psychiatric clinic followed by village level surveys to understand the unmet psychiatric needs of the rural population led to the realisation that the way to provide mental health care to the rural population is through Murthy: N.N. Wig - a man ahead of his time 761 integration of mental health care with primary health care [111-114].

The WHO study, using a research framework, provided evidence for the integration of mental health care with primary health care[115-127]. This study used the baseline studies-intervention –repeat baseline studies model . The variables were (i) the knowledge of health personnel, (ii) the screening of general health clinic patients for mental disorders and (iii) community attitude to mental disorders. The need for simplification of the mental health care resulted in training programmes for the general practitioners [117, 128] and the first mental health manual for the primary health care personnel [125].

It is significant that this body of research, along with that from NIMHANS, Bangalore under the leadership of Prof.R.L.Kapur [129-132] contributed to the formulation of the NMHP (National Mental Health Programme) in August 1982[133]. The formulation of the NMHP is worth recalling in detail for its historical relevance as well as to illustrate Prof. Wig’s leadership qualities. Prof. Wig had moved to AIIMS, New Delhi in 1980. He had led the community mental health initiative at PGI Chandigarh during 1975-1980. There was a parallel initiative by Prof. Kapur and his team at National Institute of Mental Health and Neuroscience (NIMHANS) Bangalore. At the country level, there was recognition of need for the movement to receive a national level recognition. Thus started the movement for the same. Prof. Wig, Prof. B.B. Sethi of Lucknow, Prof. R.L. Kapur of Bangalore, Prof. A. Venkoba Rao of Madurai, Prof. Pande of Ranchi, Prof. S.D. Sharma of Ranchi, Dr. H.L. Sell of Regional Office of WHO-SEARO, New Delhi, met on a number of occasions and drafted the NMHP. Prof. Wig organised a national level meeting at New Delhi, probably one of the most challenging one (July 20-21,1982). 68 professionals from different parts of India were present to discuss the draft document . There were war clouds about the inappropriateness of the move to deprofessionalise mental health care, as it meant giving responsibility of mental health care to non-specialists. I recall one of the most dramatic comments in the meeting by Prof. K.C. Dube, of Agra, “We will fly by helicopters to see each and every mentally ill, rather than allow the non- specialists to treat them”. The second meeting of 30 professionals reviewed the draft document and finalised the same on August 2,1982. Following the two tumultuous meetings, there was less than a month for the Central Council of Health and Family Welfare (CCH&FW) meeting (August 18- 20,,1982). The challenge was to include the NMHP in the agenda. In the formulation of the NMHP, one image that is etched in my mind is that of Prof. D.B. Bisht, then DGHS, dictating the summary of the NMHP without a break over half an hour. It was a brilliant effort. The other incident that I heard from Prof. Wig and Prof. Sethi was how they went to the house of then Health Secretary Mr. Siddhu and literally woke him up in his night clothes, to urge him to include the NMHP in the CCH&FW agenda! It is a historical fact that the 762 Psychiatry in India : Training & training centres CCH&FW did debate and recommend the NMHP as follows: “Mental health must form an integral part of the total health programme and as such should be included in all national policies and programmes in the field of Health, Education and Social Welfare. Realising the importance of mental health in the course curriculae for various levels of health professionals, suitable action should be taken in consultation with the appropriate authorities to strengthen the Mental Health Education components. While appreciating the efforts of the Central Government in pursuing legislative action on Mental Health Bill, the joint Conference expressed its earnestness to see that the bill takes a legal shape at the earliest.”.The formulation of the NMHP, the passion with which Prof.Wig pursued the same will be his most enduring legacy.

Prof. Wig continued his interest in this area following his move to AIIMS, New Delhi addressing the problem of mental disorders in an urban slum and its implications for mental health care at the level of primary health care, assessment of functioning of non-psychiatric physicians in the management of psychiatric emergencies and a manual for primary health care physicians [134-135].

When he moved to work with WHO as Regional Advisor on Mental Health at the Eastern Mediterranean Regional office, in 1984, he carried this mission to 22 countries of the Middle East (from Pakistan to Morocco). He has contributed richly with technical and administrative support to the development of community mental health in Pakistan[136,137] and school mental health programmes in Egypt [138,139].

I have had the privilege of being associated with many of the above initiatives of 1975-1980 period. His practical service oriented approach can be understood by the urban initiative in late 1970s. One of the pharmaceutical companies approached Prof. Wig, 1978, to carry out an open study of the first long acting injectable antipsychotic to be introduced in the country. What happened was typical of Prof. Wig’s approach. He persuaded the company to carry out the study using a psychiatric social worker and psychiatric nurse to provide longitudinal and continuous care. Ms. Suman Chandra and Sr. Baldev Saharan worked with me to develop what was one of the first home care programme for the persons with schizophrenic illness[139].

He has written extensively about the need and approaches to organising mental health care in India and developing countries on ‘rational treatment in psychiatry: perspective on psychiatric treatment by level of care’, ‘evaluation of the progress in mental health in India since independence’, ‘development of regional and National Mental Health Programmes’ [140-148]. He continues to share his thoughts, as in his article ‘THE TRIBUNE 2009’ on the occasion of World Mental health day(Mental health care-need to expand the Murthy: N.N. Wig - a man ahead of his time 763 reach). His vision for mental health India was expressed succinctly in a number of his papers and orations.

The essence of his thoughts are presented in Box 2:

Box 2: Vision of Mental Health Psychiatry in India by the year 2020 [148]

1. To make the benefits of modern psychiatry available to all sections of the population, rich and poor, urban and rural, men and women.

2. To combine both the biomedical and psychosocial approaches in psychiatric practice.

3. To effectively utilize emerging technologies to solve our national problems.

4. To make psychiatry more relevant for Indian cultural needs.

5. To keep a balance between psychiatric and physical health.

The current state of NMHP [149] with extensive coverage of the district mental health programme, measures to increase the human resources for mental health care, school mental health programmes, suicide prevention. Massive increase in the funding testify to the vision of Prof. Wig who contributed to the movement.

Psychological assessment tools

The psychiatry of the 1970’s and 80’s, the beginning phase of Prof. Wig was very different from the current psychiatry. At that time nationally there were very limited number of psychological assessment tools and it was also the period of the launch of the General Health Questionnaire by Prof. David Goldberg which was making waves in the psychiatric research circles. Prof. Wig recognised the need to develop Indian tools for psychological evaluation. The team of Dr. S.K. Verma, Dr. Dwarka Pershad and later Dr. D.K. Menon under the leadership of Prof. Wig filled this need with nearly two decades of efforts. The initial efforts were to adapt the international tools like the CMI, EPI. This was followed by the development of Indian tool to screen general population, general medical patients and for use in psychiatric patients. They also developed a tool for testing memory, a frequent need in a general hospital psychiatry setting. There were also other efforts at examining a number of other psychological dimensions for testing purposes.[150-168] Looking at this area of research effort, the positive outcome is the contribution to Indianisation of the psychological testing. However, only a few of them have reached the level of changing the psychological testing in 764 Psychiatry in India : Training & training centres the country.

Drug Dependence

Cannabis use in North India, particularly in Punjab state was widely prevalent as part of the religious and cultural practices of the community. This situation provided a natural setting to understand the psychiatric aspects of cannabis use. In the 1970’s, there was increased interest in the cannabis related health problems at an international level. A series of studies addressed this issue in the form of studies on the psychological effects of long term cannabis use in India, patterns of long term heavy cannabis use and its effects on cognitive functions, psychological correlates of long-term heavy cannabis use, why people take cannabis and the motivation of chronic cannabis users.[168-173]. There were overview reports of drug abuse in students and its relevance to the country [174,175]. During the last 30 years, every time I read about the continuing interest in various aspects of cannabis and psychiatric disorders, I cannot help feeling that PGI lost a unique opportunity to contribute to this area of research and take leadership in this area.

Religion and Mental Health

It is almost a given that nearly every Indian leader in psychiatry has contributed to the understanding of religion, culture and mental health. Notable are Prof. N.C. Surya, Prof. Satynand, Prof. A. Venkoba Rao, Prof. J. S. Neki, Prof. O. Somasundaram, Prof.A.Verghese, Prof. Ajita Cjhakraborthy, Prof. V.K. Varma, [176] reflecting both the pride of Indian culture and the richness of the mental health concepts of India. Prof.Wig wrote his first paper in 1971 on ‘the influence of religion on mental illness in India’[177]. He revisited this area by extensive writings after 20 years. His important papers in this field are ‘ Indian concepts of mental health and their impact on care of the mentally ill’ and ‘mental health and spiritual values’[177-180]. This area continues to be his special area of interest, is reflected in his interpretation of ageing in general(Why be afraid of ageing?) and his interpretation of ‘Vanaprastha’ in particular (relevance of vanaprastha ashram in modern times). The last of his articles in this area, is one of my favourite articles of Prof. Wig, as it not only presents Indian concepts but also interprets the concepts to the modern day, a special characteristic Prof. Wig. I have shared this article with hundreds of people, as part of talking to them about mental health and old age. He identifies the ageing process as ‘life has to be lived now in a detached and simple way’ and identifies four practical ways of practicing it (Box 3). Murthy: N.N. Wig - a man ahead of his time 765 Box 3: Application of Vanaprastha concept to modern life (181):

1. Voluntarily withdraw yourself from routine rush of life and try to live close to nature

2. Deliberately live a simple life. Do not try to increase your resources to meet your needs but reduce your needs to meet the resources available

3. It is time now to pay back your debt to the society and contribute to its welfare

4. Pursuit of the Spiritual health

Public mental health education

Public mental health education has been an area of special interest to Prof. Wig. He started writing for the common man early in his career (How we dream?)[182]. He has revisited this activity periodically (Live sensibly - the rest will follow) [183]. In the round table discussion of World Health Organisation, he presented his views on sensible drinking. The other articles in this area include ‘from mental illness to mental health’, ‘mental health - our most valuable possession’[184-188].The recently published book ‘The Joy of mental health’[181] is a compilation of popular writing on over a dozen topics. His ability, both in one to one situations, meetings and in writings, to simplify mental health issues is very special indeed.

In addition the above body of research of concentrated and continuous type, he published articles on a number of other areas including psychological evaluation of Ghalib and his poetry[189], psychiatric problems in university students[190-193], stigma against mental illness[194],Afghan refugees[195], mental retardation[196], anthropology and psychiatry[197], on Dr. N.C. Surya[198], and collaboration in mental health programmes[199]. Of this group of research his 1998, collaborative report on ‘Suicides in rural Punjab’ is most significant[200].

Reviewing the research efforts of Prof. Wig, the review would be incomplete without reflecting on some of the ‘missed opportunities’ of his professional contributions. In the areas of family planning, drug dependence, general hospital psychiatry, psychological testing, suicide, if the effort was more focussed and in depth, the contribution would have had longer lasting impact on Indian and international psychiatry. That would be expecting him to be superhuman!

In conclusion, out of the lifetime contributions of Prof. Wig, four things standout. Firstly, his commitment to Indian psychiatry expressed through his 766 Psychiatry in India : Training & training centres initiatives in the areas of NMHP, family planning, community mental health, development of psychological testing tools and interpretation of Indian concepts to the rest of world. Secondly, he was an internationally recognised and respected researcher, collaborator with many leaders in world psychiatry and a spokesperson for developing countries. Thirdly, most importantly, he was ahead of his time in thinking of the importance of classification, recognising the value of Indian studies to understand the nature and the course and outcome of mental disorders. Fourthly, he was very skilled in building leaders for mental health and invested a lot of his personal and professional efforts to identify the strengths of his colleagues and students and support them to achieve their full potential.

On the occasion of his completing 80 fruitful years of life, on October 1,2010, I want to express gratitude and sincere appreciation of the mental health professionals of developing countries in general and India in particular for Prof. Wig’s contributions and insights into the working of the mind and the care of persons with mental disorders. His contributions in different areas will be long enduring. At a personal level, I want to acknowledge the continuous support and guidance that has been a vital part of my professional identity. He was my mentor. I want to conclude by wishing Prof. Wig and Dr.Mrs. Veena Wig long years of good health and fruitful lives.

Acknowledgements: My since thanks to Dr. K. S. Raghavan, Ph.D., Hyderabad (formerly at PGI, Chandigarh) for his valuable insights and suggestions in the preparation of this article.

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Berner, Wolf and Than. Publ. Plenum Press New York and London 1985: 45-50. 29. Saxena S, Pachauri R, Wig N.N. DSM-III diseases categories for ICD-9 hysteria: A study on 103 cases, Indian J Psychiatry1986; 28: 47-49. 30. Kastrup M and Wig NN. The transcultural perspective of the multiaxial classification. Ind J Soc Psychiat, 1986; 2: 289-300. 31. Wig NN. The Third World perspective on psychiatric diagnosis and classification, in Sources and Traditions of Classification in psychiatry. (Ed. Sartorius, N., Jablensky A, Regier D.A., Burke Jr. J.D., Hirschfeld, R.M.A.) Published on behalf of WHO by Hogrefe and Huber Publishers. Stuttgart, 1990:181-210. 32. Wig NN. Requirement for a classification of mental disorders in the world today. In Psychiatry: A world perspective - vol.1 (Ed. C.N. Stefanis et al.) Published by Elsevier Science Publishers B.V. (Biomedical Div.) 1990: 26-33. 33. Wig NN. An overview of cross cultural and national issues in psychiatric classification. 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A phenomenological analysis of symptoms in obsessive compulsive neurosis. Brit J Psych 1975;127: 342-348. 39. Akhtar S, Wig N.N. and Varma V.K. Are obsessional potential schizophrenia? Indian J Psychiatry 1975; 17: 22-25. 40. Akhtar S, Wig NN,Varma VK. Prognostic indicators in obsessional neurosis: A follow up study of 44 patients. Indian J Psychiatry 1977; 19: 32-35. 41. Akhtar S, Wig NN, Pershad D.Socio-cultural and clinical determinants of symptomatology in obsessional neurosis. Int J Soc Psych, 1978; 24:1-6. 42. Wig NN, Mangalwedhe K, Bedi H and Srinivasa Murthy R A follow up study of hysteria. Indian J Psychiatry 1982; 24: 120-124. 43. Mehta S, Teja JS, Wig NN, Thukra SI, Pasricha S. Protein calorie malnutrition - A follow up study. Ind J Med Res 1975; 63: 576-582. 44. Verghese A,Dube K.C., John J, Menon D.K., Menon M.S., Rajkumar S., Richard J, Sethi B.B., Trivedi, J.K. and Wig N.N. Factors associated with the course and outcome of schizophrenia - I: Objectives and methodology. 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Distribution of expressed emotion components among relatives of schizophrenic patients in Aarhus and Chandigarh, Brit J Psych 1987; 151: 160-166. 49. Leff, J, Wig, NN, Ghosh A, Bedi H, Menon, D.K., Kupers et al. A Expressed emotion and schizophrenia in North India: Influence of relatives’ expressed emotion on the course of schizophrenia in Chandigarh. Brit J Psych 1987; 151: 166-173. 50. Kala AK, Wig NN. Content of delusions manifested by Indian paranoid patients. Indian J Psychiatry 1978; 20: 227-231. 51. Kala AK, Wig NN, Kala R. Degree of delusional elaboration and social factors: A study in phenomenology of delusions. Ind J Soc Psychiat 1985;1: 306-311. 52. Malhotra HK, Wig NN. Dhat syndrome: A culture-bound sex neurosis of the orient. Arch Sex Behr 1975; 4:519-528. 53. Behere PS, Wig NN, Behere M. Ancient Indian concept of Dhat Syndrome: A culture bound sex neurosis of the East. Ind J Psych Med 1991; 14: 85-87. 54. Wig NN, Varma VK, Mattoo SK, Behere PB, Phookan HR, Misra A.K. et al. An incidence study of schizophrenia in India. Indian J Psychiatry 1993; 35: 11-17. 55. Wig NN, Menon DK, Srinivasa Murthy R. Hindi version of present state examination: Problems of translation and application in Indian setting. Indian J Psychiatry 1982; 24: 309-317. 56. Wig NN. Psychiatric units in general hospitals - right time for evaluation (Editorial). Indian J Psychiatry1978; 20: 1-5. 57. Shah DK, Wig NN, Akhtar S. Status of postpartum mental illness in psychiatric nosology. A study of 102 cases. Indian J Psychiatry 1971; 13: 14-20. 58. Wig N.N. and Shah D.K. Psychiatric unit in a general hospital in India. Patterns of inpatient referrals. Ind Jl of Med Ass 1973; 60: 83-86 . 59. Broor SL, Wig NN and Wahi PL. A study of toxic effects of certain psychotropic drugs with special emphasis on their cardiotoxicity. J Ass Phys Ind1973; 21: 373-742. 60. Khannna BC, Wig NN, Verma VK. 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Cerebral cysticercosis presenting in a psychiatric clinic, Indian J Psychiatry 1977; 19: 48-50. 73. Mehta SK, Kaur S, Awasthi G, Wig NN, Chuttani PN. Small intestinal deficit in Pellegra. Amer J Clin Nut 1972; 25: 545-549. 74. Pasricha A, Verma SK, Mehta S and Wig NN. Relationship of parental education and IQ of malnourished-children - A study in nature-nurture-relationship. Ind J Ment Retard, 1972; 5: 58-63. 75. Sarin,A., Saxena S, Wig NN. Psychiatrically normal individuals in psychiatry: Outpatient department Analysis of 244 cases. Ind J of Clin Psych1983; 10: 429-437. 76. Jayaswal SK, Lal P, Nepal MK, Wig NN. Wilson’s disease presenting with schizophrenia like psychosis -a case report. Indian J Psychiatry 1984; 26: 245-247. 77. Adityanjee, Mohan D and Wig NN. Assessment of functioning of non-psychiatric physicians in the management of psychiatric emergencies. Indian J Psychiatry 1986; 28: 347-348. 78. Adityanjee, Wig, NN, Mohan D Patterns of coverage psychiatric emergencies. 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prediction of psychiatric disturbances following tubal ligation. Indian J Psychiatry 1977;19:55-50. 93. Wig NN, Gupta AN, Khatri R,Verma SK. A comparative study of rural and urban population undergoing tubal ligation. J Family Welfare 1978; 24: 34-43. 94. Wig NN, Kaur R, Pasricha S, Devi PK. Psychological sequel of medical termination of pregnancy, Indian J Psychiatry 1978; 20: 254-261. 95. Wig NN, Kaur R, Devi PK.Why women drop out of a medical termination of pregnancy clinic? J Family Welfare 1978; 25: 34-40. 96. Shah DK, Wig NN, Akhtar S. Status of postpartum mental illness in psychiatric nosology. A study of 102 cases. Indian J Psychiatry 1971; 13: 14-20. 97. Wig NN. Psychiatric complications following family planning procedures. International Symposium on Epidemiological studies in Psychiatry, Tehran, May 1974: 274-284. 98. Wig NN, Ghosh A. Psychomatic problems related to obstetrics and gynaecology. Postgraduate Obstetrics and Gynaecology, Ed. By M.K. Krishna Menon, P.K. Devi, and K. Bhaskar, Chapt. 41; 1980: 408-417. 99. Wig NN, Rustagi PK. Psychological and psychiatric aspects of Obstetric and Gynaecology. Textbook of Obst. And Gynaecology for Postgraduate Studies. Ed: M.K. Krishna Menon, P.K. Devi, and K. Bhaskar (2nd edition). 1982. 100. Wig NN, Menon DK. Psychological problems of fertility control in practice of fertility control : A comprehensive text book. Ed. S.K. Chaudhri . Published by Current Book Publishers, Calcutta. 1983. 101. Wig NN. Women and Mental Health. Keynote Address, Symposium on women and mental health. Astra-IDL Ltd. October 1, 1995. 102. Wig NN. Problems of Mental Health in India. Journal of the Clinical Society. Medical College,Lucknow, 1959; 2: 48-50. 103. Srinivasa Murthy R, Ghosh A, Wig NN.Treatment acceptance patterns in a psychiatric outpatient clinic - Study of demographic and clinical variables. Indian J Psychiatry,1974; 16: 323-330. 104. Srinivasa Murthy R, Wig NN, Ghosh A. Dropouts from psychiatric walk-in-clinic. Indian J Psychiatry 1977;19:11-17. 105. Wig NN, Srinivasa Murthy R, Pershad D. Relationship of disability with psychiatric diagnosis and treatment acceptance patterns, Indian J Psychiatry 1979;21: 355-358. 106. Malhotra HK,Wig NN. The general physician and the psychiatric patient. Indian J Psychiatry 1975;17: 191-194. 107. Malhotra HK, Wig NN, Inamshastri AS. How does the public manage deviant behaviour? Indian J Psychiatry 1976;18: 95-101. 108. Malhotra HK, Wig NN. Where do we want to treat our psychiatric patients, Indian J Psychiatry 1977; 19: 20-26. 109. Malhotra HK, Inam AS, Wig NN. Public opinion and the child guidance clinics in India. Indian J Psychiatry;19: 14-19. 110. Srinivasa Murthy R, Kala, R, Wig NN. Mentally ill in a rural community: Some initial experiences in case identification and management. Indian J Psychiatry 1978; 20: 143-147. 111. Wig NN, Srinivasa Murthy R, Manchina M Arpan D. Psychiatric services through peripheral health centres. Indian J Psychiatry 1980 ; 22: 311-316. 112. Wig NN, Srinivasa Murthy R, Manchina M. Reaching the unreached - II. Experiments in organising rural psychiatric services. Ind J Psychol Med 1981; 4: 47-52. 113. Srinivasa Murthy R, Wig NN, Dhir, A. Rural community attitudes to mental retardation. Child Psychiatry Quarterly, 1980;13: 81-88. 772 Psychiatry in India : Training & training centres

114. Srinivasa Murthy R, Wig, NN, Manchina M, Dhir A. Community care of the mentally handicapped in the rural areas. Social Welfare, 1981; 28: 4-6. 115. Harding WT, Climent CE, Giel R, Ibrahim HHA, Srinivasa Murthy R, Wig N.N et al. The WHO collaborative study on strategies for extending mental health care, II: The development of new research methods. Amer J Psych 1983; 140: 1474-1480. 116. Harding TW, Busnello E, Climent CE, El-Hakim A, Giel R, Wig N.N. et al The WHO collaborative study on strategies for extending mental health care, III: Evaluative design and illustrative results. Amer J Psych, 1983; 140:1481-1485. 117. Srinivasa Murthy R,Wig NN. The WHO Collaborative study on strategies for extending mental health care, IV:A training approach to enhancing the availability of mental health manpower in a developing country. Amer J Psych 1983; 140-11: 1486-1490. 118. Harding TW, de Arango, MV, Baltazar J, Climent CE, Srinivasa Murthy R, Wig N.N. et al. 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The burden of mental illness on the family. Acta Psych Scan, 1983; 68: 186-201. 124. Ignacio LL, De Arango MV, Baltazar J, D’Arrigo Busnello E, Srinivasa Murthy R, Wig N.N. et al. Knowledge and attitudes of primary health care personnel concerning mental health problems in developing countries. Amer J Pub Health 1983; 73:1081-1084. 125. Ignacio LL, de Arango MV, Baltazar J, . Ibrahim, HHA, Srinivasa Murthy R , NN. Wig et al. Knowledge and attitudes of primary health care personnel concerning mental health problems in developing countries: A follow up study. Inter J of Epidem,1989; 18: 669- 573. 126. Wig NN, Srinivasa Murthy R.Manual of mental disorders for peripheral health personnel. Published by Department of Psychiatry, PGIMER, Chandigarh .1980. 127. Wig NN, Srinivasa Murthy R, Harding TW. A model for rural psychiatric services - Raipur Rani Experience , Indian J Psychiatry 1981; 23: 275-290. 128. Wig NN, Varma VK, Srinivasa Murthy R, Rao U, Gupta S. 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Multisectoral approach to school mental health, Alexandria, Egypt, EMR Health Services Journal 1991; 11: 24-30. 139. Wig NN. Development of mental health in WHO Eastern Mediterranean Region. In “Many Worlds of Mental Health”, Proceedings of WFMH Congress in Cairo,1986: 33-37. 140. Suman C, Bladev S, Srinivasa Murthy R, Wig NN. Helping the chronic schizophrenics and their families in the community - Initial observations. Indian J Psychiatry 1980; 22: 97- 102. 141. Wig N.N. Training of psychiatrists in mental health services in developing countries. Editor TA Baasher, GM Carstairs, RGeil, FR Hassler. WHO Offset Publ. 1974. 22: 111-117, WHO, Geneva. 142. Wig NN, Srinivasa Murthy R. Planning community mental health services in India: Some observations. Ind J Psychol Med 1979; 2: 61-64. 143. Wig NN. The future of psychiatry in developing countries - The need for national programmes of mental health. NIMHANS Journal 1989; 7:1-11. 144. Wig NN. 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WHO and mental health-a view from developing countries, Bulletin of World Health Organisation 2000;78:502-503. 149. Agarwaal SP, Goel DS, Ichhpujani RL, Salhan RN, Shrivatsava, S. Mental Health- An Indian perspective(1946-2003), Directorate General of Health Services, Ministry of Health and Family Welfare, New Delhi. 2004. 150. Sanatan RN, Wig NN. A personality study of neurotics on a Hindi and Punjabi modified version of Maudsley Personality Inventory. Indian J Psychiatry 1967; 9: 49-52. 151. Wig NN, Verma SK. PGI Health Questionnaire N.1. A simple neuroticism scale in Hindi. Bulletin PGI 1971; 5: 152-156. 774 Psychiatry in India : Training & training centres 152. Verma SK, Wig NN. Some experience with PEN. Psychological test. Psychological studies1972;18: 11-14. 153. Wig NN, Verma SK. PGI health questionnaire NI - A simple neuroticism scale in Hindi. Indian J Psychiatry 1973;15: 80-88. 154. Wig NN, Verma SK. A cross-cultural study of psychiatric patients on CMI. Indian J Psychiatry 1973;15:363-366. 155. Verma SK, Wig NN. Some experiments with the lie scale of EPI. Journal of Clinical Psychiatry 1974; 2: 93-98. 156. Pershad D, Wig NN. A visuo-motor retention test for clinical use in India. New trends in Educational Psychology 1974;5:15-22. 157. Pershad D, Wig NN. Recognition of common objects: a clinical test for short term memory. Bulletin PGI 1974; 8: 196-200. 158. Verma SK, Wig NN, Pershad D. Some experiments with neuroticism scale in Hindi. Ind J Psychology, 1975; 50: 259-262. 159. Srinivasa Murthy R, Anuradha D, Pershad D and Wig NN. Psychiatric disability scale: preliminary report. Ind J Clin Psychol 1975; 2:183-187. 160. Menon DK, Wig NN, Verma SK, Jain S. Preliminary experience with PGI achievement value index. Ind J Clin Psych1975; 2: 177-178. 161. Menon DK, Wig NN, Verma SK, Jain S. PGI locus of control scale: Preliminary data. , Ind Clin Psychol 1975;2:170-181. 162. Pershad D, Wig NN. A battery of simple test of memory for use in India. Neurology India .1976; 24: 86-93. 163. Verma S.K. and Wig N.N. PGI health questionnaire No.2.- Construction and initial tryouts. Indian Journal of Clinical Psychology, (1976) ; 3: 135-142. 164. Verma S.K., Wig N.N, Chopra H.D. and Malhotra H.K. PGI health questionnaire No.2.: A cross-cultural study with the English version of the scale. Indian Journal of Clinical Psychology, (1976) ; 3: 79-83. 165. Verma S.K. and Wig N.N. Standardization of a neuroticism questionnaire in Hindi. Indian Journal of Psychiatry, (1977) ; 19: 48-50 166. Pershad D and Wig N.N.) Reliability and validity of a new battery of memory tests. (PGI memory scale). Indian Journal of Psychiatry 1978; 20: 76-80. 167. Pershad D and Wig N.N. Relationship between PGI Memory Scale and WAIS verbal IQ. Neurology India, 1979; 27(2): 69-72. 168. Wig NN. Psychology and drug addiction in some aspects of Toxicology. Ed. Ranjit Roy Chaudhry, Oxford and IBH, New Delhi, 1969: 81-87. 169. Mendhiratta SS, Wig NN. Psychological effects of long term cannabis use in India: A study of fifty heavy users and controls. J Drug and Alcohol Dependence 1976;1: 71-81. 170. Wig NN, Varma VK. Patterns of long term heavy cannabis use in North India and its effects on cognitive functions: A preliminary report. Journal of Drug and Alcohol Dependence 1977; 2: 211-219. 171. Wig NN, Varma VK. Present status of drug dependence treatment in 25 nations. Addictive Diseases 1977;3:1-140. 172. Varma VK, Ghosh A, Singh SD, Wig NN. Drug abuse among college students.. Indian J Psychiatry 1977 ; 19: 1-10. 173. Mendhiratta, SS, Wig NN, Verma SK. Some psychological correlates of long-term heavy cannabis use. Brit J Psych 1978;132: 482-486. 174. Wig NN. Drug scene in India, In International collaboration: Problems and Opportunities, published by Addiction Research Foundation. Ed. B. Rutledge and E.K. Fulton, Toronto, Canada,1978: 73-79. Murthy: N.N. Wig - a man ahead of his time 775 175. Mendhiratta SS,Wig NN,Verma SK.Why do they take it: A preliminary investigation into the motivation of chronic cannabis users. Ind J Psychol 1978;53: 195-201. 176. Srinivasa Murthy R. From local to global- Indian psychiatrists contributions to international psychiatry, Indian J Psychiatry Supplement 2010; S: 30-37. 177. Wig NN. Influence of religion on mental illness in India. Published in Proceedings of 3rd International Congress, Social Psychiatry held in Zagreb, Yogoslavia, 21-27 Sept. 1970. 178. Wig NN. Indian concepts of Mental Health and their impact on care of the mentally ill. International Journal of Mental Health. 1989;18: 71-80. 179. Wig NN. Mental Health and spiritual values. Mary Hemingway Rees Memorial Lecture World Federation of Mental Health World Congress, Dublin 1995. 180. Wig NN. Mental health and spiritual values. A view from the East. Int Review of Psychiatry 1999; 11:92-96. 181. The Joy of Mental health-some popular writings of Dr.N.N.Wig, Compiled and Edited by Dr.K.J.S.Chatrath, (2nd edition), Mental Health Forum, Servants of the People Society, Chandigarh. 2010. 182. Wig NN. How we dream. Everyday Science 1964; 11: 6-9. 183. Wig NN. Live sensibly - the rest will follow. In Round table discussion on Sensible Drinking. World Health Forum 1994;15: 229-231. 184. Wig NN, Srinivasa Murthy R. From mental illness to mental health. Health for the Millions (Mental Health issue) 1994; 20: 2-4. 185. Wig NN. Mental Health- Our most valuable possession. World Mental Health Day supplement. The Tribune, 10 Oct.1996, Chandigarh. 186. Wig NN. How to cope with stigma of mental illness. The Tribune, 3 Sept.1997. Chandigarh. 187. Wig NN. Human rights of the ill in mind. Mental Health Day supplement. The Tribune, 7 Oct. 1998, Chandigarh. 188. Wig NN. Why be afraid of ageing? World Mental Health Day supplement. Health Tribune, Sept. 29, 1999. Chandigarh. 189. Wig N.N. A psychological evaluation of Ghalib and his poetry. Indian Literature, 1968; 11: 36-48. 190. Wig NN, Nagpal RN, Khanna H. Psychiatric problems in university students. Indian J Psychiatry 1969;11: 55-62. 191. Wig NN, Nagpal RN. Why students fail - A psychosocial study of low achievers. I Indian J Psychiatry 1972;14:381-388. 192. Wig NN, Nagpal RN. Mental health and academic achievement - A comparison of successful and failed student. Educational Psychology Review 1972; 12: 31-39. 193. Nagpal RN, Wig NN. Non intellectual factors associated with academic achievement in University students,. Ind J Clin Psychol1975; 2: 151-157. 194. Wig NN, Srinivasa Murthy R. Collaboration in mental health programmes: Need and scope in India. Indian J Psychiatry 1977; 19: 60-69. 195. Saxena S,Wig NN. Psychiatric problems of Afghan refugees in Delhi: A study on 152 outpatients. Indian J Psychiatry 1983; 25: 40-45. 196. Wig NN, Mehta M, Sahasi G. A study of time utilisation and perceived burden of mentally handicapped child in joint and nuclear families, Ind J Soc Psychiat 1985; 1: 251-261. 197. Wig NN. Anthropology and mental health - A view from the Third World in Psychiatry and its related discipline, the next 25 years. Edited by Roserberg, Schulsinger and Stroemegrer published by World Psychiatric Association, Copenhagen,1986: 169-178. 198. Wig NN. The pioneers of Indian Psychiatry -I. Dr. N.C. Surya - The lone rider. Indian J Psychiatry 1996; 38:2-8. 776 Psychiatry in India : Training & training centres 199. Wig NN (1997) Stigma against mental illness (Editorial) Indian J Psychiatry 1996; 39:187- 189. 200. Bhalla GS, Sharma SL, Wig NN, Mehta S, Promod Kumar. Suicides in rural Punjab, Monograph Series 5. Institute for Development and Communication, Chandigarh. 1998.

R. Srinivasa Murthy Professor of Psychiatry (Retd) C-301; CASA ANSAL Apartments, 18, Bannerghatta Road, J.P.Nagar 3rd Phase, Bangalore-560076. India [email protected] Appendix www.mciindia.org accessed on 27.12.2014 Institutions offering MD Psychiatry 778 779

Institutions offering Diploma in Psychological Medicine 780

Colleges/Hospitals offering DNB (Diplomat of National Board) in Psychiatry

1 Asha Hospital, Hyderabad, Andhra Pradesh 2 2 Yashoda Hospital,Secunderabad, Andhra Pradesh 1 3 Sher-I-Kashmir Institute of Medical Sciences, Saura, Srinagar, Jammu and Kashmir 2 4 Bhabha Atomic Research Centre & Hospital, Mumbai, Maharashtra 1 5 Athma Institute of Mental Health & Social Sciences, Tiruchirappalli, Tamil Nadu 2 6 National Institute of Medical Sciences, Jaipur, Rajasthan * 7 Lourdes Hospital, Pachalam, Ernakulam,Kochi 2 8 Mental Health Centre,Thiruvanandapuram, Kerala 1 9 Dr R.N. CooperMunicipal General Hospital, Vile Parle(West),Mumbai, Maharashtra 2 10 K.J. Somaiya Medical College, Mumbai, Maharashtra 1 11 Masina Hospital, Mumbai 2 12 Schizophrenia Research Foundation, Chennai, Tamilnadu 2 13 LGB Regional Institute of Mental Health,Tezpur, Assam 3 14 Post Graduate Instt. Of Behavioral & Medical Sciences, Raipur, Chattisgarh 1 15 Vidyasagar Institute of Mental Health & Neurosciences, New Delhi 1 16 Spandan Nursing Home, Bangalore, Karnataka 2 17 Institute of Mental Health, Agra * 18 Institute of Mental Health, Government Mental Hospital, Amritsar, Punjab * 19 Sri Ganga Ram Hospital 2 781 Index

Academic centers and mental health needs 77 Atma 517 Acamprosate 578 Atypical antipsychotics and Access to medical records 247 metabolic syndrome 429,434 Admission of psychiatric patients Australia, psychiatric training 143,151 independent patients 251 comparison with India 147 minors 251 examinations 145 supported admission beyond 30 days 253 Ayurveda 509 Advance directive 243 atma 517 Affective forecasting 540 ayurvedic psycholoogy 517 Alcohol and opioid dependence 571 classification of psychiatric disorders 520 acamprosate 578 concepts of mental health 511 baclofen 579 concept of mind 511 buprenorphine 584,585 divine therapy 521 classification of opioids 581 evolution of disease 518 combination therapy 579 evolution of matter 510 craving 571 functions of mind 513 disulfiram 576 health as a state of equilibrium 511 family role 580 Kapha 515 liaison with other specialties 572 location of mind 512 management of alcohol dependence 573 manas 512 management of opioid dependence 583 Manasa Prakruti 513 medical complications 572 Pancha mahabhuta theory 510 methadone 583 Parinama 519 naltrexone 584 Pitta 515 newer treatment approaches 579 preventive measures 525 nosology of alcohol dependence 571 principles of treatment 521 ondansetron 579 psychobehavioral therapy 524 opioid withdrawal 583 psychological quality of doshas 515 tolerance 569 qualities of mind 512 topiramate 579 Rajas 513 types of alcoholics 572 rational therapy 522 withdrawal 573 Satva 513 withdrawal seizures 574 Tamas 513 Alcohol-induced psychosis 576 Tridosha 514 Alcohol intoxication 563 Trigunas 512 acute intoxication 563 Vata 515 assessment 564 clinical features 564 Baclofen 579 complications 569 Beck Hopelessness Scale 591 grading 568 Beck Scale for Suicide Ideation 591 investigations 566 Buprenorphine 585 management 566,570 Burden of mental illness 2,31 All India Institute of Mental Health 723,729 Alternative medicine (see complementary and California Risk Estimator for Suicide 591 alternative medicine) Cambodia, psychiatric training 98 Anatomy of emotions 529 Caregiver's perspectives 654 Anthropology (see cultural formulation) communication skills 655 Asian scenario in postgraduate partnership to advocacy 656 psychiatric training 93 Case-control studies 409 Atlas: Psychiatric Education and Training Across the Case presentation 297 World 14 diagnosis 303 782 Index

history 298 India 172 insight 303 school mental health program 203 management 303 Complementary and alternative medicine (also see mental status examination 301 Ayurveda) 501 Case reports 409 Ayurveda 509 Case series 409 definition 502 Centres for excellence 72 examples 503 Challenges for mental health care shortcomings of resarch 504 Changing perspectives prevalence of use 502 psychiatric practice 735 Computerized databases of medical literature 321 psychiatric training 741,745 Continuing medical education 478 Child psychiatry training in India 197 Countertransference 453 history 198 Craving 571 national initiatives 199 Criminal responsibility 265 recommendations 201 Critical care 631 specialty training 199 education 632 UK and USA 199 unit layout 633 China, psychiatric training 97 unmet challenge 632 Choosing psychiatry as a career 719 Critical reading of research papers 323 Civil responsibility 265 Crisis intervention 606 Classification of psychiatric disorders Cross-sectional studies 409 in Ayurveda 520 Culture and mentoring 483 Clinical health psychology 397 Culture, diagnosis, and formulation 463 Clinical neurology for psychiatrists (see neurology for anthropology 469 psychiatrists) cultural critique of biomedicine 468 Clinical neuropsychology 398 cultural formulation 472 Clinical psychologists cultural pluralism and sensitivity 470 annual graduation 70 cultural sensitivity 472 training 13,395 culture and diagnosis 466 Clinical psychology training in India 13,395 culture and management 467 history 395 culture and mental disorders 463 forensic psychology 398 ethnography 469 mental hospital model 396 explanatory models of illness 464 models 396 exploring diversity 472 neuropsychology 398 form-content dichotomy 467 rehabilitation institute model 396 matching and integrating therapies 470 superspeciality model 396 Culture, psychological assessment 384 university department model 397 Current Contents 321 Clinical rounds 305 Clinical viva 457 Declaration of sexual rights 219 format 457 Defining a case in epidemiology 407 grand viva 460 Diagnosis and culture 466 long case 458 Diagnostic schedules 404 purpose 457 Disability assessment (see measuring disability and short case 459 functioning) CME (see continuing medical education) Disability Assessment Schedule 639 Cohort studies 409 Discharge of independent patients 252 Columbia Suicide Screen 592 Disulfiram 576 Combat psychiatry 194 Divine therapy in Ayurveda 521 Community psychiatry Doctor-patient relationship 694 France 157 Drawing a pedigree chart 420 Index 783

Duties of psychiatrists 675 Forensic psychiatry 233,237 civil responsibility 265 Ecological studies 409 clinical assessment 264 Emergencies in psychiatry (see psychiatric concept 238 emergencies) criminal responsibility 265 Emergency treatment 254 definition 238 Emotional abuse 538 history 238 Emotional intelligence 537 knowledge and skills for postgraduates 233 Emotions mental health laws 238 affective forecasting 540 relevance in postgraduate training 237 affective style 537 syllabus 234 age-related changes 532 Forensic psychology 398 anatomy 529 Four principles approach to medial ethics 689 assessment 530 common morality 691 classification 528 dealing with conflict 692 cognition and emotions 532 speciation 693 coping 537 theories 690 concept 527 France, community psychiatry 157 disorders 538 alternatives to hospitalization 163 dramaturgical theories 535 art, culture, leisure 167 emotional intelligence 537 citizen psychiatry 171 exchange theories 535 economic rehabilitation 166 gender effects 540 health partners in towns 170 genetics 541 history 159 Goleman's model 538 housing 165 interaction ritual theories 535 networks 168 measurement 530 role of international and national network 170 morality 539 services 162 neurochemistry 529 users and family groups 169 power and status theories 535 regulation 535 Geriatric Depression Scale 593 sociocultural aspects 533 Geriatric mental health 271 sociological theories 532 curriculum 272,274 symbolic interactionist theories 535 demographics 271 Epidemiology (see psychiatric epidemiology) infrastructure development 283 Ethics (see four principles approach to medical manpower development 283 ethics) specialty training 274 Ethics in clinical trials (see good clinical practice) training 273 Ethnography (see cultural formulation) Girindrasekhar Bose and psychiatric education 749 Evaluation of training 52,63 Goleman's model of emotional intelligence 538 Evidence-based medicine 319,353 Good clinical practice 679 Examination (also see clinical viva) Ethical issues in human research 681 observed structured clinical examination 489 informed consent 682,684 Excerpta Medica 321 placebo-controlled trials 685 Experimental studies 410 Good psychiatric practice 663 avoiding boundary violations 672 Family in alcohol dependence 580 basic principles 665 First MD Psychiatry course 3 communicating with sensitivity and compassion 671 Fitness to stand trial 267 confidentiality 672 need for a screening instrument 268 duties of psychiatrists 675 Five year plans 70 harm minimization 671 784 Index

informed consent 668 contents 315 involving patients and families 667 editorials 315 providing sufficient information 667 evidence-based medicine319 Guidelines for postgraduate psychiatric training 96 impact factor 314 indexation 314 HARD diagram 592 outline of an original article 317 History of medical education in India 7 peer review 314 How to quality 314 perform an internet literature search 347 research articles 316 read a research paper 323,356 reviews 316 write a research paper 333 supplements 313 types of publications 313 IDEAS (Indian Disability Evaluation and Assessment why read a journal? 313 Scale) 640 Journal clubs 353 Index Medicus 320 choosing papers for review 355 Indian Armed Forces, psychiatric training 177,187 critical appraisal skills 356 grading system format 358 history 177,188 history 353 military psychology 189 interactiveness 359 paramedical staff 179 nature of learning 360 postgraduate training 181 purpose 353 research 181 special issues in management 187 Kapha 515 specialty training 181 Kuwait, psychiatric training 99 undergraduate training 179 Indian Association of Clinical Psychology 399 Legal issues in military psychiatry 192 Indian Lunacy Act 238 Liaison psychiatry 549 Indian Medical Council Act of 1933 7 Life skills education 206 Indian Psychiatric Society Lunacy Act 238 origins 9,32 role in postgraduate training 32 Management of the uncooperative patient 491 Indian Psychoanalytic Society 751 causes of uncooperative behavior 492 Indian psychiatrists in the USA 131 consequences of uncooperative behavior 493 Indo-US Science and Technology Forum 140 diagnoses associated with uncooperative Informed consent 682,684 behavior 492 Insight 303 dos and don'ts 496 International classification of disabilities 638 legal issues 494 International Classification of Functioning, Disability, management of uncooperative behavior 493 and Health 639 management of violent patients 496 Internet literature search 347 surreptitious medication 494 additional links 351 Manas 512 basic rules 347,350 Manasa Prakruti 513 free access journals 350 Measuring disability and functioning 637 keyword selection 348 Disability Assessment Schedule 639 refining and expanding search 349 general areas of disability 638 search engines 348 IDEAS (Indian Disability Evaluation and subscription-based journals 350 Assessment Scale) 640 staying updated 351 international classification of disabilities 638 International Classification of Functioning, Japan, psychiatric training 99 Disability, and Health 639 Journals 313 need 641 Index 785

SCARF Social Functioning Index 640 dilemmas 193 Schedule for Assessment of Psychiatric documentation 192 Disability 640 history 188 Media and mental health 657 legal issues 192 advocacy and the media 660 manpower training 190 building media allies 660 organization of services 190 choosing the right medium 661 referral system events and campaigns 659 services for families and veterans 193 media and money 661 soldier as a unique client 188 radio and the web 661 special issues in management 187 Medical colleges in India Military psychology 189 past and present 10,40,70 Mobile health initiative 82 Medical Council of India Morality and emotion 539 history 7,39 Medical ethics (see four principles approach to Naltrexone 584 medical ethics) Narendra Nath Wig 753 Medline 322 Nepal, psychiatric training 115 Mental health developmental milestones 116 burden 2 mental health resources 116,121 training 2 overview 120 Mental Health Act 239 postgraduate training 118 Mental health care theses 119 challenges 79 undergraduate training 117 current priorities 81 Networking during psychiatric training 547 focused initiatives for academic centres 82 Neurochemistry of emotions 529 innovations 81 Neuroimaging in psychiatry 365 past programs and efforts 80 current techniques 366 recommendations for academic centres 82 endophenotype approach 366 role of academic centres 77 Neurology for psychiatrists 369 Mental Health Care Bill, 2012 comorbidity 371 Mental health concepts in Ayurveda 511 neurological disorders with psychiatric Mental health establishment 242 symptoms 372 provisional and permanent registration 248,249 neurological examination 370 Mental health laws 238 neurology-psychiatry interface 371 Mental Health Review Commission 250 psychogenic disorders in neurology 373 Mental status examination 301 NIMHANS postgraduate training in psychiatry 57 Mentoring trainees 481 NIMHANS trainee perspectives in psychiatry 703 competencies and skills 483 NN Wig 753 cultural issues 483 future 485 Ondansetron 579 history 481 Opioid dependence (see alcohol and opioid mentoring process 482 dependence) mentor's role 482 Organicity in psychiatry 553 Metabolic syndrome 423 approach to a patient 554 atypical antipsychotics 429,434 general examination 557 criteria 424 investigations 557 schizophrenia 425 organic delusions 556 Methadone 583 Military psychiatry Pakistan, psychiatric training 99,107 combat psychiatry 194 college of physicians and surgeons 109 diagnosis and management 191 degrees 111 786 Index

examinations 109,110 innovations 57 general issues 111 institutional requirements 95 postgraduate training 108 Japan 99 undergraduate training 108 journals 53,313 Pancha mahabhuta theory 510 journal clubs 353 Parinama 519 Kuwait 99 Pedigree chart 420 learning objectives 41 Penalties under Mental Health Act 257 mentoring 481 Persons with Disabilities Bill, 2012 modular training 61 list of disabilities 263 national initiatives 69 Physical restraint 497,609 Nepal 115 Pierce Suicide Intent Scale 592 NIMHANS experience Pitta 515 Pakistan 99,107 Placebo-controlled trials 685 psychiatric epidemiology 401 Police officers, duties regarding mental illness 256 psychiatric genetics 419 Postgraduate training in psychiatry 1 psychodynamic psychotherapy 443 1960s 729 psychological assessment 375 academic activities 50 psychotherapy 62,439,443 agenda for the Indian Psychiatric Society 31 recommendations 39 alternative medicine 501 rehabilitation 285 Asian scenario 93 research forum 50 Australia 143,151 rotations 52 assessments 52 Russia 98 Cambodia 98 seminars 59 case presentation 297 sexual medicine 213 child psychiatry (see child psychiatry training) skills 48 China scenario 97 South Korea 98 clinical meetings 52,59 Sri Lanka 99,101 clinical postings 51 teaching and learning methods 49 clinical psychology 395 textbooks 53 clinical rounds 305 thesis writing 49 clinical viva 457 trainee forum 489 comparison with Australia 147 trainee's viewpoint 699,703 comparison with UK 128 training centers 3,32 competencies, practical 47 United Kingdom 125 competencies, theoretical 43 United States of America 131 complementary medicine 501 Prevention in Ayurveda 525 core curriculum 95 Priorities in mental health care 81 courses 3,32,95 Prisoners with mental illness 256 cultural formulation 463 Prohibited treatments 255 curriculum 43 Psychiatric education (also see postgraduate epidemiology 401 psychiatric training) evaluation 63 Girindrasekhar Bose749 examinations 52 global trends 14 forensic psychiatry 233 past, present, and future 7 genetics 419 Psychiatric emergencies 597 geriatric mental health 271 assessment 603 global scenario 94 consultant 599 guidelines 96 crisis intervention 606 history 7,13,39,723,729 dedicated mental health wing 600 Indian Armed Forces178 de-escalation 607 Index 787

disposition 609 training 13,89 general approach 601 trends in India 88 general guidelines 605 Psychiatric social work 643 history 603 annual graduation 70 mental status examination 603 curative and augmentative function 648 models of delivery of care 598 current status 649 physical examination 604 definition 643 physical restraint 497,609 future directions 650 principles 598 history 644 psychiatric emergency services model 600 need 645 psychiatric interview 604 principles 646 rapid tranquillization 608 promotive and preventive function 647 treatment strategies 606 rehabilitation and reintegration 649 triage 602 relationship with other departments 649 Psychiatric epidemiology 401 training 13 case-control studies 409 Psychiatric training (also see psychiatric education, case reports 409 postgraduate psychiatric training, undergraduate case series 409 psychiatric training) causation 408 CME 477 cohort studies 409 networking 547 cross-sectional stuies 409 overview 1 defining a case 403 then and now 741 diagnostic schedules 404,405 Psychiatric training during internship ecological studies 409 experiences 26 experimental studies 410 overview 25 importance 402 training module 27 incidence 408 Psychiatrists Indian studies 414 inadequate manpower 69 prevalence 408 roles 1 screening instruments 404,405 skills 1 types of studies 407,409 Psychiatry in the 1960s 731 variations in results in India 415 Psychiatry unbound 487 visible vs invisible problems 403 Psychoanalytic psychotherapy 445 Psychiatric genetics 419 transference 451 clinical genetics 419 Psychodynamic psychotherapy 443 drawing a pedigree 420 countertransference 453 theoretical study 421 disadvantages 444 Psychiatric institutes theory to practice 445 All India Institute of Mental Health 723,729 transference 451 Psychiatric interview 289 Psychological assessment 375 format for recording 292 approaches 377 importance of making a diagnosis 289 beyond diagnostic testing 381 purposes 291 changing culture 383 special populations 294 changing models and paradigm shifts 388 stages 291 contemporary issues for India 379 Psychiatric nursing criterion-referenced approaches 378 annual graduation 70 cultural adaptations 385 current status 90 cultural symbols 384 history 87 functional/behavioral approaches 378 institutions 91 idiometric/neuropsychological approaches 379 past, present, and future 87 meaning 376 788 Index

mistaken notions 380 Sexual medicine 213 normative or psychometric approaches 377 certification 217 postgraduate training in psychiatry 389 curriculum 228 redefining handicaps 388 declaration of sexual rights 219 technology-assisted assessments 386 ethics 218 Westernized training 386 future for India 227 Psychosocial rehabilitation (see rehabilitation history 221 training) insurance 218 Psychosurgery 255 IPS guidelines 215 Psychotherapy training 62,439 need for training 222 objectives and process 441 professional organizations 217 relevance in clinical psychiatry 440 recruitments of clients 218 suggestions for professionals 216 Rajas 513 suggestions for students 215 Rapid tranquillization 608 suggestions for training and career 215 Rational therapy in Ayurveda 522 West vs India 221 Rehabilitation psychology 398 Sociological theories of emotion 532 Rehabilitation training 285,549 Solomon 4-group design 411 curriculum 286 South Korea, psychiatric training 98 guideline for postgraduate training 287 Speciation 693 psychosocial rehabilitation 285 Sri Lanka, psychiatric training 99,101 training centres 286 community psychiatry training 103 training methods 287 postgraduate training 102 Research and the law 256 specialist training 104 Research design 409 training needs 101 Restraints and seclusion 255,497,609 undergraduate trainging 102 Rights of persons with mental illness 245 State Mental Health Authority 248 Right to access mental health care 245 Suicide 587 Risk and its assessment in psychiatry 613 biological risk factor 590 assessment 616 clinical evaluation 587 case vignettes 614,618,627-9 laws 258 categories 624 psychological risk factors 590 concepts 616 scales for evaluaton 591 limits 621 Suicide Probability Scale 591 moderators 625 Suicide Risk Eleven 593 Risk of Suicide Questionnaire 593 Suicide Risk Screen 593 Royal Medico-Psychological Association 8 Surreptitious medication 494 Rum fits 574 Russia, psychiatric training 98 Tamas 513 Tolerance 571 SCARF Social Functioning Index 640 Topiramate 579 Schedule for Assessment of Psychiatric Disability 640 Trainee's viewpoint in psychiatry 699,703,713 Schizophrenia, metabolic sydrome 423 clinical teaching 700 School mental health program 203 expectations 713 initiatives in India 204 final year trainee's perspective 707 life skills education 206 first year trainee's perspective 704 NIMHANS model 208 lectures 701 recommendations 207 needs and satisfaction about supervision 709 setting up a program 209 NIMHANS experience 703 workshop for master trainers 210 second year trainee's perspective 706 Screening instruments 404 senior resident's perspective 708 Index 789

suggestions for improvement 711 psychiatrsts of Indian origian 131 thesis 701 research training and opportunities 139 Training centres 69 residency training 132 Transference 451 specialty training 137 Triage model 601 triple certification 138 Tridosha 514 US-India fund 140 Trigunas 512 Vata 515 Uncooperative patient (see management of Violent patients 496 uncooperative patient) Viva (see clinical viva) Undergraduate training in psychiatry difficulties 21 Wig NN, 753 Indian Armed Forces 179 Writing skills for research 333 infrastructure concerns 20 abstract 338 need 17 authorship 338 Nepal 117 basic principles of writing 335 overview 17 basic structure of a paper 336 Pakistan 108 choosing a journal 343 recommendations 18 conclusions subsection 341 skills 12 discussion section 341 Sri Lanka 102 editing the manuscript 342 Understanding human emotions 527 formulating a research question 333 United Kingdom, psychiatric training 125 general principles of writing 334 comparison with India 128 introduction section 338 United States of America, psychiatric training 131 limitations subsection 341 cultural adaptation 137 methods section 339 dual certification 138 reference list 342 examinations and certification 135 results section 340 externship 137 revising a manuscript 343 fellowship training 137 tips for trainees 344 maintenance of certification 136 title of a paper 336 observership 137 title page 337 prominent programs 138