dr rao institute book 2015 - Indian Journal of Psychiatry

Transcription

Psychiatry in India:
Training & training centres
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 Psychiatry
www.indianjpsychiatry.org
Psychiatry in India : Training & training centres
Second edition, the supplement of Indian Journal of Psychiatry
Editors:
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 Psychiatrists 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,
(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
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
PRESIDENT
DR G. PRASAD RAO
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 ProChancellor, 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.
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
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
Postgraduate Institute of Medical Education & Research
Chandigarh
Alakananda Dutt
Department of Psychiatry, PGIMER,
Chandigarh
Alka A. Subramanyam
Asst. Professor
TNMC & BYL Nair Ch. Hospital
Mumbai
Amit Kulkarni
Consultant Psychiatrist
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
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
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
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
TNMC & BYL Nair Ch. Hospital
Mumbai
P.K. Dalal
Professor & Head of the department
M.S. Darshan
Formerly Resident in Psychiatry
Dept. of Psychiatry
JSS University, JSS Hospital (JSS Medical College)
M.G. Road, Mysore
Debjani Bandopadhyah
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
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
Clinic Brain
Barasat, West Bengal
Geetha Desai
Associate Professor, Coordinator, Seminars
National Institute of Mental Health & Neurosciences
Bangalore, India
Girish Menon
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
Colombo, Sri Lanka
Harish Shetty
Psychiatrist, Dr L. H. Hiranandani Hospital
Powai, Mumbai.
Ipsit V. Vahia
Stein Institute for Research on Aging
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
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
Maulana Azad Medical College,
GB Pant Hospital & University of Delhi
& Chairman, Psychiatry Education Committee
Jugal Kishore
Professor
Community Medicine,
New Delhi
Jyoti Prakash
Reader, Department of Psychiatry,
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)
JSS Medical College & Hospital
M G Road, Mysore
Laurent Defromont
Psychiatrist,
Consultant WHO Collaborating
Head Medical Information and
Research Department,
Manaswi Gautam
and Alternative Medicine, Jaipur.
L.S.S. Manickam
Professor in Clinical Psychology
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
Jaipur.
Mohan Isaac
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
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
MS Ramaiah Medical College
Bangalore
Naren P. Rao
Senior Resident in Psychiatry
NIMHANS
Bangalore
Naresh Nebhinani
Dept. of Psychiatry
rd
3 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
Bangalore, India
Nawab Akhtar Khan
Lecturer, (Clinical Psychology)
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
research and training
in Mental Health (Lille, France)
Nilesh Shah
Professor & Head, Dept. of Psychiatry,
Mumbai
Nirmala Srinivasan
Director, ACMI, Bangalore
Nishanth Jayarajan
Senior Resident
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
Bangalore, India
Prabhat Chand
Associate Professor, Coordinator Research Forum
Bangalore, India
G. Prasad Rao
Director, Schizophrenia &
Psychopharmacology Division,
Asha Hospital, Hyderabad
N.R. Prashanth
Bangalore Medical College
and Research Institute,
Prathap Tharyan
Christian Medical College, Vellore
Tamil Nadu, India
R. Raghuram
Professor & Head
Department of Psychiatry, KIMS
Bangalore
Rajan Nishanth Jayarajan
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
All India Institute of Medical Sciences
Ansari Nagar, New Delhi, India-110029
& Secretary, Central Mental Health Authority
Raman Deep Pattanayak
Senior Research Associate (CSIR)
Ansari Nagar, New Delhi
G.S. Ramkumar
Final year Junior Resident
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
PGIMER, Chandigarh
Sanjay Kumar Munda
Assistant Professor of Psychiatry
Central Institute of Psychiatry
Kanke, Ranchi.
Santosh K. Chaturvedi
Professor & Head
Bangalore, India
M.T. Sathyanarayana
”Swarnashri” 2nd Cross,
Ashoka Nagar, Tumkur, Karnataka
Prof. & Formerly Head, Department of Psychiatry,
JSS University, JSS Medical College Hospital
M.G. Road, Mysuru
Satish Kumar Budania
Junior Resident
Varanasi.
Savita Malhotra
Post Graduate Institute of
Medical Education and Research,
Chandigarh
Shaji K.S.
Medical College
Thrissur-680596
Kerala, India
P.S.V.N. Sharma
Prof. and Head,
KMC, Manipal
R. Shashikumar
P.C. Shastri
T.N. Medical College
Hon. Psychiatrist
B.Y.L. Nair Hospital
Shehan Williams
Faculty of Medicine
University of Kelaniya
Sri Lanka
Shekhar P. Seshadri
Professor & Coordinator, Psychotherapy Programme
Bangalore, India
Shiv Gautam
P.T. Shivakumar
Assistant Professor, Coordinator, Modular training
Bangalore, India
Shivaram Bhat P.
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
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
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,
S.V.S. Subbarao Ryali
Professor & Head, Department of Psychiatry,
Sudipto Chatterjee
Sangath, Goa.
Sujata Sethi
122/8, Shivaji
Colony, Rohtak-124001,
Haryana, India.
Sujit Kar
Senior resident,
C. S. M. Medical University UP
(Upgraded K. G. Medical University)
Lucknow
Suresh Bada Math
Associate Professor of Psychiatry
Bangalore
G. Swaminath
Dr B R Ambedkar Medical College
Kadugondanahalli
Bangalore.
Tapas Kumar Aich
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
Chairperson, Geriatric Psychiatry Specialty Section
of Indian Psychiatric Society.
J.K. Trivedi
Professor & Ex-Head,
Lucknow
G. Venkatasubramaniam
Associate Professor, Coordinator, Basic Science training
Bangalore, India
S. Venkatesan
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
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
2
3
4
5
6
7
8
9
Psychiatric Training
T.S. Sathyanarayana Rao, G. Swaminath & G. Prasad Rao
1
Psychiatric Education in India: Past, Present and Future
Shridhar Sharma
7
Undergraduate Psychiatry
B.S. Chavan, A.R. Rozatkar
17
Psychiatry training during internship: Can we make it better?
Rajan Nishanth Jayarajan & K.S. Shaji
25
Postgraduate Training in India: Agenda for Indian
Psychiatric Society
Ajit Avasthi, Naresh Nebhinani, Sandeep Grover
31
Recommendations for Post-graduate (MD)
Curriculum in Psychiatry
R.C. Jiloha
39
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
Provisions for Training Centres: Recent Developments
R. Sagar, R.D. Pattanayak
69
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
213
25 Sexuality training in the West and its relevance to India
Gurvinder Kalra
221
26 Forensic Psychiatry: 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 Neuroimaging 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 Psychiatric epidemiology: What do post-graduate
psychiatric residents need to Know?
Suresh Bada Math, Janardhanan Narayanaswamy,
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 Psychotherapies – 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
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 & Vikram Patel
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
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
1
medicine.
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
1
clinically effective as any other medical specialty.
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
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
1
piecing together the clues to a (hopefully) satisfying end is a regular task.
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
1
rather than an irritant.
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, neuroimaging, 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
3
6.5%, roughly translating to 71 million people. There are only around 4000
4
psychiatrists to serve this huge burden. 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
3
below this average. 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
2
knowledge base for future medical specialists is widely acknowledged. 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
1
career is by no means easy, but the rewards can be great. 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 postgraduatetraining, 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
Instituteof Psychiatry in Ranchi. Training in these institutions, including some
centres in Mumbai and Chennai, are highly sought after. Standards of training
6
vary across institutionsbut training standards in some institutions are high.
th
As on 14 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
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 entranceexaminations conducted by each state and also by a
countrywide common entrance examination. Some central institutions,
6
highlyregarded for their training, conduct their own entrance examinations.
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 guidanceof 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 theprocess of training and services planning.
REFERENCES:
1.
2.
Dean A. Career focus Psychiatry. BMJ 1996; 313 : S2-7071
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
3.
4.
5.
6.
7.
8.
5
Thirunavukarasu M, Thirunavukarasu P. Training and National deficit of psychiatrists in
India - A critical analysis. Indian J Psychiatry 2010;52:83-8
Mohandas E. Roadmap to Indian Psychiatry. Indian J Psychiatry 2009;51:173-9
Sharma S. Postgraduate training in psychiatry in India. Indian J Psychiatry 2010;52:89-94
Das M, Gupta N, Kavitha N. Psychiatric training in India. Psychiatric Bulletin 2002;26: 70-72
K Kuruvilla, Editorial: Towards Greater Integration With Other Medical Specialities. Indian
Journal of Psychiatry 1996; 38(4):194-195.
Pratap Sharan, Book Review: A Textbook of Psychoanalitically Oriented Psychotherapy :
Theory and Technique, Au. Shakuntala Dube; Indian Journal of Psychiatry, 1998; 40, 3; 306.
M.G. Road, Mysuru - 570004.
www.indianjpsychiatry.org
E-Mail: [email protected], [email protected]
G. Swaminath
Dr B R Ambedkar Medical College
Kadugondanahalli,
Bangalore.- 560045, Karnataka, India
[email protected]
G. Prasad Rao
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
1
was four years, which was later extended to 5 years in 1845. Till 1946, there
were only 16 medical colleges and by 1949, the number increased to 29 and in
th
1958 there were 50 medical colleges. As on 14 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
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
6
objectives.
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
6
experience.
The first mention of a proposed Indian Division of the Royal MedicoPsychological 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 appointed 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
of Health Services, Government of India, at Central Institute of Psychiatry at
9
Ranchi. 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
14
had undergraduate teaching programme. 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
15
have some Psychiatric facility or the other. 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 needoriented. In one of the national conferences on medical education held in
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
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 developing:
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
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
19, 20,21
total number of trainees during those years.
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
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
20
our country. There is a need to make serious efforts in this direction.
Recently, WHO in collaboration with WPA (World Psychiatric Association)
has brought out an interesting publication called "Atlas: Psychiatric
21
Education and Training across the World 2005". 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
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
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2.
3.
4.
5.
6.
7.
Patel CS. History of the Medical Council of India. M.C.I. Silver Jubilee Souvenir 1959, MCI,
New Delhi, 1959.
MCI Website: http://www.mciindia.org/InformationDesk/MedicalCollegeHospitals/
th
ListofCollegesTeachingMBBS.aspx 11 Dec 2014
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.
Berkeley Hill O.A.R. The Position of Psychology in the Teaching of Medicine. The Indian
Medical Gazette, Vol. LXV No. 5, May 1930.
Berkeley Hill O.A.R. Psychiatry and General Medicine Part III Patna Journal of Medicine. Vol.
VIII Jan 1933.
Sharma S, Nizamie SH, Goyal N. History of Indian Journal of Psychiatry. Indian J Psychiatry
2009; Commemorate Volume, 48-59.
Saha CC. Presidential Address. Indian J Psychiatry 1962; 4(1):32.
16
8.
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Indian Psychiatric Society First Report of the Subcommittee on undergraduate Teaching in
psychiatry. Indian J Psychiatry 1965; 7(1): 63-72.
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.
Sharma Shridhar. General Hospital Psychiatry and Undergraduate Medical Education.
Indian J Psychiatry1984; 26(3): 259-263
Bhaskaran K. Editorial, Undergraduate Training in Psychiatry and Behavioural Sciences –
The need to train the trainers. Indian J Psychiatry 1990; 32(1): 1-3.
Reddy IR. Undergraduate psychiatry education: Present scenario in India. Indian J
Psychiatry 2007; 49(3): 157-158.
Dale JT, Bhavsar V, Bhugra D. Undergraduate medical education of Psychiatry in the West.
Indian J Psychiatry 2007; 49(3): 166-168.
Sharma SD. Psychiatric facilities in India. Rural Mental Health Published by Indian
Psychiatric Societies at Sevagra, Wardha on 13 Feb. 1976.
Sharma S. Postgraduate training in Psychiatry in India. Indian J Psychiatry Supplement
January 2010.
Murthy RS, Khandelwal S. Undergraduate training in Psychiatry: World perspective. Indian
J Psychiatry 2007; 49(3): 169-1174.
Manickam LSS, Rao TSS. Undergraduate medical education: Psychological perspectives
from India. Indian J Psychiatry 2007; 49(3): 175-178.
Kulhara P. Postgraduate Psychiatric Teaching Centres: Finding of a survey. Indian J
Psychiatry 1985; 27(3): 221-226.
Sharma Shridhar. Postgraduate Training in Psychiatry in India. The Bulletin of the Royal
College of Psychiatrists, London Oct. 1979; pp. 154-156.
Thirunavukarasu M, Thirunavukarasu P. Retrospective introspection. Indian J Psychiatry
2009; 51(2): 85-87.
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
1-6
training of psychiatry. This justification is based on (a) high prevalence of
7
mental health problems in India, (b) high percentage of patients reporting to
8
primary care have psychological problems, (c) patients with mental illness
9
frequently report to physicians, (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 undergraduate training will decrease stigmatization of the mental health
6,10
profession and mental health services, (g) doctors would have better
4,11
communication skills when well trained in psychiatry.
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
8,13
primary health care level. In accordance, WHO has also published ICD- 10
14
Primary Care for primary care practice (ICD-10 PC Chapter V). 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
4,15
medical studies has significantly changed in most western nations. 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
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
1-3,5,6
Professionals,
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
19
(1983) and AIIMS- Delhi (1994). 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 therapy 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
9,19
report to primary care physician; usually with somatic complains. 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 'biopsycho-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 whatso-ever reasons would be more likely to approach psychological services.
Of now, India produces 416 psychiatry degree holders and 129 diploma in
22
psychological medicine holders per year. 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
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 cutdown 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
4
not have a fully functional department of psychiatry & 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
21
21
conducted, all over the country, enrolling about 51,955 students per year.
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
forums and communications. The benefit of these measures would finally be
the person in distress and the society at large.
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19.
Thiruavukarasu M. Psychiatry in UG curriculum of medicine: Need of the hour. Indian J
Psychiatry. 2007 Jul-Sep;49(3):159-60.
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.
Trivedi JK, Dhyani M. Undergraduate psychiatry training in South Asian countries. India J
Psychiatry 2007. 2007 Jul-Sep;49(3):163-65.
Murthy RS, Khandelwal S. Undergraduate psychiatry: World perspective. Indian J
Psychiatry. 2007 Jul-Sep;49(3):169-74.
Manickam LSS, Rao TSS. Undergraduate medical education: Psychological perspective
from India. Indian J Psychiatry. 2007 Jul-Sep;49(3):175-78.
Shivanand K. Undergraduate clinical posting in psychiatry: Are we paying enough
attention? India J Psychiatry. 2010 Apr-Jun;52(2):194
Math SB, Chandrashekhar CR, Bhugra D. Psychiatric epidemiology in India. India J Medical
Research. 2007 Sep;126:183-92
Reddy I. Making psychiatry a household word. India J Psychiatry. 2007 Jan-Mar;49(1):10-18
World Health Organization. Mental Health Gap Action Programme (mhGAP): Scaling up
care for mental, neurological and substance use disorders. Geneva: WHO Press; 2008.
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
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
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
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.
World Health Organization. Diagnostic and Management Guidelines for Mental Disorders
in Primary Care: ICD-10 Chapter V Primary Care Version. Geneva: WHO Press; 1996.
Dale JT, Bhavsar V, Bhugra D. Undergraduate medical education of psychiatry in west.
Indian J Psychiatry. 2007 Jul-Sep;49(3):166-68.
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
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
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.
Reddy I. Undergraduate psychiatry education: Present scenario in India. Indian J
Psychaitry. 2007 Jul-Sep;49(3):157-58.
23
20. World Health Organization. World Health Report 2001. Mental Health: New
understandings new hope. Geneva: WHO Press; 2001.
th
21. Medical Council of India. List of colleges teaching MBBS [Internet]. Last Accessed: 14 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
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
[1]
requirement. This is important for scaling up of services.
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.
[1]
We would like to share our experience.
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
NO
1
2
3
4
5
6
7
8
9
Introduction and overview
of psychiatry
Psychiatric emergencies
Common symptoms
Common drugs
Stigma
Communication skills
Management in a PHC
setting: Substance use
Management in PHC setting:
Somatoform, anxiety and
depressive disorders. District
Mental Health Programme,
Disability act,
Multiple Choice Questions,
Feedback
TOOLS AND PROCESSES USED
Group discussion
Problem based learning using case vignettes
Clippings, discussion
Drug kit, discussion
Clippings, discussion
Role play, discussion
Topic presentation
Problem based learning using case vignettes
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
[1.2]
train future doctors in mental health care.
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
[3,4]
posting. Hence we did not give any additional focus on psychotic disorders.
Conditions like depression, delirium, suicidal attempts, anxiety disorders,
sexual dysfunction, adjustment disorders, sleep 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
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. Coexistence 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
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
2
3
4
5
6
Murthy RS, Khandelwal S. Undergraduate training in Psychiatry: World perspective. Indian
J Psychiatry 2007 July;49(3):169-74.
Dale JT, Bhavsar V, Bhugra D. Undergraduate medical education of Psychiatry in the West.
Indian J Psychiatry 2007 July;49(3):166-8.
Trivedi JK, Dhyani M. Undergraduate psychiatric education in South Asian countries.
Indian J Psychiatry 2007 July;49(3):163-5.
Psychiatry 2007 July;49(3):157-8.
Oakley C, Oyebode F. Medical students' views about an undergraduate curriculum in
psychiatry before and after clinical placements. BMC Med Educ 2008;8:26.
Jacob KS. Psychiatric education for medical students. Natl Med J India 1998
November;11(6):287-9.
Rajan Nishanth Jayarajan
NIMHANS
Bangalore - 560 029
K.S. Shaji
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
[1]
psychiatry.
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
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
[4]
mental disorders.
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
[5]
in psychiatry by the NBE per year.
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
[5]
for academic exposure.
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
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
[26]
alarmingly low. 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 deaddiction, consultation-liaison psychiatry, 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
[4]
the curriculum so as to meet the local needs.
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/
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
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 19462003. New Delhi: Elsevier; 2005.p215-17.
2.
NCMH Background Papers - Burden of Disease in India. National Commission of
Macroeconomics and Health, 2005.
3.
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 : 8-122014.
6.
Bhaskaran K. Undergraduate training in psychiatry and behavioural sciences - The need to
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
Ajit Avasthi
Professor
Chandigarh 160012, India
[email protected]
Sandeep Grover
Assistant Professor
PGIMER, Chandigarh -160012, INDIA
Naresh Nebhinani
Dept. of Psychiatry
rd
3 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
[1].
the third decade of nineteenth century 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 Postgraduate Psychiatry Education to examine the status of PG training in the
[4]
country .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
assessed methods, [17] survey of postgraduate training centers [18], and the
[19]
role of general hospitals in postgraduate teaching.
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,
[1]
and be aware of the contemporary advances in the discipline . 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
3
INSTITUTIONS
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
[22]
centres; the quality and intensity of such training varies across centres. 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
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 nonpharmacological) and prevention.
SPECIFIC LEARNING OBJECTIVES
Research: Trainee should know the basic concepts of research methodology
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
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
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,
D i s s o c i a t i v e F u g u e , D i s s o c i a t i v e I d e n t i t y D i s o rd e r,
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 AnxiolyticRelated Disorders, etc.)
23. Sexual and Gender Identity Disorders (Including Sexual Desire
Disorders, Sexual Arousal Disorders, Orgasmic Disorders, Sexual Pain
Disorders, Vaginismus, Paraphilias, etc)
46
24.
25.
26.
27.
28.
29.
30.
31.
32.
33.
34.
35.
36.
37.
38.
39.
40.
41.
42.
43.
44.
Mental Health Issues In Women
Pre-Menstrual Dysphoric Disorder
Post-Partum Psychiatric Disorders
Organic Psychiatry (Including Amnestic Disorders, Catatonic
Disorders, Cerebro-vascular Disorders, Delirium, Dementia,
Endocrine Epilepsy, Head Injury, Headache, HIV – AIDS, Infections,
etc.)
Mental Retardation
Emergencies In Psychiatry
Suicide, management and medico-legal aspect.
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.)
Factitious Disorders
Culture Bound Syndromes
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.)
Forensic and Legal Psychiatry (Including Indian Lunacy Act, Mental
Health Act, Persons with Disability Act, Narcotic Drugs and
Psychotropic Substance Act)
Geriatric Psychiatry
Community psychiatry
Psychosomatic Disorders
Consultation-Liaison Psychiatry
Movement Disorders (Including Medication-Induced Movement
Disorders, etc)
Stress and related disorders
Adjustment disorders.
Trans-cultural Psychiatry
Abuse (physical/emotional/sexual) or neglect of child/adult/elderly
45.
46.
47.
48.
49.
50.
51.
52.
53.
3.
47
Placebo Effect
Psychology (Clinical) as applied (Psychometry/ Psychodiagnostics)
Psychodynamics
Psychopharmacology
Electro-Convulsive Therapy
Psychosurgery
Statistics/Research Methodology/Epidemiology
Rehabilitation of psychiatric patients
Ethics In Psychiatry
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
3.
4.
5.
6.
7.
8.
9.
10.
11.
the time of final examination and be essential component to pass the
examination separately in communication skills.
Arrive at a logical working diagnosis and differential diagnosis after
clinical examination.
Order appropriate investigations keeping in mind their relevance and
cost effectiveness and additional relevant information from family
members to help in diagnosis and management.
Be able to perform quick intervention for suicide attempt and high
risk suicidal patients.
Write a complete case record with all necessary details.
Write a proper discharge summary with all relevant information.
Obtain informed consent for any examination/procedure.
Be able to perform modified ECT
Be able to use rationale pharmacotherapy.
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.
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 psychiatric hospital.
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
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
l.
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.
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) Addiction Psychiatry
(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
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 interunit / 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
Paper III:
Psychiatric theory and Psychiatric specialties
Paper IV:
Neurology and General Medicine as related to Psychiatry
53
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.
2.
3.
4.
5.
6.
7.
8.
Kaplan and Sadock’s Comprehensive Text Book of Psychiatry
Kaplan and Sadock ‘s Synopsis of Psychiatry
Fish Clinical Psychopathology
Lishman Organic Psychiatry, The Psychological consequences of
cerebral disorder
Clinical practice guideline of Psychiatric disorders in India
Stahl Psychopharmacology
Oxford text book of Psychiatry
National Programmes and Acts
Journals
1.
British Journal of Psychiatry
54
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
American Journal of Psychiatry
Archives of General Psychiatry
Acta Psychiatrica Scandinavica
Psychosomatic Medicine
Psychopharmacology
Biological Psychiatry
Journal of Clinical Psychiatry
Journal of Child Psychology and Psychiatry
Indian Journal of Psychiatry
Journal of American Academy of Child and Adolescent Psychiatry
REFERENCES:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Sharma S. Post-graduate training in Psychiatry in India. Indian J Psychiatry.2010;52:89-94.
Patel CS. History of the Medical Council of India. M.C.I. Silver Jubilee Souvenir 1959, MCI,
New Delhi.
th
MCI Website: http://mciindia.org/apps/search/show_colleges.asp Last Accessed: 14
December 2014.
Indian Psychiatric Society First Report of the Subcommittee on undergraduate Teaching in
psychiatry. Indian J Psychiatry 1965;7:63-72.
Saha C.C. Presidential Address. Indian J Psychiatry.1962;4:1
Sethi BB. Indian psychiatric society editorial, undergraduate psychiatry. Indian J Psychiatry
1978;20:197.
Sharma S. General hospital psychiatry and undergraduate medical education. Indian J
Psychiatry 1984;26:259-63.
Bhaskaran K. Editorial, undergraduate training in psychiatry and behavioural sciences The need to train the trainers. Indian J Psychiatry 1990;32:1-3.
Tharyan A, Datta S, Kuruvilla K. Undergraduate training in psychiatry an evaluation. Indian
J Psychiatry 1992;34:370-2
Psychiatry 2007;49:157-8
Ghosh AB, Mallick AK. Why should psychiatry be included as examination subject in
undergraduate curriculum? Indian J Psychiatry 2007;49:161-2
Trivedi JK, Dhyani M. Undergraduate psychiatric education in South Asian countries.
Indian J Psychiatry 2007;49:163-5.
Dale JT, Bhavsar V, Bhugra D. Undergraduate medical education of psychiatry in the West.
Indian J Psychiatry 2007;49:166-8.
Murthy RS, Khandelwal S. Undergraduate training in psychiatry: World perspective. Indian
J Psychiatry 2007;49:169-74
Manickam LSS, Rao TSS. Undergraduate medical education: Psychological perspectives
from India. Indian J Psychiatry 2007;49:175-8.
Pickren W. Psychology and medical education: A historical perspective from the United
States. Indian J Psychiatry 2007;49:179-80.
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.
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
GB Pant Hospital & University of Delhi
& Chairman
Psychiatry Education Committee
[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
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
Systems
Peers
Beliefs
Curiosity
Courage
Effective
Methods
Opportunities
Varieties
Safety
Learning
Feedback
Guidance
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
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
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, Emergency Psychiatry, Psychopharmacology, Geriatric
Psychiatry, Presentation skills, Sexual dysfunction, Ethics, Psychiatric
rehabilitation, Consultation Liaison Psychiatry and Forensic Psychiatry. Each
62
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
[1,3]
popular with trainees.
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.
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, traineetherapists 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 therapies. 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
1. Patient related
a.
b.
c.
d.
e.
Availability to the patients in times of crises
Education about treatment and illness
Ensuring confidentiality and maintaining boundaries
Involving patients and care givers in decision making
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.
b.
c.
d.
e.
f.
Descriptive psychopathology
Rational use of psychotropics
Understanding of prescribing practices
Diagnostic skills
Prognostication
Keeping abreast with latest advances
3. Skills
a.
b.
c.
d.
e.
Handling psychiatric emergencies
Skills in treating difficult patients and families
Communicating prescription to patient and families
Writing adequate round notes and OP notes
Ability to translate theoretical knowledge towards patient
care
4. Participating in teaching programs
a.
b.
c.
d.
Prior preparation
Asking questions and raising issues
Quality of presentations
Participation in discussion/making comments
5. Communication with superiors and peers about patients
a.
b.
c.
d.
e.
With peers (residents/other trainees)
With senior residents and consultants
Discussion about ward behaviors with nurses
Communication and clarity about treatment orders to nurses
Communicating with senior residents/consultants from
other disciplines-Clinical psychology/Social work/Neurology
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
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.
2.
3.
4.
5.
6.
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.
Channabasavanna SM. Psychiatric education. Indian J Psychiatry 1986 ;28:261-262.
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.
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.
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.
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.
Professor & Head
Prabha S. Chandra
Professor & Chairperson, Academic Programmes
Shekhar P. Seshadri
Professor & Coordinator, Psychotherapy Programme
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
Bangalore, India
For Correspondence:
Professor & Head
NIMHANS
Bangalore 560029
[email protected]
67
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
1
disorders. 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
successive five-year plans since the beginning of National Mental Health
2
Programme (NMHP) in 1982. The budgetary allocation for mental health was
th
3
severely limited till the 10 five year plan (2002-07) , 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
th
As of 14 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 nonexistent 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
7
resources, as per the WHO data , 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
8
provide a comprehensive training . 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.
2
The National Mental Health Programme (NMHP) 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
10
eighth five year plan. During the ninth five year plan (1997-2002) , 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 reoriented 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.
th
The 11 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
12
consultation with various stakeholders. Part one of NMHP is primarily
directed at Manpower Development and a strong commitment has been
made for human resource development by allocating Rs 408 crores for
th
Manpower Development Component for NMHP under 11 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
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
13
work and psychiatric nursing. In the most recent year (2009-10) , 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
th
been funded earlier during the 10 plan period will be supported as part of
this spill-over scheme. Some of the deserving areas where there is no well
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
th
priority for hospitals which have not been funded previously in the 10 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 fiveyear plan. These include relaxation of the existing norms for infrastructure
and training requirements, amendments for setting up of medical colleges
4
and increasing postgraduate seats by revision of teacher: student ratio. 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
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
14
districts. 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
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.
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/
th
InformationDesk/CollegesCoursesSearch.aspx Accessed 14 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
Rajesh Sagar (Author for correspondence)
Associate Professor
&
Secretary, Central Mental Health Authority
Tel: 011-26588500-3644, 3236
E-mail: [email protected]
Raman Deep Pattanayak
Senior Research Associate (CSIR)
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 health in India: 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
[1]
community.
Academic centres have an important role in the provision of mental health
[2]
care to the total population (WHO,2006, Box 1) .
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
l
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.
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
[3]
approaches.
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 nonprofessionals 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
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
[4]
changes has been an important contribution of NIMHANS. 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).
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 reestablish their role in the NMHP-DMHP, especially in the monitoring and
[5]
evaluation of the mental health care provided through these programmes.
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
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
[6]
'hooked'.
[7]
One other example is the MOBILE HEALTH initiative of IIT, Madras.
Similarly, the PDS system in Chattisgarh state has been revolutionised by (I)
expanded reach (ii) expanded number of beneficiaries (iii) better vigilance(iv)
[8]
increased awareness in the population and (v) improved economic viability.
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
[9]
savings and better control of hospitals and fully in-house administration.
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
[2]
resources to achieve maximum advantage to the country at all levels.
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
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
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
[10]
research. 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
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
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2.
3.
4.
5.
6.
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8.
Scientific Program: Conference Theme: “Providing Mental Health Care to All”.Retrieved on
27th Dec. 2011.www.ancips.com/scientific-program.
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.
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.
Isaac MK. District Mental Health program at Bellary. Community Mental Health News
1988.NIMHANS Bangalore;11-12(April-Sep)8.
Sinha SK, Kaur J. National Mental Health Programme: Manpower development scheme of
eleventh five year plan. IndianJPsychiatry 2011;53(3):261-265.
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/tpfeatures/tp-opportunities/article646447.ece.
Building Mobile Health-Editorial, The Hindu, September 17,2010.Retrieved on Dec 29
2011 from: http://www.thehindu.com/opinion/editorial/article672982.ece.
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
[1]
modern psychiatric nurses.
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
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:
th
In 4 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 lunatic asylum 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), insulin shock therapy (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
[2,3]
were derived from practical experiences of caring for psychiatric patients.
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
[4]
Diploma in Psychiatric Nursing.
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
[4]
year 2005.
90
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
[5,6,7,8]
care.
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
[9]
inadequately equipped to play their role.
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
[11]
authority and central mental health authority at centre.
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,
[12,13]
psychiatric rehabilitation, community mental health and family therapy.
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 (Referwww.indiannursingcouncil.org for details). Among these some key
[14]
institutions are:
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
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 superspecialties, 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
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
[1]
Adjusted Life Years (DALY) . 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
[2]
health care delivery systems . 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)
[3, 4]
countries whereas in developed countries it is 77% .
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. Superspeciality 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
[4]
bodies or medical or psychiatric councils . 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.
II.
III.
IV.
Diploma in psychiatry
Master's degree in psychiatry
Ph D in psychiatry
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
[5]
curriculum are :
l
l
Basic sciences ( human growth and development, neurosciences,
genetics, behavioral science, social science and psychopharmacology)
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
l
l
l
l
Prevention and mental health promotion
Primary / secondary / tertiary prevention
Mental health education / health promotion/ reinforcement of
healthy behavior
General aspects
l
l
l
l
l
Teaching skills and methodology / research methodology and
statistics
Evidence – based medicine / psychiatry
Cross – cultural psychiatry / religion and spirituality
Ethics, legal aspects / forensic psychiatry
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,
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:
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
l
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
rd
before commencement of the examination in 3 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
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
st
1 year of training the residents need to acquire basic knowledge in
nd
psychiatry and competency in inpatient care. In the 2 year, the resident has
st
to continue 1 year curriculum and acquire competency in outpatient care. In
st
third year, the residents have to master the curriculum of 1 & 2nd year and
are trained in super-specialities of psychiatry. The last year of residency
st
nd
rd
includes development of clinical competency and supervising 1 , 2 and 3
year residents. The faculty members provide regular clinical group
supervision. The residents have to publish at least one original article under
[6, 7]
supervision of faculty during their psychiatric training.
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
[8]
the west.
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]
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
0
0
0
0
4
Child psychiatry course 0
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%
10%
10%
Rare
50%
*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
[10]
oral and written examination .
CONCLUSION
Psychiatric training is developing rapidly in Asia. Psychiatric education and
training, whilst playing a pivotal role in addressing the burden of mental
100
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.
2.
3.
4.
5.
6.
7.
8.
9.
10.
World Health Organization (2004). The World Health Report 2004: Changing History. World Health Organization.
Geneva. World Health Organization (2001a).
The World Health Report 2001: Mental Health: New Understanding, New Hope. World Health Organization. Geneva.
World Health Organization (2005). Mental Health Atlas 2005. World Health Organization. Geneva.
www.who.int/mental_health/evidence;atlas/index.htm
World Health Organization, World Psychiatric Association (2005), Atlas, Psychiatric education and training across
the world, 2005.
World psychiatric association institutional program on the core training curriculum for psychiatry; YOKOHAMA,
JAPAN, AUGUST 2002.
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.
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.
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.
Daniel Savin; Developing Psychiatric Training and Services in Cambodia Psychiatr Serv 51:935, July 2000 © 2000
American Psychiatric Association.
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,
Lucknow-226003
[email protected]
J.K. Trivedi
Professor & Ex-Head,
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
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
3
hopeful minimization of stigma within the profession .
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
4
never returned to Sri Lanka . 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
5
been approved by the Government of Sri Lanka for the first time in 2005 . 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
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
6
disorders .
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
7
patients have been cared for in the community by their families . 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.
2.
3.
4.
5.
6.
7.
8.
9.
Nisha Dogra and Khalid Karim. Diversity training for psychiatrists. Advances in Psychiatric
Treatment (2005) 11: 159-167
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
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.
Malik Hussain Mubbashar and Asma Humayun. Training Psychiatrists in Britain to Work in
Developing Countries. Advances in Psychiatric Treatment 1999; 5: 443 - 446.
The Mental Health Policy of Sri Lanka: 2005-2015. Ministry of Healthcare and Nutrition
2005.
Atlas: Nurses in Mental Health 2007. World Health Organisation 2007.
Saeed Farooq and Fareed A. Minhas. Community psychiatry in developing countries — a
misnomer? Psychiatric Bulletin, 2001; 25: 226 - 227.
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.
Atlas: Psychiatric education and training across the world. World Health Organisation
2005.
Harischandra Gambheera
Colombo, Sri Lanka
[email protected]
Shehan Williams
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
1
fresh influx of 200,000 refugees, mainly women and children . 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
3
4
specialists (PMDC. 2006). The magnitude of mental illness is alarming 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
5
units . 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.
6
A recent survey 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
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
9
Surgeons of Pakistan website.
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.
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
12
knowledge.
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
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
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
15
promoting sound mental as well as physical health is imperative .
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
www.who.int/countries/pak/en/ date accessed: 24th June, 2006.
UNICEF. State of the world’s children, New York, USA 2006: 96-111.
Actionaid (2002). http://www.actionaid.org.uk/wps/content/documents/
new_pakistan_2432004_113938.pdf
Gadit A. A & Khalid. N. In State of Mental Health in Pakistan — Service, Education and
Research. Hamdard University Hospital, Karachi, Pakistan. 2002.
Niaz U, Hassan S, Hussain H, Saeed S. Attitudes Towards Psychiatry in Pre-Clinical and PostClinical Clerkships in Different Medical Colleges of Karachi. Pakistan J Med Sci: 2003; 19(4):
253-63.
Farooq, S. Psychiatric training in developing countries. British J Psych 2001; 179: 464.
Naeem F, Ayub M. Psychiatric training in Pakistan. Med Educ Online [serial online] 2004;9:
19.
Ijaz Haider, Diploma in Psychological Medicine (DPM) at Postgraduate Medical Institute,
Lahore. Psychiatric Bulletin (1995);19:446-447.
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.
Davies T, McGuire P .Teaching medical students in the new millennium. Psychiatric Bul
2000; 24: 4-5.
Table from http://www.med-ed-online.org
Khan MM. The NHS International Fellowship Scheme in Psychiatry: robbing the poor to
pay the rich? Psychiatr Bull 2004; 28: 435-7.
Khan MM. The International Fellowship Scheme. Letter to Editor. Psychiatr Bull
2004;28:433-4.
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.
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 NEPAL: DEVELOPMENTAL MILESTONES IN BRIEF
1,2
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
3
UMN Mental Health Project from 1990 to 2000 .
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, TUTH with technical assistance of WHO and summated to ministry of health for
necessary action4-6. Centre for Mental Health and Counseling-Nepal (CMCNepal) 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
2,8-10
UNIVERSITY-TEACHING HOSPITAL (TU-TH) :
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
9
district by mental hospital in collaboration with World Health Organization .
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
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
11
separate subject with increased allocation of time .
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
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
13
PSYCHIATRY IN NEPAL : 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
2,15-17
3. Research Activities and Publications
: 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
nd
conducted 2 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.
2.
3.
4.
5.
6.
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.
Sharma VD. Editorial. Mental health in Nepal. Nepalese J Psychiatry 1999, 1(1): 3-4.
Acland S. Report on mental health camp at Gandruk village, Kaski district. Kathmandu, United
Mission to Nepal, 1998.
Shrestha NM. National Mental Health Policies, Strategies and Action Plan. Mental Health
Manual for Medical Doctors. Government of Nepal & WHO, 2005.
Shrestha NM. The annual report of mental health status of Nepal 2007-08. Ministry of
Health and Family Planning, Government of Nepal, Kathmandu 2007.
Upadhaya KD. Proceedings of National Seminar on Implementation of National Mental
Health Policy: Accelerating the Rate and Meeting the Challenges. Kathmandu 1999.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
121
Shrestha RL. Annual Report 2007-2008: Centre for Mental Health & Counseling – Nepal.
Kathmandu, 2008.
Chhetri AM, Jareg E, Sinha RN. Evaluation of the Mental Health Project in Nepal [Redd BarnaNepal]. Kathmandu, 1994.
WHO and Ministry of Health and Population Nepal. WHO-AIMS Report on Mental Health
System in Nepal. Kathmandu, Nepal, 2006.
Regmi SK, Pokharel A, Ojha SP, Pradhan SN, Chapagain G. Nepal mental health country
profile. Int Rev Psychiatry 2004 16(1-2):142-9.
R Srinivasa Murthy, S Khandelwal. Undergraduate training in Psychiatry: World
perspective. Indian J Psychiatry 2007 49(3):169-174.
Shrestha DM, Pach A, Rimal KP. A social and psychiatric study of mental illness in Nepal [United
Nations Childrens Fund, Nepal]. Kathmandu, 1983.
Chhetri AM, Jareg E, Sinha RN. Evaluation of the Mental Health Project in Nepal [Redd BarnaNepal]. Kathmandu, 1994.
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.
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.
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.
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.
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
6.
7.
8.
9.
10.
UCMS, Bhairahawa
NMC, Birgunj
Manipal, Pokhara
M. Phil. in Clinical Psychology:
(IOM, Kathmandu)
M. Sc. Psychiatric Nursing:
(BPKIHS, Dharan)
Diploma in Psychiatric Nursing:
(IOM, Kathmandu)
Psychiatric Social worker:
Occupational therapist:
1PG student/year
1-2PGstudents/year
1PG student/year
1-2/year
2/year
4/year
Nil
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.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Dr Saroj Prasad Ojha. Emotional and behavior problems in physically disabled
children and adolescents. 2000.
Dr Anupam Pokhrel. A phenomenological study of a patient in stupor and stupor
like state. 2000.
Dr Mohan Raj Shrestha. An open randomized comparative study of efficacy and
tolerability of amitriptyline and sertraline in major depression. 2001.
Dr SN Pradhan. Attempted suicide –a study of socio-demographical variable,
method employed and associated mental disorder. 2001.
Dr Ghanshyam Chapagain. A study of depression in MI. 2001.
Dr CP Sedain. An exploratory study of depressive disorder in patient with GI
carcinoma. 2002.
Dr NR Koirala. Presenting symptoms of depressed patients at PHC. 2002.
Dr Lumeshwar Achariya. A sociodemographical & clinical profile of depression
following CVA. 2002.
Dr Sailendra Raj Adhikari. Prevalence of emotion and behavioural problem
among school going children. 2003.
Dr Namrata Rawal. A study of psychiatric consequences among patients with
RTA. 2004.
Dr Binu Champakasssery Balan. Gender difference in unipolar depression–A
comparative study. 2004.
Dr Manisha Chapagain. Study of prevalence of post-mortem depression and
impact of psychological intervention on it. 2004.
Singh Bahadur Henjan. A study of anxiety depression and suicidal ideation
among HIV infected people. 2004.
Dr VD Sharma. Cognitive dysfunction in adult schizophrenic patients and their
first degree relatives. 2005.
Dr Rabindra Kumar Thakur. A study of dissociative disorder– phenomenology
and other correlates. 2005.
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
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
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
in common. For several decades textbooks used in undergraduate and postgraduate 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
2
(PMETB) in 2005 itself. 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
3
assessments and training.
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
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 multiethnic 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
6
other in Child and Adolescent Psychiatry (CAP) at NIMHANS, Bangalore,
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
9,10
workplace in addition to achievements in periodically held examinations.
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
11
current training programs in the country. 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
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,
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
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
6
Committees (RRC) to oversee specialty-specific training .
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
6, 7
Improvement, Interpersonal and Communication Skills .
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/
Primary Institution Training Sites
Program Personnel
Program Resources
Program Director
Clinical Resources
Letters of
Agreement
Program Faculty Program Staff
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
8
the psychiatry-specific requirements , 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
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
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
7,8
evaluations .
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
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
l
l
l
l
Physician-patient relationship
Conduct of psychiatric interview
Organization and presentation of data
Phenomenology, diagnosis, and prognosis
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.
137
All ABPN time-limited certificates are valid for 10 years. The ABPN MOC
program includes four components: (1) Professional Standing, (2) SelfAssessment 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
12
such programs may be obtained from the AAPI .
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
13
referred to the articles annotated by Nyapati Rao and colleagues on 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 Sleep Medicine. 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
1
detailed guidelines for the curricula and training for these programs .
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, neuropsychiatry, 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
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
15
are listed below in Table II .
Institution
City
1 UNIVERSITY OF PITTSBURGH SCHOOL
OF MEDICINE
PITTSBURGH
2 UNIVERSITY OF PENNSYLVANIA
SCHOOL OF MEDICINE
PHILADELPHIA
3 YALE UNIVERSITY SCHOOL OF MEDICINE NEW HAVEN
4 DUKE UNIVERSITY SCHOOL OF MEDICINE DURHAM
5 UNIVERSITY OF CALIFORNIA SAN DIEGO
SCHOOL OF MEDICINE
LA JOLLA
6 WASHINGTON UNIVERSITY SCHOOL
OF MEDICINE
SAINT LOUIS
7 JOHNS HOPKINS UNIVERSITY SCHOOL
OF MEDICINE
BALTIMORE
8 MOUNT SINAI SCHOOL OF MEDICINE
NEW YORK
YORK
9 UNIVERSITY OF TEXAS SOUTWESTERN
MEDICAL CENTER
DALLAS
10 UNIVERSITY OF MARYLAND SCHOOL
OF MEDICINE
BALTIMORE
11 DAVID GEFFEN SCHOOL OF MEDICINE
AT UCLA
LOS ANGELES
State
PENNSYLVANIA
PENNSYLVANIA
CONNECTICUT
NORTH CAROLINA
CALIFORNIA
MISSOURI
MARYLAND
NEW
TEXAS
MARYLAND
CALIFORNIA
Pandurangi:Psychiatric training in the USA & India
Institution
12 UNIVERSITY OF MICHIGAN
MEDICAL SCHOOL
13 STANFORD UNIVERSITY SCHOOL
OF MEDICINE
14 UNIVERSITY OF WASHINGTON SCHOOL
OF MEDICINE
15 UNIV OF COLORADO HEALTH SCIENCE
CTR SCHOOL OF MEDICINE
16 UNIVERSITY OF CALIFORNIA SAN
FRANCISCO SCHOOL OF MEDICINE
17 EMORY UNIVERSITY SCHOOL
OF MEDICINE
18 COLUMBIA UNIVERSITY COLLEGE OF
PHYSICIANS & SURGEONS
19 UNIVERSITY OF NORTH CAROLINA
SCHOOL OF MEDICINE
20 MEDICAL UNIVERSITY OF SOUTH
CAROLINA COLLEGE OF MEDICINE
21 UNIVERSITY OF CINCINNATI COLLEGE
OF MEDICINE
22 UNIVERSITY OF IOWA COLLEGE
OF MEDICINE
23 UNIVERSITY OF MIAMI SCHOOL
OF MEDICINE
24 UNIVERSITY OF ILLINOIS COLLEGE
OF MEDICINE
25 NEW YORK UNIVERSITY SCHOOL
OF MEDICINE
City
State
ANN ARBOR
MICHIGAN
STANFORD
CALIFORNIA
SEATTLE
WASHINGTON
AURORA
COLORADO
139
SAN FRANCISCO CALIFORNIA
ATLANTA
GEORGIA
NEW YORK
NEW YORK
CHAPEL HILL
NORTH CAROLINA
CHARLESTON
SOUTH CAROLINA
CINCINNATI
OHIO
IOWA CITY
IOWA
CORAL GABLES FLORIDA
CHICAGO
ILLINOIS
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
16
Fogarty International Center 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
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
19
International Center . 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
20
and Training program, and the genetics training program with Drs
Nimgaonkar and Deshpande as project directors in USA and India
respectively.21
22
The Indo-US Science & Technology Forum (www.Indousstf.org) 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.
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
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
Virginia Commonwealth University
P.O. Box 980710
Richmond, Virginia, 23298 USA
[email protected]
17
Psychiatry Training in Australia
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
Australia, 80% of whom are in private practice. In terms of training, there are
close to 700 trainees (registrars) with approximately 100 qualifying each
[1]
year . 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 undergoa 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 theend 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 tomeet 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 shortanswer 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 askedto 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
independently, either privatelyor 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 registrartraining scheme dealing with
phenomenology and a variety of clinical topics at the outset progressing onto
neurosciencesand 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
[4]
psychiatry 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
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 specialinterest during training.
Australian training and its relevance to Indian Training
There are positive aspects of the Indian training scheme in that itis 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
[9]
in all regions, although pilot schemes like the Raipur Rani project in Punjab
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
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 lackof 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 beensuggested 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.
2.
3.
4.
Henderson, S. Focus on psychiatry in Australia. Br J Psychiatry 2000;176: 97-101.
RANZCP. Training and Examination By Laws for Fellowship 2000.
Alexander, P. J. & Kumaraswamy, N. Impact of medical school experiences on senior
medical students interested in psychiatry. Indian J Psychiatry 1995;37: 31-34.
Kapur, R. L. Mental health care in rural India: a study of existing patterns and their
149
implications for future policy. Br J Psychiatry 1975; 127: 286-293.
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.
5.
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
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
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
1,2
from the RANZCP website (www.ranzcp.org)
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
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
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
3
to care.
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-deCalais 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 (medicopsychological 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
the stereotypes of “mental illness” and “madness” and the stigmatization of
“mentally ill” or “mad” people. This research work, supported by the NordPas-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 fulltime 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.
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-enBaroeul, 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
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 LilleMétropole). 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-
163
patient unit, remains located in EPSM Lille-Métropole at Armentières. This inpatient 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 socioeducational 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 LilleMétropole. 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
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
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
87
63
Compulsory treatments
Number of people admited in host
families (AFTAH)
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
165
4,5
recommendations 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 socioeducational 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
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”
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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
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. LilleMétropole. 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.
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
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 (medicopsychological 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:
l
l
The studying of all good practices in Trieste6-9 in 1976 led to their
implementation in east Lille suburb in 1977.
Host families as an alternative to hospitalization (one family= one
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
11-14
representatives. For that purpose, it is essential to go beyond hospitalcentrism and to clearly shift from “psychiatry hospital services” to “individual
15-16
health and social services”, in the person's living environment. Networking
172
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
17
citizens after a preparative work is also a powerful anti stigma strategy. 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
18
of expenditure.
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
22
that mental health delivery is possible through primary health centers.
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
173
All” by the year 2000. Since then training of PHC doctors, nurses and
community level workers started to handle mental health and replacing
23-26
psychiatrists which were available in meager number.
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
27
mental hospitals and mental health units of the general hospitals. 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
28-30
community. 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
Anganwadi 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
30
PHC. 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
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.
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Jean Luc Roelandt
Psychiatrist,
Director of the WHO Collaborating
Head of East Lille Services
176
Nicolas Daumerie
Clinical Psychologist, Project Manager
research and training
in Mental Health (Lille, France)
www.ccomssantementalelillefrance.org
Laurent Defromont
Psychiatrist,
Consultant WHO Collaborating
Head Medical Information and
Research Department,
Aude Caria
Psychologist
Project Manager
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
New Delhi 110002, India;
[email protected]
Specialty Section
20
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
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
[3]
with civilian patients continues in Great Britain . 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
[4]
Centre (MGMC) . 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
[5]
Armed Forces . 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
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
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 multispeciality 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
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,
[14]
Impact of Events Scale and Fatigue Scale in their sample . 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
[15].
efficiency, frustration, maladjustment, tension, isolation and depression
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
[17]
alcoholism in soldiers in Low Intensity Conflict . 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
[18]
persistent scholastic backwardness on review after one year . 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
[19]
area . 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
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 Military Psychiatry 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
liaisons with their civilian counterparts and military medical specialists in
friendly armed forces.
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Surgeon Commodore V.S. Subbarao Ryali
Armed Forces Medical College, Pune 411040.
[email protected]
Col P.Shivram Bhat
K. Srivastava
Scientist 'F' & Clinical Psychologist,
Lt Col K.J. Divina Kumar
185
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
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
th
Indian military psychiatry services can be traced back to 19 century. The first
hospital for the mentally ill Indian sepoys was established in 1975 in Monghyr,
1
Bihar . 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
3.
comfortably even when located in Field areas
Military Psychology
Military Psychology is the application of psychological principles and theories
to the military context determined by the requirements of the armed
4
forces .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
5
Indian Army . 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
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
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
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
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
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
7-8
kind of stressors . 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,
9-12
substance abuse, suicide and shooting at superiors may occur . 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.
2.
3.
HRA Prabhu. Military Psychiatry in India. Indian Journal of Psychiatry 52, supplement,
January 2010.
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.
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
4.
195
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
[email protected]
Mobile- 963776825
Surgeon Commodore V.S. Subbarao Ryali
Armed Forces Medical College, Pune 411040
Lt Col R. Shashikumar
Lt Col Jyoti Prakash
Reader, Department of Psychiatry,
Lt Col S. Nath
Classified Specialist in Psychiatry
Command Hospital(SC), Pune 411040
22
Training in Child Psychiatry in IndiaA 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
[1]
disorders to vary between 15-22% worldwide, and about 12% in India.
[2]
Annual incidence is reported to be about 18/1000 in India in general
population studies. Prevalence in school children is reported to be about
[3,4]
6%. Considering that nearly 50% of India's population comprises of children
and adolescents, the total number of children in need of psychiatric
198
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
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 (<a dozen) established Child Psychiatry
Departments/Units and a handful of trained child psychiatrists. Some of the
child guidance clinics attached to general hospital psychiatric units, are
manned by general psychiatrists or psychologists and not by the child
psychiatrists. Many of the child psychiatric units are not equipped enough in
terms of manpower, facilities, and infrastructure etc. and provide a patchy
and piece meal service.
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 subspecialty 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
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
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
[6]
[7]
issues with the students – drug abuse , bullying improving relationships
[3]
with peers and improving academic performance
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
towards a School Mental Health Program in the major metropolitan cities
[8]
like Mumbai, Delhi and Bangalore . 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
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-economicpsychological 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.
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
[11]
. The model has been implemented as a program in more than 261
[12]
Karnataka government schools and its effectiveness established . 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.
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
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).
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.
3.
4.
211
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): 207214.
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
NIMHANS , Bangalore
[email protected]
K.V. Kishore Kumar
Senior Psychiatrist
NIMHANS, Bangalore
24
Practicing Sexual Medicine A primer for trainees
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
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
3
and women from the womb to tomb . 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
4
for sexual medicine: Agenda for Indian Psychiatric Society' in its 2008 issue .
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
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.
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
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
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
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.
2.
3.
4.
5.
Steen, E.B & Price J.H (1998) Human Sex & Sexuality. Dover Publication Inc. New York.
TSS Rao (2004) Emerging Frontiers of Psychiatry. Sexuality Practice in the Indian context
ANCIPS 2004 Souvenir, Mysore, India
Prakash Kothari (2000) A conceptual model for Human sexuality. Souvenir, KANCIPS 2000,
Mysore, India
Sathyanarayana Rao TS, Avasthi A 'Road Map for sexual medicine: Agenda for Indian
Psychiatric Society. Indian Journal of Psychiatry 2008: 50: 153 – 4.
John P Wincze & Michael P Carey (1991) Sexual Dysfunction. A guide to assessment &
treatment. The Guilford press. New York.
M.G. Road, Mysuru - 570004.
[email protected],
25
Sexuality training in the West
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 KamaSutra, 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, 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
1
222
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
2
physical and mental health affect each other to a large extent. 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 relationshipheterosexual, 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
5
an unpublished study by Kalra and Kamath (2009), 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
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
8,9
patients. These and certain other factors work negatively in the sexualityconsultation 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
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
12
schools; fewer than half of which have formal sexual health curriculum. A
similar picture emerges in the U.K. undergraduate medical education where
10
minimum hours are dedicated solely to sexual health education. 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
13
with the teaching they received on the subject. Sadly, less than 50% of US and
9,14
Canadian medical schools spend more than 2 hours on sexual health, while
only 43% of North American medical schools offer clinical exposure to the
management of sexual dysfunction in detail.15 A multidisciplinary team was
15
involved in sexuality training in almost 63.4% medical schools. 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
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
20,21,22,23,24
talked about the need for research in sexuality;
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
28
deficient in their sex knowledge and harbored undesirable attitudes. 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
227
29,30,31,32
on sexual behavior and dysfunction in diverse populations.
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
36
sexuality specific issue portrayed in the film. Dunn and Abulu (2010) 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
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
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.
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Malhotra S, Khurshid A, Hendriks KA, Mann JR. Medical school sexual health curriculum
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18807442].
Morreale MK, Arfken CL, Balon R. Survey of sexual education among residents from
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Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and
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Solursh DS, Ernst JL, Lewis RW, et al. The human sexuality education of physicians in North
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Steinert Y, Levitt R. The teaching of human sexuality in a family medicine training
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26. Aggarwal O, Sharma AK. Study in sexuality of medical college students in India. Chabra P J
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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 specialitypsychiatry. 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
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
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]
235
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
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; theother 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
th
compiled under Emperor Justinian in 5 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
[1]
[2]
his acts ,therefore not accountable in justice. Paulus Zacchias , the personal
th
physician of the pope in 17 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
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
[5]
holders.
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
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
[7]
context otherwise requires :
“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
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.
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
[7]
communicate by any means, his or her decision.
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
[7]
by the person.
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
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]
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
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
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
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.
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
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)
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
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)
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
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
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
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
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.
If there are reasonable clinical grounds to believe the suicide
ü
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
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
[7]
determination.
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
[9]
of India on 1st January, 1996.
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
[10]
Convention.”
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.
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 VISpecial provisions for persons with benchmark disabilities; Chapter VIISpecial 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 XIVSpecial 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
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 noncoercive, 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
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
[10]
guardian and the person with disability.
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 selfemployment (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 socioeconomic 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
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
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
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
[13]
suggested:
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
[13]
Peel.
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
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
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
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
[19]
in the assessment of fitness to stand trial of mentally ill patients. Some of
the well-known instruments are MacArthur Competence Assessment ToolCriminal 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
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
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
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2.
3.
4.
5.
6.
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Lebigrs A. Quelques Aspects de la Responsibility Penale endroit Romain Classique Paris :
Presses Universitaires de France 1967.
Zacchias P. Quaestiones Medico- legales Roma : Lib II,1625.
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.
Mental Health Act, 1987. Bare act with short comments ; Commercial Law Publishers ,
Delhi 2007.
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)
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.
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]
The Hindu: Cabinet clears Mental Health Care Bill. June 14,2013. Available at:
http://www.thehindu.com/news/national/cabinet-clears-mental-health-carebill/article4812291.ece
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).
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)
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.
Grisso, T .Evaluating competencies: Forensic assessments and instruments , 2nd edition
New York: Kluwer Academic/Plenum 2003.
Heilbrun K. Principles of forensic mental health assessment. New York: Kluwer
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McNaughten : His Trial and Aftermath . London : Gaskel 1977.
Release Decision-Making, 2nd Edition (2006), Webster, C.D. & Hucker, S.J.,Wiley:
London. forthcoming: 2006.
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.
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.
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.
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.
Poythress NG, Nicholson R, Otto RK . Professional Manual for the MacArthur Competence
Assessment Tool-Criminal Adjudication (MacCAT-CA). Odessa, FL: Psychological
Assessment Resources 1999.
Rogers R, Tillbrook CE, Sewell KW. Evaluation of Competency to Stand Trial-Revised
(ECST-R) and Professional Manual. Odessa, FL: Psychological Assessment Resources
2004.
Everington C, Luckasson R. Manual for Competence Assessment for Standing Trial for
Defendants with Mental Retardation: CAST-MR. Worthington, OH: IDS Publishing 1992.
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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.
Professor and Formerly Head
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
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.
2.
3.
4.
5.
6.
7.
8.
9.
History of GMH in India
Scope of GMH
Aging and theories of aging
Epidemiology of GMH problems
Classification of GMH problems
Phenomenology and diagnosis of GMH problems
Common GMH and other specific problems of elderly
Management of GMH problems
National policies and programs for GMH care
The program for teaching should include long clinics of three hours for two
th
th
th
weeks for 4 and 5 semester MBBS students, short clinics of one hour for 8
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 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
l
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
postings of residents of MD psychiatry towards the later half of 2
rd
year or the early half of 3 year of their residency training.
nd
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:
The Prolongation of Youth and Life
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, Neurophysiology, Neuropathology and
Neuropharmacology Of Aging and Behaviour:
l
l
l
Neuroanatomy:
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
l
l
275
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:
Normal Aging
l
Alzheimer's Disease
l
Dementia with Lewy Bodies
l
Vascular Dementia
l
Frontotemporal Dementia
l
l
Neuropharmacology of Behaviour:
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
l
Acetyl-Choline and Behavioural Functions
l
Non-Neuropeptides and Behavioural Functions
Prostaglandins
l
Thromboxanes
l
Purines
l
l
Neuropeptides and Behavioural Functions:
Endogenous Opiods
l
GUT Peptides
l
Hypothalamic, Pituitary and Pineal Peptides
l
3. Genetics of Geriatric Psychopathology:
l
Fundamentals of Genetics:
l
Molecular Genetics
l
Linkage Analysis
l
Candidate Gene
276
l
Genetic factors in Normal and Accelerated Aging:
Cognitive impairment with Advancing Aging
l
Cellular Aging Research
l
l
Methodology in Psychiatric Genetics:
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:
Schizophrenia and Related Psychosis
l
Mood Disorders
l
Schizo-affective Disorder
l
Anxiety Disorders
l
Alcohol and Substance Abuse
l
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
l
l
l
l
l
l
277
Health and Disease Interaction with Intellectual and Cognitive
Functioning
Health and Self-Related Health
Personality and Aging in the Social Context
Coping in later Life
Care-giving issues in the Normal Psychology of Aging
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
l
l
l
Classical and Operant Conditioning Theories
Drive reduction and Reciprocal Inhibition Theories
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
l
l
l
l
l
l
l
l
279
Disorder of Consciousness and Orientation
Disorder of Attention and Concentration
Disorder of Affect
Disorder of Thinking
Disorder of Perception
Disorder of Memory
Disorder of Intelligence
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
l
l
Health.
Concepts of mental illnesses and its treatment in Ancient Indian
Thought, and Promotive aspect of Mental Health
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:
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
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
Handedness and Cerebral Dominance
l
Split brain and reported studies on Cerebral Lateralization of
Functions.
l
Plasticity and Restoration of Functions
Psychophysiology
l
Methodology and Measurement
l
Psychophysiology of Cognition And Emotional States
l
Studies in Psychiatric Conditions
l
l
14. Psychiatric Disorders in Late Life:
l
l
l
l
l
l
l
l
l
l
l
l
l
281
Cognitive Disorders
Movement Disorders
Mood Disorders
Schizophrenia and Paranoid Disorders
Anxiety and Panic Disorders
Somatoform Disorders
Sexual Disorders
Bereavement and Adjustment Disorders
Sleep and Circadian Rhythm
Alcohol and Drugs Problems
Personality Disorders
Agitation and Suspiciousness
Sub-syndromal Mental Health Problems
15. Treatment of Psychiatric Disorders in late life:
Principles and practice of 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
l
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
B a s i c S c i e n c e s : N e u ro a n a t o m y, N e u ro p h y s i o l o g y,
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
l
l
Probability
l
Probability laws, Binominal, Poisson and Normal
Distributions, Sampling from finite population, Sample Size,
Sample Spare, Student t-statistics, Chi-square statistics, FVariate, Statistical Inference.
l
Estimation, point estimation, interval estimation, Test of
hypothesis, Type I and Type II errors, Tests based on studentt, 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
l
Measurement Nominal, Ordinal, Interval and Ratio Scales,
Constructing Rating Scales and Attitude Scales, Reliability and
Validity.
Epidemiological Studies:
l
l
Various methods to ascertain knowledge, Scientific method
and its features, Courses and effect: Mill's canons.
Theory of Measurement:
l
l
Central limit theorem, One sample and Two sample problems,
Analysis of variance of rank order statistics.
Scientific Methods:
l
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.
Non-parametric Statistics:
l
l
Special measure of association: Rank Order Correlation
Coefficient, Tetrachonic Correlation Coefficient and PhiCoefficient.
Prospective and Retrospective Studies, Prevalence,
Incidence, Age Specific Disease and Adjusted Rates, Life Table
Technique.
Survey Technique:
l
l
Various Tools, Mail Questionnaire and Interview Schedule
Sampling Methods: Complete Enumeration, Sample Survey,
l
l
283
Sampling and Non-Sampling Errors, Random and NonRandom Samples
Sample Random, Systematic Random, Stratified Random and
Cluster Random Sampling Design; Methods of minimizing
Non-Sampling Errors.
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
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 MCINominated group of experts).
S.C. Tiwari
Professor and Head
Department of Geriatric Mental Health
Chairperson, Geriatric Psychiatry Specialty Section
of Indian Psychiatric Society.
[email protected]
Anindya Das
Senior Resident, Department of Geriatric Mental Health
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
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
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
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
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:
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
c.
d.
e.
f.
Repetitive behaviours and compulsive phenomenon
Perceptions: Document illusions or hallucinations
Mood and Affect of the patient.
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
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.
2.
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
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.
2.
3.
4.
5.
http://web.jjay.cuny.edu/~pzapf/classes/PY761/Week%202%20Notes.htm
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders.
4th Edition. 1994
Practice Guidelines. Psychiatric Evaluation of Adults. 1996. American Psychiatric
Association. Washington DC
Merkel, L.G. http://www.healthsystem.virginia.edu/internet/psych-training/seminar/pgy-ipsychiatric-interview.pdf. Downloaded Dec 24, 2010
'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
University of California, San Diego
9500 Gilman Drive #0664
La Jolla, CA 92093
Amit Kulkarni
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
Aim of the clinical interview: The psychiatric interviews are performed with
the following aims.
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l
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Assessing history and performing mental status examination
Understanding personality, social circumstances, life story and
possible causative, contributory, perpetuating and maintaining
factors of the illness
Assessing diagnosis and differential diagnosis
Deciding nature and setting (indoor, outdoor etc) of the treatment
required
Explaining the diagnosis and management plan to the patient
Discussing future investigations or referral if needed
Discussing course and prognostic factors of the illness
Establishing therapeutic alliance, instilling hope and encouraging
self help if possible
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
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. Charactera. 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:
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:
arousable with difficulty.
Attention is described as easily arousable or
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
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)
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
Non pharmacological- Type of approaches required, psychoeducation,
Cognitive behavior therapy etc and strategies for rehabilitation.
Personal suggestions:
l
l
l
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.
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.
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.
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.
2.
3.
4.
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
Goldbloom DS. Psychiatric clinical skills, Pheladelphia, 2006, Elsevier
Psychiatric assessment in Oxford Handbook of Psychiatry, 1st Edition. Eds: Semple, David;
Smyth, Roger; Burns, Jonathan; Darjee, Rajan; McIntosh, Andrew. 2005
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
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
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
[4]
clinical rounds. Sokol writes about 'the substantial difference between
studying ethics in a class and doing ethics on the wards'. Furthermore, as Ker
[5]
et al. 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
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
[5]
or referral setting also. As Ker et al. 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
[6]
clinical rooting for the student to associate with. Coomarasamy and Khan
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
[7]
instruction, Mascola 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
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
[9]
help the student to learn the reflective habit. Driessen et al. 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
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
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.
2.
3.
4.
5.
6.
Grantcharov TP, Reznick RK. Teaching procedural skills. BMJ 2008; 336: 1129-31.
Spencer J. Learning and teaching in the clinical environment. BMJ 2003; 326: 591-4.
Irby DM, Wilkerson L. Teaching when time is limited. BMJ 2008; 336: 384-7.
Sokol DK. Ethicist on the ward round. BMJ 2007; 335: 670.
Ker J, Cantillon P, Ambrose L. Teaching on a ward round. BMJ 2009; 338: 770-2.
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,
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
(1)
practicing evidence based medicine . 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
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
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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.
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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.
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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
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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
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 lifelong 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
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
l
l
l
Level A: Consistent Randomised Controlled Clinical Trial, cohort study, all
or none, clinical decision rule validated in different populations.
Level B: Consistent Retrospective Cohort, Exploratory Cohort, Ecological
Study, Outcomes Research, case-control study; or extrapolations from
level A studies.
Level C: Case-series study or extrapolations from level B studies.
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
l
l
l
l
l
l
l
l
l
First volume published in 1879
Idea proposed by John shaw Billings 1865
Upto 1960, only monthly updates in the name of index medicus were
published
Since 1960, along with this, a cumulated version of the monthly
volumes – cumulated index medicus is published
Materials are selected for inclusion by a board of analysts
Materials selected are assigned terms from Medical Sub Headings
Each year 13 volumes
Volume 1 contains MESH (Medical subject Headings) – list of
keywords used. MESH is to be seen first for keyword
Volume 2-7 author index
Volume 8-13 subject index
l
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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)
2)
3)
4)
Medline (Index Medicus)
Embase (Excerpta medica)
Current contents on diskette
Biosis (Biological abstracts)
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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
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 postgraduation 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
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
2
patient values”. 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
3
objectively by scientific studies. 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
3,4
expert/personal opinions are placed at the lowest level of hierarchy. 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, casecontrol 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
5
and assessing their relative contribution to a decision.
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
6
intervention. 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
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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
6
top journals also have flaws. 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
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
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
4
measure adequately reflect changes in the status of the patient.
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
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 followedup 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
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
7
and confidence intervals will be dangerously misleading. 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
4
done rigorously and objectively if systematic bias is to be avoided.
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.
331
REFERENCE
1.
2.
3.
4.
5.
6.
7.
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.
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.
Pwee KH. What is this thing called EBM? Singapore Med J 2004; 45: 413-417.
Greenhalgh T. How to read a paper. Fourth Edition, John Wiley & Sons Ltd, The Atrium,
Southern Gate, Chichester, UK, 2010.
Atkins D, Best D, Briss PA et al. Grading quality of evidence and strength of
recommendations. BMJ 2004; 328:1490.
Makela M, Witt K. How to read a paper: critical appraisal of studies for application in
healthcare. Singapore Med J 2005; 46: 108-114.
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
Chandigarh 160 012, India
[email protected]
Vineet Kumar
Senior Resident
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
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
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
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.
2
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
3
discussion. 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
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
4
manuscript.
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
4
blind review process. 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
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.
6
However their names should appear in the acknowledgement.
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
8
encourages a reader to go through the full paper. 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.
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
9
as to introduce the topic in a better way.
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
9
carrying out the research.
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
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
11-14
of articles by Ng & Peh.
In brief, the basic principles which should be
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
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.
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
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
17
learning the rules of the game. 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
345
first author- look for journals which encourage trainees or early career
researchers- you may have better chance of acceptance
REFERENCES
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
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17.
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Nicolaides A, Thornton E. The process of writing a scientific paper. Int Angiol 2000; 19:
184–90.
Peh WCG, Ng KH. Basic structure and types of scientific papers. Singapore Med J 2008; 49:
522-4.
Peh WCG, Ng KH. Title and title page. Singapore Med J 2008; 49: 607-8.
Peh WCG, Ng KH. Authorship and acknowledgement. Singapore Med J 2008; 49:563-5.
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.
Welch HG. Preparing manuscripts for submission to medical journals: the paper trail.
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Cunningham S. J. How to . . . write a paper. Journal of Orthodontics, Vol. 31, 2004, 47–51
Peh WCG, Ng KH. Writing the introduction. Singapore Med J 2008; 49:756-7.
Ng KH, Peh WCG. Writing the material and methods. Singapore Med J 2008; 49:856-8.
Ng KH, Peh WCG. Writing the Results. Singapore Med J 2008; 49: 967-8.
Ng KH, Peh WCG. Preparing effective tables. Singapore Med J 2009; 49: 117-8.
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49: 117-8.
Ng KH, Peh WCG. Preparing effective illustrations. Part 2: photographs, images and
diagrams. Singapore Med J 2009; 49: 330-4.
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Peh WCG, Ng KH. Preparing the references. Singapore Med J 2009; 50: 659-61.
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Sandeep Grover
Assistant Professor
[email protected]
Alakananda Dutt
Department of Psychiatry, PGIMER, Chandigarh
Archana Malik
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
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 freetext 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
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 freeaccess 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
2
the single study.
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 nonsystematic 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 nonsystematic 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
REFERENCES:
1.
2.
Greenhalgh T. How to read a paper. Fourth Edition, John Wiley & Sons Ltd, The Atrium,
Southern Gate, Chichester, UK, 2010.
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
[email protected]
Archana Malik
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
(1)
disseminate information from the latest journals .
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
(1)
practice and improve patient care . 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
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
(3)
created EBM Journal clubs .
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 aboutthe care of individual patients' ( 4).
The focus is on the evidence and its judicious application. This definition is
(5)
based on a positivistic view of science and knowledge and is
epistemologically more rationalist in position.
(6)
Nine years later, Martin Dawes 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
(6)
those providing care, within the context of available resources” .
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
(1)
started . However, with the explosion in number of medical journals this task
has become difficult. It has been estimated that an average doctor would
(9)
need to read 627.5 hours a month to keep up with primary care literature .
Some Journal clubs have attempted to overcome this problem by analysing a
(9)
number of papers in one single session . 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
(10)
specific questions and c) researching: seeking a comprehensive view . In
(11)
practice most doctors get their information by browsing . 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
(12)
generated in practice and that doctors identify gaps in their knowledge .
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
(13,14)
development of ideas for future change
. The problem with using clinical
questions to generate searches is that most clinical questions generated in
356
practise go unanswered. Primary care physicians only try to answer a limited
number of their clinical questions, and when they do, they first consult
(15)
colleagues and later other resources . 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
(15)
practice .
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
(20, 21)
and statistics
. 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
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
(23)
trainees in various settings . Within Psychiatry the addition of a critical
review paper to exams could be one reason why trainees feel this is an
(23)
important aim of Journal clubs . 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 whetherJournal clubs enhance critical appraisal skills,
and objective measurement of skills shows less improvement than self-
358
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
(27)
There are several formats to Journal clubs . 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
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(30)
importance . A Journal club needs a dedicated, committed and skilled
(28)
moderator to ensure the longevity of the session . 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
(31)
make them more successful .
Interventions to change the format of Journal clubs have focused on the issue
(27; 31; 32;
of critical appraisal and the teaching of epidemiology and biostatistics
33)
. Some have attempted to contextualise learning by linking Journal clubs to
Case discussions. The interventions have varied in a spectrum of an exclusive
(27)
focus on critical appraisal (31) to doing away with it totally .
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
(34)
people to meet, interact and form bonds. Spillane
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
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
(35)
languages of the community and practice . 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
(20)
separate from faculty Journal clubs . 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
(36)
the learning occurs . 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
(37)
physician behaviour . 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.
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
(38)
on performance, and offer opportunities for practising newly learned skills .
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
(41)
the formation of identities . 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(42)
directed learning . 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
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.
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Coumou, H.C.H., & Meijman, F.J. 2006. How do primary care physicians seek answers to
clinical questions? A literature review. J Med Libr Assoc. January; 94(1).pp. 55–60.
Spillane, A.J. & Crowe, P.J. 1998. The role of the Journal club in Surgical training. Aust NZ
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Christakis, D.A. et.al. (2000): Do physicians judge a study by its cover? An investigation of
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Hatala, R. et al; 2006 . Beyond Journal clubs: Moving Toward an Integrated EvidenceBased Medicine Curriculum. J Gen Intern Med, May; 21(5). Pp. 538–541.
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appraisal, and evidence-based medicine: a critical review of curricula. Acad Med.,74.
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Fu, H.Y.C. 1999. Is a Journal Club Effective for Teaching Critical Appraisal Skills? A
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Combe, G., et.al.1999. Oedipus to Jack the Ripper: Alternate Journal clubs. Psychiatric
Bullettin, 1999 ,23.pp. 497-499
Sidorov, J. 1995. How are internal medicine Journal clubs organised and what makes
them successful? Arch Int Medicine 115.pp.1193-1197
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32. Inui, T.S. 1981. Critical reading seminars for medical residents. A report of a teaching
technique. Med Care.19. Pp.122–4.
33. Kitching, A.D. 1992. 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
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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 ,
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Arun N.R. Kishore
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, neurofunctional 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
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 neurohemodynamic 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
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imaging. Neuropsychol Rev 2007 Jun;17(2):107-125.
Malhi GS, Lagopoulos J. Making sense of neuroimaging in psychiatry. Acta Psychiatr Scand
2008 Feb;117(2):100-117.
Gottesman, II, Gould TD. The endophenotype concept in psychiatry: etymology and
strategic intentions. Am J Psychiatry 2003 Apr;160(4):636-645.
Hariri AR, Weinberger DR. Imaging genomics. Br Med Bull 2003;65:259-270.
Lutz A. Neurophenomenology and the study of self-consciousness. Conscious Cogn 2007
Sep;16(3):765-767.
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
NIMHANS
Bangalore – 560029
[email protected]
Naren P. Rao
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
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
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.
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Sachdev PS. Whither neuropsychiatry? J Neuropsychiatry Clin Neurosci. 2005;17:140-4.
Albucher RC, Maixner SM, Riba MB, Liberzon I. Neurology Training in Psychiatry
Residency: Self-Assessment and Standardized Scores. Academic Psychiatry. 1999;23:77-81.
Ovsiew F. Neuropsychiatric approch to the patient. Eighth ed. Saddock B, Saddock V,
editors. Lippincott Williams and Wilkins; 2005.
Kaufman DM. Clinical Neurology for Psychiatrists. Saunders; 2007.
Cascella NG, Schretlen DJ, Sawa A. Schizophrenia and epilepsy: is there a shared
susceptibility? Neurosci Res. 2009;63:227-35.
LaFrance WC, Jr., Kanner AM, Hermann B. Psychiatric comorbidities in epilepsy. Int Rev
Neurobiol. 2008;83:347-83.
Slaughter JR, Slaughter KA, Nichols D, Holmes SE, Martens MP. Prevalence, clinical
manifestations, etiology, and treatment of depression in Parkinson’s disease. J
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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
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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
NIMHANS
Bangalore – 560029
[email protected]
Ganesan Venkatasubramanian
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
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
1
with identical focus .
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
4
whole person . At a technical level, psychological assessment is defined as the
process of “systematic collection, organization and interpretation of
5
information about a person and his situations” , to which is added, “and the
6
prediction of his behaviors in new situations” . The key element in
7
assessment is “the act of acquiring and analyzing information” . 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
12
who are supposedly like them . 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, subnormality, 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
14
performance scores . 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
to diagnostic decisions; they are only remotely connected to planning,
15
programming or interventional decisions . 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
17
education and rehabilitation medicine . 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
20
whether a person can or cannot do a given skill or activity . 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
379
22
behavioral assessment . Earlier approaches to behavior assessment involved
specification of target behaviors intended for change and their change
through arrangement / rearrangement of environmental contingencies in a
23-24
manner loosely conforming to operant conditioning principles . The
procedure involved obtaining frequency, rate and duration of target
behaviors by observing, recording and counting them. Later, with the concept
25
of applied behavior analysis , 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
11
complete and integrated view of the assessed individuals . Wherein the
intended objective is to assess clinical samples for enabling programplanning 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
To begin with, psychological assessment must be distinguished from
33
psychological testing. Although related, both are not the same .
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
34
assessed variable' . 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
36
about other behaviors of the person' . 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
37
diagnosis of certain clinical conditions in individual cases . 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
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
38
support the diagnosis of referring psychiatrists . 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
39-40
and the consequent report must take into account these living realities .
(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 'premodern 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
43
organicity . 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
44
patients .
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
43
negative (i.e. correct test identification of patients not diagnosed as such) .
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
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
49-50
51
Questionnaire , Beck Depression Inventory , General Health
52-54
55
Questionnaire , Goldberg General Health Questionnaire , Depression56
57
Happiness Scale , Hamilton Depression Scale . 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
58-59
kind of a unitary dysfunction . The inter relationships between brainbehavior is not a simplistic binary classification between brain damage or not.
The better approaches have invariably looked upon cerebral functioning from
60-61
a multidimensional point of view . 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
62-65,
to the growth of this discipline
Current researches on psychological
44
assessment focus pertinently on its direct use in treatment or rehabilitation .
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
69-70
Developmental Disabilities' , 'Assessment of Kids with Special Handicaps in
71-72
Arithmetic and Reading-Writing Activities' . 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
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
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
76
their disinterest in continuing schooling . A similar report was made on
differential perceptions in parents, teachers and clinically affected with
71-72
scholastic/academic problems . 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, selfdisclosure 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
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,
85
validity, standardization, and bias . 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
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 populationsall of which contribute to the poor understanding of westernized mental
86-87
health providers .
(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
88-89
developmental disabilities . 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
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
(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
90-91
between impairment, disability and handicaps
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
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
95-97
content or textual analysis
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
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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[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
[2]
Psychology) and was recognized by the Medical Council of India
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
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
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.
2.
3.
4.
Manickam L S S. Enabling the Disabled, Ind J of Clin. Psy 2009: 36;7-10.
Handbook of All India Institute of Mental Health, Bangalore: All India Institute of Mental
Health (NIMHANS) 1959.
American Psychological Association. 2009 Presidential Task Force on the Future of
Psychology Practice Final Report. Washington: American Psychological
Association;2009.
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.
2.
3.
Sweekar Rehabilitation Institute for Handicapped, Secunderabad- Andhra Pradesh
sweekaar.org/secbad.html
Post Graduate Institute of Behavioural and Medical Sciences, Raipur, Chatishgarh
Institute of Human Behavior And Allied Sciences, Delhi. ihbas.delhigovt.nic.in
400
4.
5.
6.
7.
8.
9.
10.
11.
Central Institute of Psychiatry, Ranchi, 834006, Jharkand cipranchi.nic.in/Index.html
Ranchi Institute of Neuro-Psychiatry & Allied Sciences (RINPAS), Ranchi Jharkhand
rinpas.nic.in/index.html
Kasturba Medical College, Manipal University, Manipal, Karnataka manipal.edu
National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka.
nimhans.kar.nic.in
Regional Institute of Medical Sciences, Imphal, Manipur, www.rims.edu.in
Sri Ramachandra University, Chennai, Tamil Nadu, www.srmc.edu
Amity Institute of Behavioural Health & Allied Science, Noida, UP amity.edu
Department of Psychology, University of Calcutta, Kolkata,700009.:
[email protected]
L.S.S. Manickam
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
[1]
study. Epidemiology can be defined as the study of the distribution and
[2]
determinants of disease frequency in human populations Psychiatric
epidemiology is study of the distribution and determinants of mental illness
frequency in human beings with the fundamental aim to understand and
[3]
control the occurrence of mental illness
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
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 layinterviewer 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]
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
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[29]
experimental) and experimental studies (Figure 6).
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
[30, 32]
why diseases are distributed the way they are
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
[33]
subsequent interventions .
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
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
409
Psychiatric epidemiological studies
Observational studies
Surveys
Case Reports
Prospective
Cohort studies
Ecological
Experimental studies
Case control studies
Retrospective
Classic
Cohort studies
Prospective
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
when considering the relative roles of genetic and environmental factors on
[29]
the disease
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
[29].
receive placebo) 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
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
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
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
[37]
under reporting, differing informant characteristics etc .
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[37]
economic changes and genetic variations (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
Table 2
DCP = Diagnosis confirmed by
a psychiatrist(s)
CHM = Case History Method
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
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
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.
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[email protected], [email protected]
Janardhanan Narayanaswamy
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 plantshave 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
[1]
with genes is likely to yield the most fruitful results.
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
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
[2]
patient may clarify issues for them too.
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
[3]
asked.
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
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.
2.
3.
http://support.infotechsoft.com/aspect/forms/pdf/FIGS_GSQ.pdf (24/12/2010)
Sadock BJ, Sadock VA, Ruiz P, Kaplan & Sadock's Comprehensive Textbook of Psychiatry, 9th
edition, 2007, Lippincott Williams and Wilkins.
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
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)
5
cholesterol, it was found in 48.3% of all patients( McEvoy JP et al 2005)
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
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
8
1989) , which is far higher than the rate in the population at large (1.2%–6.3%)
9
(Adams PF et al 1994) .
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.
10
De Hert Marc A. et al 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 ageadjusted 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
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
12
disorder Cohn T et al (2004) 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
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
429
population, but lower than in other reports regarding the schizophrenia
population.
15
Heiskanen T et al (2003) 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 firstepisode 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
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
increasein levels of fasting lipids and in non-fasting glucose mayprovide early
signs of drug-induced progression towards themetabolic 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 forketoacidosis.
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
diabetesand 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
antipsychoticsis 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
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 baselinebody 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
19
P. Mackin et al (2005) 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
20
patients taking atypical antipsychotics
432
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 drugnaive 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, highdensity 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.
22
Kelly DL et al (2008) 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)
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.
23
Simpson MM et al (2001) 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.
24
Sanjay Jain et al (2006) 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
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.
25
Saddichha S, Manjunatha N et al at (2007) 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
26
Gautam S et al (2011) 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.
435
27
Vaios Peritogiannis et al (2006) 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
28
this respect (Masand PS 1999, Meyer JM 2001, Wetterling T 2001) .
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
30
follow-up study. Manit Srisurapanont et al (2007) 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
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.
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Shiv Gautam
Director, Professor
[email protected]
P.S. Meena
Psychiatric Center
Anita Gautam
and Alternative Medicine,
Jaipur.
Manaswi Gautam
I.D. Gupta
Psychiatric Center
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
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
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 psychodynamic 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
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 respo

dr rao institute book 2015 - Indian Journal of Psychiatry

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