Accessibility Page Navigation
Style sheets must be enabled to view this page as it was intended.
The Royal College of Psychiatrists Improving the lives of people with mental illness

India

RSS Logo RSS 2.0
22/12/2017 14:44:48

Bristol University medical students visit to South India

Medical Students in South IndiaMedical student’s experience of psychiatry as a specialty in medical school has been shown to be highly correlated with their future career choice (Goldacre, 2005; Goldacre, Fazel, Smith, & Lambert, 2012; Korszun, Dharmaindra, Koravangattu and Bhui, 2011).

During their fourth year at Bristol University medical students have the opportunity to undertake a period of self-selected learning through the external student selected component (eSSC) programme.  Bearing this in mind, we organised an eSSC that would provide students an opportunity to experience mental healthcare in India. While the primary aim of the project was to help students gain an insight into mental healthcare in a developing nation, the secondary aim was to ignite interest in Psychiatry.

India with its rich history through medieval times to modern India offers a unique learning opportunity to the students to able to experience mental healthcare in a developing country with a vast and diverse cultural and religious setting.  Transcultural psychiatry considers the cultural context of mental disorders and continues to gain further importance to medical trainees as they live in an increasingly multicultural society (Kripalani, Bussey-Jones, Katz, & Genao, 2006).The students would also be able to apply their experience to a range of medical specialities that treat across diverse ethnic and religious groups.

Clinical experience was organised at the Institute of Mental Health in Chennai, Schizophrenia Research Foundation in Chennai, CSI Rainy Hospital in Chennai and Sowmanasya Hospital in Trichy. 

During the two weeks in India students spent their time in various clinics and wards in general adult and old age as well as in specialist clinics, including telepsychiatry. They also had the opportunity to spend time with Clinical Psychologists, Occupational Therapists and Alternative Therapists (yoga).  As part of the trip, the students also visited temples which housed psychiatric inpatients where they were able to observe faith healing rituals.  

All 6 students found the field trip very valuable and fascinating and have shared their experience from their trip below.

Dr Sherlie Arulanandam

Psychiatry Tutor, University of Bristol Medical School

 

References

Goldacre, M (2005). Career choices for psychiatry: national surveys of graduates of 1974-2000 from UK medical schools. The British Journal of Psychiatry, 186(2), pp.158-164.

Goldacre, M., Fazel, S., Smith, F., & Lambert, T. (2012). Choice and rejection of psychiatry as a career: surveys of UK medical graduates from 1974 to 2009. The British Journal of Psychiatry, 202(3), 228-234.

Korszun, A., Dharmaindra, N., Koravanattu, V., & Bhui, K. (2011). Teaching medical students and recruitment to psychiatry: attitudes of psychiatric clinicians, academics and trainees. The Psychiatrist, 35(9), 350-353.

Kripalani, S., Bussey-Jones, J., Katz, M. G., & Genao, I. (2006). A Prescription for Cultural Competence in Medical Education. Journal of General Internal Medicine, 21(10), 1116–1120. http://doi.org/10.1111/j.1525-1497.2006.00557.

 

The Institute of Mental Health, Chennai

Alys Roberts
4th Year Medical Student University of Bristol Medical School

Dr Jeshoor Jebadurai
Psychiatrist, Tirunelveli, India.

Institute of Mental Health South IndiaOur visit started in Chennai, which is situated on the Bay of Bengal in Eastern India, the capital of the state of Tamil Nadu. With a population of over 7 million, it is the 7th most populous city in India.[1] The state has a population of 63 million, but only 3000 psychiatric beds- the Institute of Mental Health in Chennai providing 1800 of those.[2] Moreover, there are 315 psychiatrists in the state, which means that one psychiatrist is responsible for a population of over 200,000 people.[3]

We drove through the busy streets of Chennai- an attack on all the senses, with horns beeping, seas of people, and the smell of jasmine flowers. Children running to school in their uniforms, their hair identically plated. Tuk-tuks filled with families. Women dressed in sarees of all colours, riding side saddle on motorbikes. The minibus turned off the busy roads and we entered through the gates of The Institute of Mental Health (IMH), Chennai.

In order to fully understand the set-up of psychiatric services in India today, one should attempt to understand its recent history. Prior to colonization by the British, mental health services in India were virtually non-existent; the mentally unwell were cared for by family or in religious institutions.[4] During the 17th and 18th century the British introduced mental asylums to India. The asylums stemmed from the popular stance in Britain at the time, that to lock the mentally unwell in institutions would make the community safer.[5] One such asylum that was set-up by the British was The Institute of Mental Health in Chennai, which was founded in 1794.[6] It was established as a house for accommodating persons of unsound mind and was originally a private hospital, intended to house 20 British patients.[7] In 1922 asylums in India were designated as mental hospitals.[8]

During the 1950’s, 60’s and 70’s the face of psychiatry changed in India. Family members became involved in the treatment of mentally unwell patients, which meant quicker recovery time and reduced inpatient stay.[9] General Hospital Psychiatric Units (GHPUs) became common place. They are less stigmatizing than psychiatric hospitals and encourage more outpatient care.[10] The Institute of Mental Health in Chennai opened an outpatient clinic in the 1940’s.[11] The possibility of outpatient psychiatric services was the first step in providing community psychiatric services in India. Moreover, it was, and still is, an opportunity to educate the public.

The minibus drove on a track through some of the hospital grounds. Through the bus window the land looked dry, with trees strewed all over- a reminder of cyclone Vardah. Brick buildings every few hundred meters, Tamil writing identifying wards. The bus passed a group of patients working on the land- a form of rehabilitation. They all wore green or blue scrub-like clothes, hair short. Their beady eyes following the bus- the first overseas students ever allowed a glimpse inside the walls of the hospital.

We parked outside the modern administrative building. Stepping outside the air conditioned minibus, the heat hit us again. We were welcomed by the hospital director and a consultant- they gave us a brief history of the hospital and an idea of what sort of patients to expect.

A psychiatrist working at the IMH took us on a tour of the inpatient unit of the IMH . The grounds of IMH is so vast (about 25 acres) and the walls are so tall (to prevent patients scaling the wall) . It seems to be a quiet space in the middle of a bustling city. The brick buildings of each ward were scattered around the large hospital grounds. (We walked along the dusty track that the minibus followed, leaves and grass covering the rest of the land).

A chalk board hung at the entrance of each ward, on it the patient census - the number of new patients, existing patients and so forth. We were warmly welcomed to the wards by the post-graduate doctors (the UK equivalent of a registrar in psychiatry), the ward nurses and the ward social worker. The teams had a small room at the entrance of the ward, from where they wrote in patient notes, held meetings, and dispensed medication. In most wards the patients were found outside sitting on concrete courtyards, or watching television.

Patients were designated to a ward depending on their symptoms or function. If function improved patients would be moved “up” a ward. The ward buildings consisted of two or three rooms where the patients slept- bare except for beds. There was also an educational room where posters hung, showing how to brush teeth and how to eat healthily.

Walking into the hospital in Chennai was so completely different to any ward in the UK. Due to it not yet being monsoon season the patients mostly sat outside- this gives physical as well as emotional space for the patients. However, during the night tens of patients shared rooms, and this means that there is little privacy. But it must be noted that the general notion of privacy is of much greater significance in the UK compared to India, where living with a large extended family is the norm.

Although there was no real expectation of anything, there was a much greater sense of care than expected. When departments are scarce of money in the NHS it seems to be care that suffers the most. However, in the institute they have a much smaller pot of money as well as limited resources but care did not seem to suffer. The clinician that was kindly giving us a tour of the hospital seemed to know most of the hundreds of patients’ names. This was not only an act of care but also of respect to each and every individual patient.

We were granted access to the ‘criminal ward’ (Equivalent to the forensic wards in the UK) at the hospital. It is the only criminal ward in Tamil Nadu, and was established in 1892.[12] The ward was surrounded by a wall, and we had to pass through a gate, at which a security guard sat. Different to the other wards, the inpatients here wore white. And, instead of trousers they all wore shorts- in order to deter the patients from committing suicide by hanging, which happened with trousers. The ward was all male and there was an interesting conversation with the doctor when he was asked where the female criminals stayed. He answered that there were no female criminal wards in Tamil Nadu, may be not even in India. In India females do not usually commit as serious a crime as males, and therefore there is no need for them to be kept in criminal wards. However, mostly women who commit crime are sent to female only prisons.

(On our tour of the hospital grounds we passed an abandoned building. It looked different to the wards- numerous small rooms and only few high windows. We were told that this was the confinement building- rarely used now due to better medical treatment and legislation).

We also stopped by the bust of Phillippe Pinel; a French physician who was instrumental in the move away from asylums and towards the humane treatment of mentally unwell patients.

It was a fruitful sight to visit the hospital bakery which was a large barn like building, with a big industrial oven in one corner. Interestingly, the oven was donated by the old students of the IMH (The IMH UK Alumni) .In charge of the bakery was an old inpatient of the hospital- he now lived at home with his family and was an employee of the Institute. Two current inpatients also worked in the bakery- a great privilege.

The clinician was, rightly, extremely proud of the hospital bakery and how it acted as a form of rehabilitation for current and ex patients. The aim of rehabilitation is very different in the UK and India, due to the difference in individuals’ roles in each country. In the UK the aim of rehabilitation is complete independence, whereas in India the aim is for interdependence. That is for family and society members to be able to depend on each other. The former patient who was in charge of the bakery now lived at home with his family who could once again depend on him- emotionally and financially.

We approached another gate, with a tall wall either side- this was the entrance to the female ward. Initially it felt as though the women were living in a cage- a similar jail like feel to the criminal ward. However, it was explained that the wall was there for the women’s safety, since most of them are vulnerable- physically and emotionally. Inside the walls were numerous buildings, closer together than seen elsewhere in the hospital.

We were immediately welcomed, not only by staff but also by patients. The majority of patients were sitting outside, on a concrete floor. A few women rushed up to greet us. Speaking in Tamil they asked the IMH clinicians about us. Some of the women wanted to hold hands, one particularly playful lady performed a song. We were shown the educational room, which was one large building with tall windows. Women sat weaving bags and drawing. These products are then sold, and the money put back into the hospital.

The female ward had a much greater sense of community than was seen on the male wards. The women interacted with each other. Indeed, the more functional younger patients cared for the older less functional patients, and called them mother/aunt/grandmother. Although we were there for only a short period, one could appreciate some of the patients’ personalities. It was enjoyable to see the patients take pride in the products they were making- it meant they had a sense of purpose.

As with the other hospital wards the female patients wore green scrub-like clothes. It was interesting that it was here that it became evident that wearing a patient uniform, although important for safety, meant that they lost their individualism. This was especially pertinent in India, since outside the hospital women wore beautiful coloured saris or other traditional dress- a way of expressing personality and mood.

Towards the end of the tour the psychiatrist was asked what happens when the hospital is full, where do the patients go? He laughed and said the hospital is never full and we never send people away, there will always be space on the floors for a few more mattresses.

This shows that despite the resource disparities across the world, ultimately the most important thing is the healthcare professionals’ compassionate and altruistic attitudes.

It was a great privilege to visit the Government Mental Hospital, Chennai, and I look forward to returning again someday.

References

  1. India Online Pages. 2017. Population of Tamil Nadu 2017. [ONLINE] Available at: http://www.indiaonlinepages.com/population/tamil-nadu-population.html [Accessed 11 November 2017]
  2. Somasundaram, O., 2008. The Government Mental Hospital Kilpauk, Madras: Memoirs of the Fifties. 2nd ed. Chennai
  3. Somasundaram, O., 2008. The Government Mental Hospital Kilpauk, Madras: Memoirs of the Fifties. 2nd ed. Chennai
  4. Avasthi A. Preserve and strengthen family to promote mental health. Indian J Psychiatry 2010; 52(2): 113-126
  5. Avasthi A. Preserve and strengthen family to promote mental health. Indian J Psychiatry 2010; 52(2): 113-126
  6. Somasundaram, O., 2008. The Government Mental Hospital Kilpauk, Madras: Memoirs of the Fifties. 2nd ed. Chennai
  7. Somasundaram, O., 2008. The Government Mental Hospital Kilpauk, Madras: Memoirs of the Fifties. 2nd ed. Chennai
  8. Somasundaram, O., 2008. The Government Mental Hospital Kilpauk, Madras: Memoirs of the Fifties. 2nd ed. Chennai
  9. Bhatti RS, Janakiramaiah N, Channabasavanna SM. Family psychiatric ward treatment in India. Family Process 1980; 19: 193-200
  10. Avasthi A. Preserve and strengthen family to promote mental health. Indian J Psychiatry 2010; 52(2): 113-126
  11. Somasundaram, O., 2008. The Government Mental Hospital Kilpauk, Madras: Memoirs of the Fifties. 2nd ed. Chennai
  12. Somasundaram, O., 2008. The Government Mental Hospital Kilpauk, Madras: Memoirs of the Fifties. 2nd ed. Chennai

 

Schizophrenia Research Foundation (SCARF) - Chennai

Elliot Raymond-Taggert
4th Year Medical Student University of Bristol Medical School

SCARFSCARF is the organisation that impressed me most during my time in India leaving me with much admiration for the way they treat their psychiatric patients. SCARF is a non-governmental, not-for-profit organisation that was founded in 1984 (1). Since its inception it has provided outstanding mental healthcare services from its central unit in Chennai.

The founding principle of SCARF is to aim for psychosocial rehabilitation of its patients, which is achieved through a variety of innovative engagement activities at the unit.  To name a few, patients are encouraged to explore their creativity through murals and mosaics, which decorate the walls of the unit; they make plates from palm tree bark, which are intricately woven; they are also encouraged to assist in the pharmacy, in the outpatient clinic ushering patients to their appointments, in the kitchen with food preparation, and in being attendants at the front gate of the organisation. The outcomes of these activities are the development of social skills in patients and a sense of confidence and self-worth.

Having spent time at SCARF I felt that there was certainly a tangible feeling for the success of its aims and objectives as I met many patients who despite once having endured significant psychological distress, were receptive to my visit and willing to openly engage with me, a complete stranger. Alongside the support provided within SCARF work is done to find employment for patients outside of the organisation with employers being invited to be a part of SCARF’s jobs fair in May 2017. This struck me as a great idea and is certainly something I have not come across in my 7 years’ experience in healthcare in the UK.

One thing that struck me as fascinating during my time in India was the terminology used to describe patient outcomes. The so-called ‘third revolution in healthcare’ in the 1970s saw a surge in interest in the measurement of outcomes of medical care, giving rise to terms like ‘health status’ and ‘quality of life’ (2). These can be referred to as ‘patient-based outcome measures’, which are widely used in the west (2). The medical vernacular used in India however is quite different. There, outcomes are largely defined by whether the patient is ‘productive’ within society or not. India has an unprecedented work ethic engrained in its culture. This is likely the result of high levels of social deprivation coupled with the lack of a comprehensive welfare state, meaning there is a real need for every family member to be productive for the unit to survive.

The more time I spent time with the people at SCARF the more I truly began to appreciate their modus operandi. I started to see the value of a care-model that not only addresses the patient’s psychological needs but aims to rehabilitate them back to being ‘productive again’. After all, being productive and having purpose must surely have a positive impact on an individual’s psychological well-being as opposed to the vicious cycle of withdrawal, social isolation, and the reliance on a welfare state that many patients with psychological distress fall into in the west.

Alongside its central unit in Chennai SCARF has seven peripheral telepsychiatry units which serve the rural communities of Tamil Nadu. This service is of paramount importance, particularly when you consider the fact that 70% of India’s psychiatrists live and work in the main cities, whereas 70% of India’s population live in rural villages (1).

Even more incredible is another stream of innovation, which takes the form of SCARF’s free mobile telepsychiatry unit. This is a sizeable air-conditioned bus, which is driven to the most rural areas of the Pudukottai district in Tamil Nadu to deliver care to patients. I had the privilege of observing one of these skype consultations and I was struck by the resourcefulness of it all. Every patient consultation was electronically documented; medication could be dispensed via the on-board pharmacy; mobile phones were used in conjunction with skype video to reduce the amount of bandwidth that would be required to do a skype video call; and health promotion films were played on a large screen attached to the bus. It truly was amazing to see.

I was also very pleased to read that the ‘accuracy of diagnosis and level of satisfaction for consultations conducted through telepsychiatry were similar to that seen in face-to-face consultations’ (1). This begs the question of why in the context of mental health representing a global burden of disease (3), more countries do not explore this approach to service provision?

My time in India was an insightful experience. My expectations of psychiatry in a developing nation was that of an archaic system where the basic standards of care would not be met. SCARF challenged this view and showed me that there are centres for excellence in Indian Psychiatry, ones where we could learn a lot from in the west.

 

References

  1. Thara R, Sujit John MA, Kotteswara Rao MSW. Telepsychiary in Chennai, India: The SCARF Experience. Behavioural Sciences and the Law 2008; 26:315-322.
  2. Gilbody SM, House AO, Sheldon TA. Outcome measurements in psychiatry: A critical review of outcomes measurement in psychiatric research and practice 2003. Report 24.
  3. Summerfied D. How scientifically valid is the knowledge base of global mental health? The British Medical Journal 2008; 992-994.

 

Auroville and visiting the Matrimandir

Katherine Jones
4th Year Medical Student University of Bristol Medical

Our mini-bus bounced along the numerous dirt roads that lead into the town of Auroville on a scorching Indian summer’s day in 2017. Visitors are very welcome at this multinational settlement which is described as the largest experiment in human unity to ever exist. As well as welcoming citizens from anywhere in the world world to live and work together, Auroville’s vision is to ensure humanity’s progress and encourage those who attend to open themselves up to their inner truth, let go of their ego and be a willing servitor to the divine consciousness.

Without knowing of how this vision came into being, it was difficult for me to understand it. My initial thoughts were that this sounded like a very spiritual place, but was it religious? What is the difference between spiritualism and religion? A part of my being wondered if anyone was profiting from such an organisation; a reaction which is typical of a sceptical Westerner, such as myself. The phrase, “what’s the catch?”, sprung to my mind.

Back in the mini-bus, the 8 of us were running slightly late to view a video about the spiritual vision from which Auroville was founded in 1968 by a woman known as “The Mother”. The viewing of this informative video is compulsory for all those wishing to visit a part of the site called the Matrimandir; a massive golden orb around which the town is centred. I learned that the spiritual practice of Auroville was not intended as a religion, and that the settlement was designed to be free from religious and political influence. I hate to admit that I was still sceptical of such as vision for reasons which I cannot put my finger on easily.

Our party of 8 and the dozens of other visitors were driven a short way to the Matrimandir site and asked to surrender our phones and other unnecessary personal possessions ready for a guided tour of the area. I felt more connected to the present moment by ridding myself of my items for a short while, but also slightly frightened for the safety of my wallet and phone! I told myself to stop worrying, as I am certain that was the kind of egotistical thinking that Aurovillians are advised to avoid.

After a short talk from the guide, our tour of the site began. We were instructed to be silent now for the remainder of our time there. The silence was deafening, but so welcome after driving on the hectic roads of India. It is supposed to aid concentration and reflection, which it did perfectly. The Matrimandir is a huge structure which houses an inner chamber where we were headed. To get there, we walked nearly single file through the beautiful surrounding gardens. We then travelled up a spiralling walkway that circumscribed the inside of the orb to reach the inner chamber.

The interior was extremely minimalistic; white walled, dark and cool with electric white lights on the path. Once we reached the inner chamber, we experienced another level of silence. There was now no outside noise at all and we were instructed to leave it if we so much as needed to cough; so important was the maintenance of silence. We encircled a centre piece which reflected sunlight from the very top of the building, creating a wonderful point to concentrate upon. There was easily space for 50 to be seated in a circle around this ornament whilst we were invited to meditate and be thoughtful for a short time.

I have a vivid memory of this meditation. I think this is because it was such a unique experience in an awe-inspiring location. A short while after, we were returned our possessions and back at the entrance of the town. I began to reflect on the experience and thought that India was an excellent host to this spiritual town, since spiritualism in all its forms is so common there. A part of myself felt calmed and healed from the experience; I can really understand the role of spiritualism within a community after this visit. I can also understand why such centres might positively influence the mental health of its citizens through its reflective practices and ethical teachings.

 

Sowmanasya Hospital and Institute of Psychiatry, Trichy.

Priya Chukowry
4th Year Medical Student University of Bristol Medical School

SnowmanasyaOur last week was spent at the Sowmanasya Hospital and Institute of Psychiatry of Trichy. ‘Sowmanasya’ means ‘harmony of the mind’ in Sanskrit and this hospital was privately run. In the 5 days spent at this institution, we saw several patients with schizophrenia, bipolar disorder, alcohol dependence and depression as well as 1 patient with catatonia and 1 patient having a manic episode after the delivery of her child.

Having done our Psychiatry and General Practice attachment for the University of Bristol Medical School in the UK, one of the major differences noted between our experience in the UK and in India was in family involvement. While very few patients suffering from mental illness were accompanied by a family member for appointments in the UK, all the patients I saw at the Sowmanasya Hospital were accompanied by at least 1 family member. Several patients even had 4-5 family members accompany them.

The extensive involvement of family members in the care of patients has been a recurrent theme throughout our attachment in India.  Dr G. Gopalakrishnan, founder of the institution and consultant psychiatrist, gave us a tutorial daily. The topics discussed include stigma, the impact of culture and religion on mental health as well as how to work alongside faith-healers to ensure that mentally-ill patients who need treatment are encouraged to see psychiatrists.

Dr Gopalakrishnan had a copy of the Bhagwad Gita, the most influential text of ancient Hindu literature. One of the most intellectually and spiritually stimulating discussions we had with Dr Gopalakrishnan was the relevance of ancient Hindu to modern psychotherapy. He described the Bhagwad Gita as one of the best resources for crisis-orientated psychotherapy. The Bhagwad Gita is a discourse between Lord Krishna and Arjuna; Arjuna tells Krishna about his feelings of confusion, anger and sadness and Lord Krishna gives him advice on how to handle conflict.  Important similarities have been found between modern psychotherapy and the principles of the Gita.

Recently, there has been an increased interest in the use of eastern philosophical principles in mental healthcare in Western countries. Cognitive Behavioural Therapy (CBT) and Mindfulness-Based Cognitive Therapy, which are widely-used in the UK, use principles found in ancient Hindu literature. As religion plays a key role in Indian society, psychiatrists have advocated the use of the timeless principles of the Gita to enhance the efficacy of the psychotherapies being delivered to patients in India1.

In addition, we learnt about the extent of the influence of Indian cinema on Indian society. In India, movies reach more people than education and ways to use Indian cinema to raise awareness about mental illness and reduce stigma were discussed.

The time spent at Sowmanasya Hospital significantly helped in better understanding the interplay between culture, religion, stigma and mental health in Indian society.

 

References

Bhatia S, Madabushi J, Kolli V, Bhatia S, Madaan V. The Bhagavad Gita and contemporary psychotherapies. Indian Journal of Psychiatry [Internet]. 2013 [cited 10 September 2017];55(6):315. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3705702/

 

The Temples of Tamil Nadu – A Medical Student Perspective

Philippa Walker Smith
4th Year Medical Student University of Bristol Medical School

Way to DharshanIndia is busy. Overwhelming. An assault on the senses. The rich array of colour is what often leaves the strongest impression on visitors, who on their return wax lyrical about the memories of their trip. But it is not just the colour – it is the heat, the smells, the sounds, the smiles from people you pass in the street and the food! And all of this life is experienced in the temples.

 

The aim was to increase our cultural understanding of the environment in which the people we encountered in the hospitals and clinics operated. It soon became apparent the religion and spirituality was an inherent aspect of people’s everyday lives. Before we had even stepped foot into our first temple we could see the number of people presenting with the mark of ash on their foreheads – a sign that they had visited the temple that day.

Temple in PondicherryOne of the first temples we visited was Arulmigu Manakula Vinayagar Temple in Pondicherry.  Famous for its elephant blessings we arrived on a Friday evening to experience it for ourselves. Upon stepping into the temple it was immediately apparent that the temple was a community, a gathering place, and performed both a religious and a social function. Sat in groups on the floor were families and friends, eating meals together, while children ran around them.

It was noisy, boisterous and fun – a vastly different religious setting to that of my own culture.

In Trichy, the first temple we visited was the Rock Fort Temple. From the moment we had driven into the city you could not fail to be aware of the temple perched 83m above us on a massive rock outcrop. 417 stone cut steps later we reached the Uchipillaiyar Temple, dedicated to Ganesh. The views across the Trichy were wonderful, but just below the temple was a tree, with offerings tied all over it. We were told that these were offerings to assist in Fertility. This was the first example I saw of help-seeking primarily occurring in temples for medical issues.  It poignantly illustrated the weight many people place on religion and spirituality in Tamil Nadu.

Fertility TreeRock Fort Temple

 

In complete contrast to the small-but-perfectly formed Rock Temple, Sri Ranganathaswamy Temple in Trichy was all about scale! As you enter you have to walk through seven ornate and colourful gopurams. It was so large it felt like it was a city within itself, especially as within the temple complex you passed through street with shops, motorbikes, restaurants and cars until reaching the central temple. This is exactly what I meant by all of life is within the temples! There are roof viewpoint allowed us a view across the complex to appreciate quite how vast it was and to our relief, to have a cool breeze for a few minutes.

On the outskirts of Trichy is Tanjore, the historic capital of the Chola empire. While swathed in antiquity, it is still very much part of the present, as displayed by the bustling 21st century town around it. Every day, hundreds of people visit the Brihadishwara Temple to worship.  We arrived towards the end of the day, just as the light was catching the stone work and glowing red, oranges and yellows in the sun. The historical importance and relevance to our trip was to highlight the antiquity of concern with mental health in India. Ancient Tamil scriptures engraved on stone include treatise on medicine and healing. 

Temple in TrichyThe final temple we visited, again on the outskirts of Trichy, was called Prasanna Venkatajalapathi and was dedicated to Vishnu. It has long been famous for healing and looking after people with mental illness. Set up in the ground of the temple is a mental health rehabilitation centre, the first of its kind. Treatment at the temples involves admission for 48 days. During this time they take part in Temple rituals 6 times a day and are seen and treated by psychiatrists at twice- weekly clinics. These patients are usually those with psychosis but occasionally will have affective disorders. Historically, before the Erwadi Fire incident, these patients would have been chained. The present working relationship between the temple and the medical profession represent a giant step forward in the treatment of those with mental illness.

 

Anecdotally, the outcomes from this setting are better than those treated by the bio-medical approach alone.

The welcome we received from worshippers, patients and those who worked at the temple was lovely. The patients and their families welcomed us with sand drawings on the floor, and they were very keen to talk to us about their experiences. Many had travelled far to reach this service. After observing a clinic we went to one of the temple rituals and were invited to join in – we had purifying water flung in our faces with an incredible and surprising, force! Visiting this temple and rehabilitation centre was a highlight of the entire trip and a complete privilege.

Overall I came away from this trip in love with India, Tamil Nadu and psychiatry.

02/05/2012 13:37:20

One psychiatrist per 200,000 people

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

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


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


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

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

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

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

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


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

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

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


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


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

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


References:
30/07/2012 15:48:11

$3.3 billion worth of alcohol sale

$3.3 billion worth of alcohol sale in one state in India!

Chennai is the capital of the Tamil Nadu state which is one of the 28 states in India. The population of Tamil Nadu (72.1 million)1 is slightly higher than that of the UK (62.2 million)2, but the total area of Tamil Nadu (50,216 sq miles) is nearly half the size of the UK (94,060 sq miles)!

India is traditionally viewed as a ‘dry’ or ‘abstaining culture’3. Those who drink alcohol are looked upon as ‘outcasts’ in society. In 2004, the per capita alcohol consumption for the UK was 10.39 compared with 0.82 for India4. The National Household Survey of Drug and Alcohol Abuse (India) showed in 2001 that the prevalence of men using alcohol was about 21% and it was only between 2% and 5% among women5, 6.


"...alcohol consumption is still considered a taboo in Tamil Nadu. The society does not accept any form of drinking...".


But in recent years things have changed. The change is visible especially in major cities like Mumbai, Delhi, Pune, Chandigarh, and Bangalore. Women-only Alcohol Anonymous (AA) meetings held in these areas have found an increase in the number of women who drink in India7. Also the average age of first time alcohol use in general has reduced from 28 in 1980s to 18 years in 20108.

However, alcohol consumption is still considered a taboo in Tamil Nadu. The society does not accept any form of drinking (either ‘social drinking’ or ‘binge drinking’). Local magazines reported that bar workers lack social dignity9 and hence many of them remain unmarried as the parents are hesitant to give their daughter in marriage to them10.

The Indian government has given rights to individual states to develop their own rules in terms of alcohol production, sale and taxation. Historically, consumption of alcohol was totally banned in Tamil Nadu state between 1937 to 1991 and the ban was lifted only 3 times during those periods11. The whole production and sale of alcohol is controlled by the Government company called TASMAC (Tamil Nadu State Marketing Corporation) which has nearly 7000 sale outlets and about 30,000 employees11. There has been a steady profit over the years. Reports suggest that in 2005-06, the annual revenue was about 7,335 crores of Indian rupees (73.35 billion rupees, equivalent to $1336 million). The most recent data (2011-12) showed annual revenue of an astonishing 18,018 crores of Indian rupees12 (180.18 billion rupees, roughly equivalent to $3.3 billion)!

With the sale of alcoholic beverages soaring high over the last decade, I believe that alcohol-related morbidity and mortality have been on the rise. Hence there is a great demand for alcohol treatment services. Let me give a brief account on the treatment model at the CSI Rainy Hospital, Chennai, Tamil Nadu. There are some striking contrasts from the western world:

First, the referral system is entirely different. Anyone can self refer to the psychiatric out-patient clinic. There are no waiting lists and the patients are seen on the same day of referral. Frequently, those who are already undergoing treatment bring their friends or relatives who have alcohol or mental health problems.

Assessment of a patient (with alcohol history) with his carers at CSI Rainy Hospital, Chennai


Secondly, the patients are always seen with their family members (mother, spouse etc), and counselling forms an inevitable part of the treatment process. Thirdly, there is striking gender difference - only male patients access the service! As for the possible reasons, a local report suggests female drinkers are less in number13. But apart from this, I believe it is due to the stigma attached to drinking. The initial assessment consists of history taking, administration of questionnaires (such as Addiction Severity Index) and alcohol withdrawal scale (CIWA-AR) and blood tests. If the patient presents with severe withdrawal symptoms, he would be admitted to the medical ward for detoxification. However, those with minimal or no withdrawal symptoms are assessed for the suitability of initiating disulfiram (about 12 to 24 hours after their last drink). If there are no contraindications, the patient is started on disulfiram after giving information about the medication and obtaining consent. This process constantly involved the participation from the family. As a rule of thumb disulfiram would not be commenced if there are no carers available at the time of the assessment.
A family counselling session at CSI Rainy Hospital, Chennai

"The patients (and the carers) are then given weekly appointments for up to a month – during which time an intense short term (both individual and family) counselling sessions takes place."


It has become the responsibility of the carer to supervise this medication and it is done meticulously. The patients (and the carers) are then given weekly appointments for up to a month – during which time an intense short term (both individual and family) counselling sessions takes place. Emphasis is given to restoration of marital relationship during recovery. It is interesting to note that these sessions are based on ‘Steps to Freedom’, a faith-based intervention in resolving personal issues such as anger, ego defences, dysfunctional coping, pseudo self-esteem, sexuality and genetic traits.

This was tried by Hurst et al14 and found to produce positive results for depression, anxiety and other mental disturbances. The same version is currently applied for patients with alcohol dependence. One of the remarkable differences I noted is that there are no set time limits for these sessions. They are so flexible and each session could carry on for few hours!

A short review of patients with history of alcohol use was done at the CSI Rainy Hospital:

 

A short review of patients with history of alcohol use was done at the CSI Rainy Hospital



Of those 33 patients with history of alcohol use 11 attended for the first time for assessment.The rest of the 22 patients are currently abstinent and attending regular follow ups.Their case notes were analysed to check how long they were in treatment and abstinent.

 

The table is as follows:

A short review of patients with history of alcohol use was done at the CSI Rainy Hospital


In conclusion, the sale and consumption of alcohol in Tamil Nadu is escalating day by day and it raises alarm bells. This has become a major public health concern. The available alcohol treatment services are too few in number and the country is ill equipped with resources to address the issues. However, there are pockets of excellence where a tiny unit such as the CSI Rainy hospital in Chennai shines like a lode star in the dark!

CSI Rainy hospital in Chennai

References:
  1. Census India 2011 www.census.tn.nic.in/whatsnew/ppt_total2011.pdf
  2. The World Bank data
  3. Bennet et al, 1993.
  4. WHO Global status report on alcohol 2004. Page 17-18.
  5. Prasad R. Alcohol use on the rise in India. The Lancet, Volume 373, Issue 9657, Pages 17 - 18, 3 January 2009.
  6. Benegal V, Nayak M, Murthy P, Gururaj G et al. Alcohol, gender and drinking problems – perspectives from the low and middle income countries. Chapter 5: Women and alcohol use in India. World Health organization. 2005.
  7. Suryanarayan D. A dubious high for ‘spirited’ women in India’s cities. Daily News and Analysis. Published: Wednesday, May 26, 2010.
  8. Gururaj G, Murthy P, Rao G N, Benegal V et al. Alcohol related harm: Implications for public health and policy in India. Publication No. 73, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, India. ISBN No: 81-86428-00-X.
  9. The Hindu: TASMAC staff request CM to make them full-fledged government employees. 18 July 2012.
  10. D.L.Sanjeevi Kumar. Junior Vikadan article: Mayakkam Enna. 24 June 2012.
  11. Wikipedia, the free encyclopedia: TASMAC.
  12. The Times of India. Tamil Nadu's liquor revenue rises to Rs 18K cr. 27 April 2012.
  13. Linda A. Bennett, Carlos Campillo, C.R. Chandrashekar and Oye Gureje. Alcoholic beverage consumption beverage in India, Mexico and Nigeria – a cross cultural comparison.
  14. George A. Hurst, Marion G. Williams, Judith E. King and Richard Viken. Faith-based intervention in depression, anxiety and other mental disturbances. Southern Medical Journal: - Volume 101 - Issue 4 - pp 388-392 April 2008 doi:10.1097/SMJ.0b013e318167a97a
Login - Members Area

If you don't have an account please Click here to Register

Make a Donation