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 cares or
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.
Check out Dr Peter Hughes recent blog: Take home message
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
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
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.
- Size, growth rate and
distribtion of population, Census report 2011, Office of
the Registrar General & Census Commissioner, Government of
- Importance of undergraduate psychiatric training, Trivedi, J.K.
Indian Journal of
Psychiatry, 40, 101-102. (1998)
Training and National deficit of psychiatrists in India - A
critical analysis. Thirunavukarasu M. Thirunavukarasu P.
Indian J Psychiatry 2010; 52:83-8.
- Salhan RN, Sinha SK, Kaur J. Country Report-India. Asia
Australia Community Mental Health Development Project, Asia
Australia Mental Health; Melbourne, 2008.
- The history of CSI Rainy
Subscribe to this post's comments using
Thanks to Jeshoor & I wish well for his
efforts in bringing the work of CSI Rainy’s team to the wider
attention. I reckon from my own experience that it's a classic
description of a scenario from the out patient services in the
'developing world'. The presenting condition here (dissociative
disorder) coupled with number of carers/family members in
attendance is largely the norm in this part of the world. WHO
reports India spends just 0.83% of its total health budget on
mental health less than other developing nations; Malaysia spends
1.5% of its total health budget, China 2.35%, South Africa 2.7%,
Australia 6.5% and New Zealand 11% (WHO 2001a). WHO's Mental Health
Atlas 2005 says that, as far as community care for mental health is
concerned, India and south eastern Asia lag behind the rest of the
world. India has a very limited number of mental health
facilities and professionals (one bed per 40,000 population and
three psychiatrists per million populations).
Christian missionary funded health care
organisations like CSI Rainy Hospital &Christian Medical
College Hospital, Vellore have been providing much needed succour
to the local population’s mental health needs in addition to the
now prevalent National Mental Health Programme(NMHP) & District
Mental Health Programme(DMHP) catering to the mental health
needs nation wide. Due to various funding reasons as
highlighted in the Mission report 2003, much of the funding
allocations had been focussed in developing hospital based
infrastructures than community oriented projects. Any more light in
this regard, where the parallel organisations like CSI Rainy
Hospital have been able to meet the mental health needs in the
community would be an helpful information.
Over and above these odds, the experience of
stigma in its deep rooted inherent nature in this multicultural
country is a greater debacle to overcome on a more personal,
cultural and national level.
Dr Karthik Bommu
ST6 – Psychiatry of Intellectual
Royal Edinburgh Hospital, UK
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