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The Royal College of Psychiatrists Improving the lives of people with mental illness

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 cares 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.


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 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:

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Comments

 

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.

Best Wishes,

Dr Karthik Bommu

ST6 – Psychiatry of Intellectual Disabilities

Royal Edinburgh Hospital, UK


If you would like to post a response to Jeshoor's blog, please email your message to the Website Manager (Jburnside@rcpsych.ac.uk)


 

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About this blog

Dr Jeshoor Jebadurai

Dr Jeshoor Jebadurai is an ST6 in general adult psychiatry in South Wales Specialty Training Programme and currently working with community mental health team in Swansea. He is interested in International Psychiatry.

Prior to his move to the UK, he was trained at the Institute of Mental Health, Chennai, India. He has been travelling to India over the last few years conducting health screening camps in rural parts of South India and raising the awareness about mental health.

 

This personal blog reflects Dr Jebadurai's own views and does not represent any organisation he is working with. Dr Jebadurai is thankful to Dr Shanthi Davidar, Consultant Psychiatrist for her clinical supervision and her team at the CSI Rainy Hospital, India.