India

$3.3 billion worth of alcohol sale

Wed, 30 Jan 2013 10:04:33 GMT

$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 women^{5, 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.

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.

"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:

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:

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!

References:

One psychiatrist per 200,000 people

Wed, 30 Jan 2013 10:04:32 GMT

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."

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:

Size, growth rate and distribtion of population, Census report 2011, Office of the Registrar General & Census Commissioner, Government of India.
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 Hospital.