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Anjali Prayag

In its golden jubilee year, NIMHANS's Department of Psychiatry reaffirms its commitment to the ideals set by its founding fathers.

When the killer wave struck coastal India in December 2004, relief poured in from many sources and in many ways. Generous donations of food, clothes, water and medicines took care of the physical needs of the affected people. But there was a crying need for emotional support to help survivors tide over the trauma inflicted by the worst natural disaster in recent times. There is fear, anxiety, depression, and even guilt feelings among the survivors who have lost a loved one... A group of 70 psychiatrists, social workers and doctors from NIMHANS (National Institute of Mental Health and Neuro Sciences), the country's leading mental health institute, is attempting to bring normalcy into victims' lives.

As Dr D. Nagaraja, Director, NIMHANS, says, "The acute initial stress is over. What the victims now need is rehabilitation."

Post-traumatic adjustment has to be sensitively handled. So far, the institute's disaster management group (DMG) has trained about 1,200 people including administrative officials, volunteers and social workers to help communities cope with the abnormal situation. The DMG had earlier worked with people affected by natural disasters in Latur, Gujarat and Orissa.

Disaster management is just one of the services that NIMHANS, set up in 1847, offers to a traumatised community. On a normal day, doctors at the hospital's 125-acre sprawling campus in Bangalore, see more than 1,000 outpatients, of which 500 are new patients, and handle over 250 emergencies. And the Department of Psychiatry, currently in its golden jubilee year, handles almost one lakh patients every year.

It was in 1847 that Dr Smith, a physician to the Mysore Resident, Sir Mark Cubbon, convinced the latter to establish a ward for the mentally ill at the Hospital for Peons, Paupers and Soldiers. This is the first available record of a separate facility for the mentally ill in Bangalore. The same year, a separate facility for the mentally ill was appended to the Pettah (the old city) at the General Hospital.

In 1881, an elaborate status paper was brought out on the condition and future of health services in Mysore. This included suggestions for a mental hospital, as the population of Bangalore was expected to cross one lakh soon.

The old asylum was expanded but by 1918, the building could not accommodate the increasing number of patients and the Government of India established an All India Institute of Mental Health in 1954.

Though the hospital's origins can be traced to 1847, it is ironical that even after 150 years, the stigma attached to mental disorders remains. Statistics show that about 10 per cent of Indians suffer from neuro-psychiatric disability that requires medical attention and about two per cent require hospitalisation. More important, about 30 per cent of them require rehabilitation services. Psychiatrists at the institute say that about 5-10 per cent have common mental disorders such as depression, anxiety and fear. "A mental disorder, unlike a physical disability, is subtle and often not accepted as a problem," says Dr Nagaraja. In fact, diagnosis and treatment of mental disorders is often thrust upon family doctors. Thus it is imperative that general physicians are trained to recognise psychiatric problems.

Unfortunately, medical education in the country does not even recognise psychiatry as a full-fledged subject. "During the entire course, medical students answer just one question in psychiatry, and that too a short notes type," says Dr Nagaraja.

The District Mental Health Programme, launched in 1982, seeks to train primary health officers in recognising psychological disorders among the rural population. A multi-disciplinary team comprising a psychiatrist, a counsellor, a psychologist and a nurse will be stationed in all districts covered under the programme. The experimental project, launched in Bellary district of Karnataka, is now being replicated all over the country.

In fact, the Centre's National Mental Health Policy covers 27 districts in the country. This means primary health officers have been trained to recognise the problem, and each district equipped with a 10-bed unit and paramedical staff to treat mental disorders. By the end of the 10th Five Year Plan, the Government intends to cover 100 districts across the country.

Dr Sanjeev Jain, Additional Professor, Department of Psychiatry, says anxiety and depression are very common. "It generally needs 4-5 months of medical care and nearly 4-5 per cent need psychiatric help to overcome the condition." Nearly two per cent of these patients need intensive treatment.

But diagnosis is a major problem because in over 30 per cent of the cases there are no identifiable physical problems, he says. Where physiological disorders are present, they tend to be cardio-related, panic attacks, lower back pain, etc. "There is a physical overlap and it's important to recognise this," says Dr Jain.

Psychiatric disorders are not restricted to specific regions or economic strata of society, says Dr Nagaraja. Mental health problems are on the rise both among the rural and urban populace, but unfortunately supportive systems are missing.

Women more vulnerable

Dr Prabha Chandra, Additional Professor, Department of Psychiatry, who counsels women on anxiety and stress-related problems, says modern lifestyle has put extra burden on the mother. "Most workingwomen feel de-motivated and frustrated post-35, because they cannot move up the career ladder like their male counterpart." This is due to reasons not related to their work and because they have to take on the extra burden of running the home and bringing up children, she says. "Hence they are not able to network or travel," she says.

Dr Shobha Srinath, Professor and Head, Chief of Child and Adolescent Psychiatry Services, sees an increasing occurrence of autism and speech and language problems in children. She attributes this trend to shortcomings in the parenting process, particularly lack of an interpersonal relationship between parents and children. "Families need to find some mechanism such as split working hours or flexi time to spend more time with children," she says.

Also, there are not enough trained professionals to meet the mental health needs of the population. Pointing to the dismal number of psychiatrists in the country (about 3,500), Dr Nagaraja says, "Most of them migrate and 80 per cent prefer to work in the metros due to economic reasons. Do you know that there are more Indian psychiatrists working abroad than here?"

NIMHANS, which has about 20 psychiatrists at present, faces yet another dilemma: to focus on community healthcare, which is basically non-technical primary healthcare, or on high-end research or cater to both. "How do you balance and allocate resources," asks Dr Nagaraja.

Like all government hospitals, pricing (subsidised healthcare) is a major concern at NIMHANS too. Decision-makers in the healthcare sector are still not clear about who should bear the cost: the individual or the government. Notwithstanding these contentious issues, the institute has managed to live up to the ideals set by its founding fathers. Dr Shobha says, "This institute has the ability to make people come together. In specialisation, there is a fear that the holistic view is never taken. But here this is not true, because psychiatry cannot be worked from office. We have to work in teams — the doctors, the rehab person, the occupational therapist, nurses, counsellors, etc."

The institute currently has 900 beds funded by public contribution. There are plans to start a facility offering long-term treatment, says Dr Nagaraja. "It will be a 40-bed unit in a rural setting, charging nominal fees," he explains. The team also wants to use telemedicine to reach the District Mental Health Programme to more regions.

Pictures by K. Bhagya Prakash

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