A journey through psychiatry - A personal perspective.

Abstract

INTRODUCTION Respected Chair Persons, past presidents of our Indian Psychiatric Society, senior professors, and my dear colleagues, at the outset I thank the respected President of our IPS and beloved members of the executive council including the awards committee for selecting me for this prestigious Prof. J. K. Trivedi Lifetime Achievement Award. This being the first presentation for this award, I feel that a few words about the stalwart in psychiatry in whose name this award has been instituted will not be out of place. Born on the March 15, 1952, Prof. Trivedi graduated from KGMC Lucknow and rose to the rank of Professor in 1995. To his credit, there are about 300 publications which speak for his academic and research excellence. He is the recipient of many prestigious awards including the Dr. DLN Murti Rao Oration and Marfatia awards of our IPS. He has held several positions, to name a few, Hon. Editor of our IJP, President of IPS, and WPA Zonal Representative for Zone XVI southern Asia. He was also the Vice President of IASP, but before he could take over as its President, he left this world on September 16, 2013. It is worth recalling my close friendship with him ever since we started our career in psychiatry and more importantly the pleasant moment when I handed over the Presidentship of our IPS to him in Jan 2004. After a stint for about 5 years as assistant surgeon in Tamil Nadu Medical Service, my journey in psychiatry which started from January 1974 as a tutor still continues as an emeritus professor. In search of an apt topic for my present deliberation, it dawned on me to highlight my own personal perspective on some of the issues in the field of psychiatry, although I know it may not reflect the consensus view of this learned audience. PSYCHIATRIC INTERVIEW – DILEMMAS AND DISCRETIONS Patient presents alone and is unable to provide proper history Unlike in the other fields of Medicine, whenever the patient presents alone, it poses a challenge in examination and formulating appropriate treatment plans in our field. This is more relevant in conditions such as psychotic disorder, substance abuse, and depressive disorder, to name a few. At the same time, asking the patient to bring a suitable informant before starting the treatment may be viewed as unethical. In such circumstances, it has been found to be appropriate to prescribe drugs for a couple of days and later arrange to involve the family members in the treatment program. Whenever the patient is accompanied by family members, who is to be interviewed first? I was unable to find a satisfactory clarification on this aspect from the textbooks. My experience has shown that if possible, it is preferable to have a preliminary interview with the patient alone first although it may not be exhaustive, and later get the detailed history from the informants. This would eliminate from the patient's mind the suspicion that “the psychiatrist has already become biased and would have drawn a conclusion about him from the information provided by the family members.” Usually, interviewing the patient again might not evoke a hostile response from him. The above procedure would help to establish a better rapport with the patient who is harboring delusional ideas and would eliminate the risk of evoking his hostile responses. When the family members report that the patient refuses to come to the psychiatrist for treatment claiming himself “normal” and the family requests for some medication, can we prescribe the same? There may be circumstances, when the patient refuses to come for treatment and his family also avoids the proper legal procedure due to stigma, rendering the treatment of such patients difficult. Neither it will be advisable for the psychiatrist to visit them at their house, for, if the patient harbors symptoms such as delusion and hallucinations, not surprisingly, the psychiatrist might find himself implicated in the patient's delusional system. The close family member might plead that the prescription may be given for himself/herself claiming either falsely or even factually that he/she too has complaints such as disturbed sleep. More often than not the psychiatrist could infer that the family member might administer the prescribed medication surreptitiously to the patient. Amid a dilemma, obliging to such requests, albeit, after a written request, might perhaps prove to be beneficial to the patient. After a period of such covert treatment strategies, experience shows that most of such patients voluntarily will seek the help of the psychiatrist for some of their complaints and later report himself for follow-up treatments regularly. Furthermore, such patients, who have been manifesting psychotic symptoms and not going for work due to their illness, have resumed their work much to the relief of the family. Notwithstanding the confidentiality maintained by the family about the covert medication, many of these improved patients might be able to arrive at a conjecture about such administrations, but usually, they do not explicitly express or question it. Perhaps, as a result of such a treatment, there is an improvement in their insight too. Furthermore, the ill-conceived relevant sections of the Right to Information Act[1] or the Mental Health Care Act 2017-Section 25: Right to access medical records[2] are not applicable here, as the actual management was done by the family in their house only and not in any hospital or by any medical practitioner/psychiatrist. In an interesting paper, it was concluded that covert treatment is widely used and rarely acknowledged. It probably needs to be used a little less commonly, as a last resort and under guidance which needs to be prescribed.[3] The author of this paper while quoting Section 89 of the Indian Penal code has rightly noted that although “Unsoundness of mind” is not defined, the provision, as it exists seems to convey that covert medication is not a legal offense, as it is done in good faith and with guardian consent. TRANSPORT OF AN UNWILLING AND UNCOOPERATIVE PATIENT TO A MENTAL HEALTH-CARE FACILITY Can we transport a patient with mental illness from his house without his consent in ambulance or by other means? Elsewhere, it has been pointed out that the civil society has to appreciate that in psychiatric practice, where some patients lack insight completely; others have to take decisions for them and forcible admission without a patient's consent also has to be done at least on some rare occasions. It was also reiterated that a psychiatrist is required to do it, taking into consideration the various genuine concerns expressed by a patient's family, and also making judicious application of mind.[4] In a study on ambulatory services for the mentally ill, the authors concluded that separate ambulance services for psychiatric patients is a need. According to these authors, the experience of running such a service is gratifying, though there are many legal and financial hurdles requiring a standard operating procedure to be worked out.[5] Nevertheless, it has to be noted that such services may also be misused causing medicolegal problems as well as violation of human rights.[6] Mentally ill are “entitled to use” ambulance services as per Section 21c of The Mental Health Care Act 2017. Nevertheless, if the patient refuses to get into the ambulance claiming himself “normal” and the family or mental health personnel forcibly transport him in an ambulance or by other means, the patient could even file a police complaint that he is “kidnapped” with an ulterior motive. In such an eventuality, the police will have to file a case under the Indian Penal Code and ultimately, the family or the mental health personnel including the psychiatrist will have to be exonerated of the charges through the court of law. DOCUMENTATION OF FINDINGS Diagnosis of psychiatric disorders depends mainly on listening to the client, eliciting the history, recording the mental status and the like, in addition to the usual physical examination and relevant investigations, as provided in the standard textbooks of psychiatry. Detailed documentation of these findings in addition to the recording of the demographic data such as name, age, sex, address – both present and permanent, phone no, etc., is an integral part of schedules for the management of our clients. Recording the findings and the treatment given on each of the patient's follow-up visits are equally important. A written statement about the patient's behavior and reasons for consultation from the informants who had accompanied the patient needs to be filed. If the patient is cooperative and educated, a note by him about his own problems will be another helpful document. Much to my embarrassment, a few of my regular clients even after being under my management for over 30 years had asked me to narrate the actual state of their minds for which they landed up for my consultation. Apart from the need for the follow-up treatment, such documentation will be needed to offer clarifications to the clients and their caregivers. What is more important is, even after several years, medicolegal issues due to problems such as property disputes, divorce, and criminal offenses may arise for which the case records will be required. To this end, Mental Health Care Act 2017 has also provided an impetus to documentation. Noteworthy is the vivid description regarding the various issues related to the documentation provided elsewhere.[7] Recently, some of the clinicians find electronic documentation as user-friendly option, which the court of law also seems to be approving of. It might be helpful to overcome some of the cumbersome procedures. However, this electronic system including telepsychiatry must be ensured with proper encryption and cybersecurity as it involves personalized sensitive data. ISSUE OF CERTIFICATES AND PRESCRIPTIONS It is generally advisable to issue certificates, after retaining a copy of it, about the mental illness of the patient with his/her written consent only, after duly explaining him/her about the consequences. Especially, when the request for a certificate is made by a caregiver or a nominated representative proper application of mind is needed, lest the same certificate is used against the interest of the patient. The same “care giver” might become a “problem giver” to our patients. What is more startling is that there are instances where the husbands have used the certificates for exploiting or even to divorce their wives, and by close family members to grab a property. The psychiatrist must also be guarded in instances where a person may seek shelter under a feigned psychiatric illness for regularizing his unauthorized absence from his duties or try to escape from charges after committing a crime by submitting a clandestinely obtained psychiatrist's prescription, or hospital document in a court of law. Hence, the prescriptions must also be correctly dated, legible, and signed with the name affixed keeping in view of the required standard protocol. IMPACT OF NEURO BIOLOGICAL ADVANCEMENTS Ever since we have witnessed advancements in radioimaging techniques in the late 1970s that have replaced investigations like carotid angiogram and pneumoencephalogram, there have been encouraging breakthrough findings in localizing the areas of the brain linked to the various symptoms of psychiatric disorders. It is speculated that such radiological findings might serve in future as a supplement investigation to reiterate the mental status examination findings that could be held valid even in a court of law. In comparison to our experience with the drugs used in the 1970s, the significant advancements in neurosciences, especially in neurochemistry and pharmacotherapy, during the last four decades have paved the way for the significant amelioration of resistant depression, intense delusions, perceptual abnormalities, somatic symptoms, and other intractable conditions. Noteworthy is also the gradual decline in the usage of electroconvulsive therapy (ECT) in many centers for the simple reason that pharmacotherapy has become an effective replacement for ECT in many cases. Nonetheless, such advancements are not without their inherent adversities such as metabolic side effects and blood dyscrasias. Therefore, it becomes imperative that the psychiatrist gets the written consent of the clients after informing the various possible side effects. In the early stage of treatment, giving the prescription only for short terms and careful observation for the emergence of possible side effects will be beneficial. Periodical mandatory investigations should also be undertaken. Not surprisingly, in future, a psychiatrist might face legal problems if he is not competent in assessing and managing above such issues. During my early career in the 1970s, I learned that psychosurgery yielded better results in acutely psychotic, agitated, highly deluded, and obsessive–compulsive disorder cases. However, the procedure went out of vogue soon, not due to unequivocal evidence of lack of safety but due to quality of outcome being poor and development of complications including seizures and severe cognitive impairments. A few of such cases with these complications have been seen by this author also. Recent advances in brain stimulation methods such as cranial electrical stimulation, transcranial direct current stimulation, transcranial magnetic stimulation, magnetic seizure therapy, cortical brain stimulation, deep brain stimulation, and vagus nerve stimulation appear to be promising, but further follow-up studies will be beneficial for their wider acceptability. HAS THERE BEEN AN ESCALATION OF BIOLOGICAL FACTORS? It is increasingly evident that mental illness will be best understood as having malfunctioning of specific areas of brain resulting in disturbances in the domains of cognition, emotion, and behavior. It is noted elsewhere[8] molecular genetics and neuroscience will play an increasing role in the understanding of etiology and pathogenesis of psychiatric disorders. Nonetheless, it is uncertain that there is an increase in the occurrence of these factors leading to a corresponding increase in the incidence of psychiatric disorders over the years. In addition, the frequency of occurrence over the years of genetic mutations and the role of various factors including environmental pollutions, infections, and intra- and extrauterine pathologies on the neurodevelopment require an in-depth research to draw a valid conclusion on the increase in occurrences of such biological factors. Whether the cell phones, Internet, and modern electronic media have a bearing on these biological predisposing factors also requires further research. However, in recent years, behavior problems including addictions and suicides encountered as a result of being hooked to the programs on cell phones, Internet, and such media have been documented.[91011] The occurrence of psychiatric disorders including neurocognitive impairments in HIV-seropositive individuals has been well-documented.[121314] It could not be unequivocally asserted whether there is an increase in female substance abusers in India contributing to the psychiatric complications in their children. Similarly, it might be difficult to draw conclusions on the role of male substance abusers. HAS THERE BEEN AN ESCALATION OF PSYCHOGENIC FACTORS IN INDIA? After my entry from the early 1970s, there has been a steady increase in the family problems including divorce, domestic violence, and maladjustment with in-laws and broken homes[1516] leading to an exponential increase in depression and suicides. In addition, growing unemployment, underemployment, and love failures appear to be contributory too. Poverty and debts among farmers leading to suicides[17] were unheard-of in India until the previous decade. Escalation in the psychogenic stressors leading to suicide among students in recent years has been observed.[15] Notwithstanding the above, another debatable factor leading to an increase in suicides over the years in India might be frequent write-ups about suicide in the press including those of mental health professionals and other media coverages. These might perhaps serve as “suicide arousals” in suicide-prone individuals, as a result of leaving an “imprint” in their minds the thought of “suicide” and related issues. Nonetheless, the task of suicide prevention is daunting. The solution to suicide prevention may prove to be more complex than the problem of suicide itself.[18] THE NEED FOR THE PSYCHIATRIST TO PROVIDE PSYCHOTHERAPY COMBINED WITH PHARMACOTHERAPY The psychiatrist must get well trained in psychotherapeutic techniques too. Even as he spends time in interviewing and prescribing drugs, he should not turn out to be a prescribing doctor only. It will be beneficial to the client if the psychiatrist spends some time on nonpharmacological interventions also, such as psychotherapy and behavior therapy, based on the patient's need. Such an integrated treatment approach has been advocated by others too.[192021] The beneficial effect of one therapist undertaking both pharmacotherapy and cognitive behavior therapy for managing a depressive disorder has also been highlighted elsewhere.[22] It has been stated that the unique capacity of the psychiatrist to provide combined psychotherapy and pharmacotherapy will maintain a special robustness to the discipline in both its practice and research.[23] CLASSIFICATION OF PSYCHIATRIC DISORDERS Having come across several revisions from International Classification of Diseases (ICD) 8 and Diagnostic and Statistical Manual of Mental Disorders (DSM) III to the present stage, it is noted that a re-look appears to be worthwhile to assess the validity of some of the older diagnostic concepts such as endogenous depression, reactive depression, catatonic schizophrenia, hebephrenia, and the like as some of them might be relevant even now. The then APA President elect Dr Jeffrey Liebermann and Thomas Insel issued a joint statement, as quoted by Vahia[24] “Looking forward, laying the groundwork for a future diagnostic system that more directly reflects modern brain science will require openness to rethinking traditional categories.” Also, of relevance is the observation that DSM 5[25] does not claim to be the ultimate final word in the classification of mental disorders.[26] The increasing trend to sub judicate under the assertive superiority of a country should be decried. The observation that most psychiatry's illness concepts are still provisional and their definitions are arbitrary[27] appears to be noteworthy. However, recent efforts by researchers to validate the diagnostic concepts are promising. In an Indian Psychiatric Society multicentric study of first-episode depression,[28] it was noted that many of the functional somatic complaints of our patients are not included in the nosological systems of DSM-IV[29] and ICD 10.[30] Such variations have been reported in the typology of complaints of our patients suffering from disorders such as depression,[3132] conversion/dissociation disorder,[3334] and posttraumatic stress disorder.[35] While arguing for Indianization of psychiatry, it has been pointed out by Avasthi[36] that presentation of mental illness is different in the Indian culture and many a time, it is difficult to fit patients into the categories developed by the western world. In addition, the suggestion given by the author that modifications especially with respect to pharmacotherapy and psychotherapy to suit our people require a serious consideration appears to be not unreasonable. More importantly, more than four decades ago, a proposal has already been contemplated for the classification of psychiatric disorders for use in India.[37] DSM is said to be a blockbuster publication of the American psychiatric publishing and it gives the APA considerable clout in world psychiatry.[8] With such an enviable power DSM gives to APA, it is unlikely at least in the near future, the various classificatory systems such as DSM, ICD, Latin American Guide for Psychiatric Diagnosis, and Chinese Classification of Mental Disorders (CCMD 3) will come together. It seems the time has come for realization that our Indian Psychiatric Society can also embark upon the task of developing an Indian Classificatory system. The disorders and symptoms that are observed in our Indian cultural setup could be incorporated even in the ICD while formulating our own “Indian classification of psychiatric disorders.” IS THERE A NEED FOR INSTITUTES OF MENTAL HEALTH RUN BY GOVERNMENTS IN OUR COUNTRY? The undeniable fact is that there are a substantial number of our patients whom the family cannot manage at home due to their suicidal, homicidal, and violent unpredictable behaviors. Especially, the family cannot manage such patients on long-term basis even if their behavior problems are intermittent. In a study conducted for a month at the Institute of Mental Health, Chennai,[38] among the total of 274 male patients, 32 had to be directly admitted in closed wards of the main campus on the 1st day of their entry. Of the remaining 242 patients who were admitted in the open wards, the caregivers of 116 patients even within a couple of weeks after admission wanted to get the patients shifted to closed wards inside the main campus owing to their inability to stay along with the patients in the open ward for taking care of them during the treatment period. Thus, a total of 148 out of 274 males (54.01%) had no relative to be with them even for a short period forcing the authorities to admit them in the closed wards for management in the absence of their relatives. Similarly, among the females, 35.7% had to be shifted to closed wards inside the campus owing to the inability of their relatives to look after them in the hospital open ward for a long period. Expectedly, the enthusiastically launched National and later the District Mental Health Programmes that have fallen far short of even their intended objectives, except perhaps in a few districts, could not have relieved the burden of such frustrated families. The general hospital unit has its limitations in managing such patients for long, especially in the absence of capable and responsible caregivers. The burden of patients with schizophrenia has been well described by Martyns-Yellowe.[39] Not infrequently, citing their personal commitment, the caregivers express their inability to stay for longer periods with the patients and plead with the mental health professionals to take care of their wards themselves on their behalf. In fact, over the course of time, the patients' frontline caregivers such as parents or children may pass away, leaving the patients under the care of their siblings or a close relative if any are available. In such an eventuality, even the patients' siblings or the close relative due to various reasons including the hostile attitude of their own family members may find it difficult to accommodate them on long-term basis. Ultimately, such patients may be put into the so-called “community Rehabilitation centres” many of which are profit oriented, unregulated, and poorly equipped. Hence, state-run institutes will be beneficial for those patients who have no relatives coming forward to take care of them. In these government institutes in addition to routine therapies, other provisions for recreation, rehabilitation, etc., should be in place. NGOs could be encouraged to help such government-run institutes. TRAINING, ACADEMIC, AND RESEARCH NEEDS IN PSYCHIATRY UG training The hesitation displayed by Medical Council of India (MCI) for making psychiatry as a separate subject of examination for undergraduates in medicine as noted by Raju[40] is intriguing. For one reason, the core of MCI's dilemma could be based on the untenable argument that psychiatry is still included as part of the subjects in general medicine, and for another, the reluctance of our own medical fraternity in MCI who perhaps unreasonably argue that already many subjects are included for separate examinations for MBBS. However, the Indian Psychiatric Society has been consistently advocating an increase in the psychiatry curriculum at the undergraduate level along with an examination to equip MBBS doctors to function effectively as primary mental health-care physicians.[41] PG training The indispensable need for acquiring a reasonable knowledge and diagnostic skill not only in psychiatry but also in general medicine, and neurology, could be realized by a psychiatrist after he starts his career, especially when he happens to work in a medical college hospital setup or where liaison psychiatry becomes an integral part of his services. To this end, in addition to mandatory training, it is necessary to make neurology and medicine as subjects of examination also with neurologist and general physician on the board of examiners along with the psychiatrist who shall be the chairman. Academic and research Furthermore, a psychiatrist should be in a position to display confidently his knowledge not only in psychiatry but also in other medical conditions whenever he takes part in forums such as physician conference and CME programs of other departments. More often than not, some of our medical fraternity may not even know the difference between “psychiatry” and “psychology,” and it should be the endeavor of the psychiatrist to enlighten them in this regard also. Notwithstanding our pioneering research in several areas, still, there is a dearth of studies designed to explore the underlying etiology and pathophysiology of psychiatric disorders. More innovative studies will undoubtedly make India a pioneer in all areas of psychiatric research. MENTAL HEALTH CARE ACT 2017 Despite some of the positive aspects of the recent Mental Health Care Act such as safeguards in the rights and privileges of mentally ill, decriminalizing attempted suicides, there are also several negative aspects. Empowering persons with inadequate qualifications and training in vital decision-making processes including admission and discharges could have a negative impact on the welfare of our patients. Equally disturbing are the undesirable conditions laid down for inpatient care, diagnosis, electroconvulsive therapy, etc., Not surprisingly, some of the patients will go untreated and our colleagues might also resort to defensive practice. Several critical studies have already pointed out the various shortcomings of the mental health-care bill.[4243444546] In the wake of several provisions of this act that require rectifications, it seems not unreasonable to plead for a new act, by nominating a panel of experienced psychiatrists, who are actually in the frontline for the management of mentally ill, for this task. CONCLUSION Ever since the medical management of mentally ill had taken roots almost a century ago, the psychiatrists have been in the forefront in the field of mental health. What should bother us is, in the recent past, there seem to be clandestine maneuvers to undermine this role to the detriment of proper patient care as we could discern from the recent mental health-care act. However, it is gratifying to learn that more and more youngsters are coming forward to choose psychiatry as their specialty in their medical career. In parallel with this, public awareness about mental health and access to psychiatric services has exponentially increased. On the pragmatic side, there seems to be increased recognition by our own medical colleagues, as there are effective treatment outcomes due to advancement in neurochemistry and pharmacotherapy in the last few decades. Nevertheless, the persisting stigma and misinformation about mental illness among the public still require to be addressed. At any rate, we are still in the nascent stage and the challenges pointed out above have to be borne in mind by the youngsters in their career in psychiatry. ”The woods are lovely, dark and deep, But I have promises to keep, and miles to go before I sleep, And miles to go before I sleep.” –Robert Frost Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest. Acknowledgment I am deeply indebted to my beloved teacher Prof. A. Venkoba Rao at whose feet I learned the ABCD of psychiatry. Also, I owe my gratitude to my mentors Prof. M. Sarada Menon and Prof, O, Somasundaram for their constant guidance in my academic endeavors. Thanks are also due Dr. Mubeen Taj, Professor and Head, Department of Psychiatry, A. C. S. Medical College, for nominating me for this prestigious award. The help rendered by Dr. Shajahan, consultant psychiatrist, NHS, UK, Dr. J. Jayakar, former professor of psychiatry, Madras Medical College, and Dr. Roy Abraham Kallivayalil, Professor and Head, Department of Psychiatry, Pushpagiri Institute of Medical Sciences, Tiruvalla, Kerala, in the preparation of this paper, is also gratefully acknowledged.