|Year : 2018 | Volume
| Issue : 4 | Page : 268-272
From the immediate past president: Musings on Indian social psychiatry on the occasion of silver jubilee conference of Indian Association for Social Psychiatry
Sudhir K Khandelwal
Senior Consultant Psychiatrist, Department of Psychiatry, Holy Family Hospital; Formerly, Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India
|Date of Web Publication||19-Nov-2018|
Prof. Sudhir K Khandelwal
Senior Consultant Psychiatrist Holy Family Hospital, Okhala, New Delhi - 110 025
Source of Support: None, Conflict of Interest: None
The Indian Association for Social Psychiatry (IASP) celebrates its Silver Jubilee National Conference this year in the state of Haryana, on the theme of “Prioritizing Rural and Community Health Care in India.” It is a time to rejoice and also an opportunity to reflect on the objectives with which the society was founded. It is important to reflect if we have achieved our aims and where and how we need to direct our efforts for this society to make noticeable change in the way mental health services are planned and delivered to the vast majority of Indian public deprived of this essential component of total health. Currently, a large section of our population, predominantly rural, is served through the implementation of the District Mental Health Programme (DMHP). It is an offshoot of the National Mental Health Programme, a revolutionary idea in the 1980s. However, since then, the health systems have undergone tremendous changes. We are stuck with the old delivery methods. It is time the mental health too adopts new digital technologies to reach its unreached population. IASP can and must take lead in making collaborations with all the stakeholders and partners and use modern health systems to achieve its aims and objectives. After all, the nation's prosperity depends on mental well-being of its citizens.
Keywords: Indian, mental health program, psychiatry, social, technology
|How to cite this article:|
Khandelwal SK. From the immediate past president: Musings on Indian social psychiatry on the occasion of silver jubilee conference of Indian Association for Social Psychiatry. Indian J Soc Psychiatry 2018;34:268-72
|How to cite this URL:|
Khandelwal SK. From the immediate past president: Musings on Indian social psychiatry on the occasion of silver jubilee conference of Indian Association for Social Psychiatry. Indian J Soc Psychiatry [serial online] 2018 [cited 2022 Nov 26];34:268-72. Available from: https://www.indjsp.org/text.asp?2018/34/4/268/245651
| Introduction|| |
It is a matter of great pride that the Indian Association for Social Psychiatry (IASP) is celebrating its Silver Jubilee National Conference (though IASP is more than 30 years old) this year at the Institute of Mental Health, Pt. B D Sharma University of Health Sciences, Rohtak, on November 16–18, 2018, under the dynamic leadership of Prof. Rajiv Gupta.
| Silver Jubilee: A Time to Rejoice....|| |
A silver jubilee is a period of celebrations and usually marks the successful completion of 25 years of an event. Hence, it is a time of rejoicing and festivity. In olden times, especially in Europe, the silver jubilee events were celebrated to mark 25 years of a monarch's reign. Gradually, even commoners also started celebrating some important events of their life, and what could be a better reason than celebrating one's own wedding! I think there was a reason why it happened. In olden times, it was not very often that a monarch completed 25 years of his/her reign. There were constant wars, or at times, the monarch was victim of a conspiracy of someone from within the close acquaintances. Similarly, not many couples spent 25 years of togetherness. From the 1500s onward, till around the year 1800, life expectancy throughout Europe hovered between 30 and 40 years of age. At around the year 1900, it increased to 40 for males and 42 for females. Strangely, even during those times, women were surviving longer than men. Obviously, they did not go to the war, but death during labor was a common cause for their early mortality. A number of reasons are ascribed to the increasing lifespan 1850 onward, and one important reason remains that surgeons started washing their hands before any surgical or medical interventions!
For a long time for us in India, term “silver jubilee” was reserved only for films. Hence, any film that completed a continuous run in a cinema hall in the city was considered to have celebrated silver jubilee. A certain star of yesteryears, who was known to give silver jubilee hits frequently, was nicknamed “Jubilee Kumar” by his fans.
I am not sure since when commoners started celebrating silver jubilee events of their lives in India. My intelligent guess is that it must be during the time of rise of socialism in Europe and of socialist themes in Bollywood. There was a time in Bollywood history, lasting again about 25 years, when Bollywood was strongly influenced by socialism, and there were famous producers, directors, story writers, and lyricists, who were of socialists' leanings, and gave some of the memorable films and unforgettable lyrics during the 1950s and 1960s.
Hence, if kings, queens, and film stars were celebrating silver jubilee events, what prevents common people in what they wish to rejoice in modern times? Hence, people now celebrate their silver jubilee birthdays and wedding anniversary; organizations and institutions celebrate their 25 years of existence; countries celebrated their independence, and scientific bodies too have reasons to celebrate silver jubilee anniversary. Hence, it is a matter of sheer joy that the IASP is celebrating its 25th National Conference this year. It is not a mean achievement. Not many scientific societies in behavioral sciences could boast of such accomplishments, such as having a robust constitution, increasing memberships, timely elections of its office bearers and executive council members, regular annual national meetings, having a distinction of organizing three world level meetings, and regional symposia on behalf of the World Association for Social Psychiatry and World Psychiatric Association. It also publishes a peer-reviewed journal, Indian Journal of Social Psychiatry, where you are reading this article.
| .... But also a Time to Reflect|| |
It is time to reflect with what aim did IASP start its journey, what objectives and visions the founding fathers held for its course, what have been its gains and achievements, and where have been its failures and lacunae. And what role shall we like to see for the IASP in next few decades that are likely to throw up challenges never seen before.
IASP is the culmination of the collective effort of mental health professionals across the country to create a platform for exploration, discussion, research, and action on the social determinants and correlates of mental health.
It was formed under the chairmanship of Prof. A. Venkoba Rao in 1984 with Prof. V. K. Varma as its Founder Secretary-General-cum-Treasurer, with the aims to examine the interface between culture and humanity to devote itself to the scientific study of the issues relevant to the society. The overarching goal of IASP is to examine the role of social and cultural factors in the phenomenology, course, outcome, and treatment of psychiatric disorders. The association strives to advance the application of mental health knowledge for the greater public good. IASP aspires to set high standards for research and education and is determined to support psychiatrists and mental health professionals throughout their career. The IASP represents the first national society for social psychiatry in India and has current member strength of over a thousand mental health professionals. Members include mental health professionals from different fields including psychiatrists, clinical psychologists, psychiatric social workers, and psychiatric nurses.
As per its constitution, the purposes and objectives of the IASP are as follows:
- To study the nature of man and his cultures and the prevention and treatment of his vicissitudes and behavioral disorders
- To promote national and international collaboration among professionals and societies in fields related to social psychiatry
- To make the knowledge and practice of social psychiatry available to professionals in social psychiatry and other sciences and to the public by such methods as scientific meetings and publications
- To advance the physical, social, psychological, and philosophic well-being of humanity by such methods as promotion of research and deliberations into it
- To extend consultations and carry out charitable and voluntary work for the furtherance of the objectives mentioned above
- To do all such things and matters that are incidental or conducive to the attainment of the above objectives.
Notwithstanding all the above achievements, one would like to see IASP achieve something more critical than the numbers. Members of the IASP would like IASP to achieve the status of opinion maker or become a voice for the issues that have been outlined in its charter of objectives. Can it take up social and cultural issues and establish its own force to make academicians, policymakers, and health planners sit up and take stock of the situation? Can it commission cutting-edge research so as to make difference, howsoever small, in the society? Sometime back, when the annual conference of IASP was held in Chandigarh in 2012, migration and mental health was the theme of the conference. It was considered a very relevant topic since Punjab (Chandigarh being its capital) along with Assam and Bengal had borne the brunt of the tragedy of migration. Partition of India had seen approximately 14 million people displaced on religious lines across two newly created dominions. It is considered the largest human migration in history and had created a multifold crisis of unimaginable proportions. Till date, we do not have any study done on impact of migration on the mental health or social consequences of displaced people and their subsequently families. Although the 2012 conference had some excellent papers presented over 2 days, it failed to capture what should have been the essence of the theme in the Indian context. As one distinguished delegate remarked, “the theme symposium went horribly wrong.” The author himself is guilty of doing a bad job as one of the speakers in the theme symposium. In fact, a look at the various themes of annual conference of IASP would show that the chosen themes are so relevant to the objectives of the association, yet there has been no prequel or subsequent follow-up on those very themes.
| Reflecting on the Silver Jubilee Conference Theme|| |
For its silver jubilee conference this year in Rohtak, the IASP has chosen “Prioritizing Rural and Community Mental Health Care in India.” I believe that the state of Haryana is the right venue for a conference on social psychiatry with this theme.
It is salient to note the beginning of rural psychiatry, though making a beginning at the AIIMS, New Delhi by Prof. SatyaNand in the 1960s, it took deep roots through the experiences and experiments at Raipur Rani, in the state of Haryana (1975–1981) by PGIMER, Chandigarh. Let us first examine if there is a need for having a discussion on rural mental health in India. That is, whether the mental health program for rural areas has to be a part of mainstream mental health or it has to form its own niche for the vast majority of the Indian population. The continuing challenge for mental health services in India has been accessibility, affordability, and acceptability by its population. Let us understand what a rural area or settlement means, what are its defining characteristics. According to the Census of India, a rural settlement (village) is one which has <5000 population, its population density is much <400 persons/km2 (in contrast to an urban area), and at least 75% of male working population is engaged in agriculture activities. As per this definition and Census of India (2011), there are 640,867 villages in India having 68.84% of India's more than 121 crores (83 crores) population. It is a huge number, in absolute terms more than 83 crores. What are the other characteristics? Since the time of independence, villages of India have lagged far behind in terms of development. All the benefits of India's growth, development, and continuous rise in gross domestic product (GDP) have largely gone to urban areas, though the latter themselves are victims of unplanned and poor growth. Rural areas thus have remained deprived of better education facilities, health services, and basic amenities of life, for example, safe drinking water, flush latrines, roads, and electricity. Since the 1970s, there has been relentless migration of rural population to urban areas. It is not that the urban areas were providing easy jobs, but because declining rural productivity has been pushing (in contrast to urban pull that happened in America and Europe in wake of industrialization) its male population to urban cities in search of any livelihood. The urban areas also provided better health services and education opportunities along with other basic amenities and entertainment provisions. Even if poor urban migrant population receives inferior education and health services as compared to urban rich, yet it is better than the rural population. The economic conditions and sociocultural practices also differ a lot between urban and rural areas. Nevertheless, many of rural socio-cultural practices are fast changing under the influence of urban phenomenon.
A typical village household in Haryana has usual gadgets such as cable television, electrical appliances, motor vehicles, and mobile phones and Internet connectivity. It is also true that the growth rate of rural population is declining with more and more people still migrating to urban areas for still better living conditions and facilities such as health, education, and housing.
Community mental health movement started in India way back in the 1960s. However, a firm footing in organizing services took place in the 1970s in Chandigarh and Bangalore. In Chandigarh, it was associated with the WHO project, “Strategies for Extending Mental Health Care in Community” and in Bangalore through setting up of Community Psychiatry Unit by Prof. R L Kapur. The main objective of community mental health or community psychiatry was to reach the unreached population living in villages, where there were no psychiatric services or availability of mental health professionals. It was erroneously believed by health administrators and policymakers that rural areas had no significant mental health problems, and the rural practices and beliefs in magico-religious practices and faith-healing rituals were sufficient to look after some odd case of mental disorder. A number of well-designed epidemiological studies done in India have conclusively shown that the extent and burden of mental disorders are similar in India as compared to the Western countries, while we are not fully equipped to deal with the situation in view of poor mental health infrastructure and workforce. Within India also, the proportionate burden remains the same between rural and urban communities, while rural areas get only a miniscule in terms of infrastructure development and workforce deployment. The burden of mental disorders is only likely to increase in decades to come.
| The First Big National Commitment for Community Mental Health Care: National Mental Health Programme|| |
In view of the poor mental health services in rural community, community psychiatry came into being with pioneer work of Prof. N N Wig and Prof. R S Murthy in Chandigarh and Prof. R L Kapur in Bangalore (now Bengaluru). The main beneficiary of this movement was considered to be rural population, where mental health services were meager, to say the least. Excellent original studies and reviews are available, and it is beyond the scope of this commentary, but the visions of these stalwarts culminated into the finalization of landmark National Mental Health Programme (NMHP) for India with the following objectives. It came at a time when there existed no plan, policy, or program for mental health in India.
- To ensure the availability and accessibility of minimum mental health care for all in the foreseeable future, particularly to the most vulnerable and underprivileged sections of the population
- To encourage the application of mental health knowledge in general health care and in social development
- To promote community participation in the mental health service development and to stimulate efforts toward self-help in the community.
The architect of NMHP, Prof. N N Wig, has recently summarized the birth and journey of NMHP in India. To quote, “The adoption of the NMHP in August 1982 was a milestone in the history of Indian Psychiatry. Such an ambitious program was formulated at a time where there were <1000 psychiatrists is a triumph of need for mental health care in the country.” The story of the NMHP, both in terms of the technical forces and the personalities, needs to be recorded for posterity. The current article recalls the community mental health initiatives of Bengaluru and Chandigarh centers providing the reason for integrating mental health care with general health care and the support of the World Health Organization, along with the role of mental health professionals and the health administrators. The lesson that comes through is the value of working together with different professionals for the common good. Recording the events for posterity is especially timely in view of the formulation of a new mental health policy and the revision of the national health policy during the last few months.”
| The Next Ambitious Step in Community Mental Health Care: From the National Mental Health Programme to District Mental Health Programme|| |
The District Mental Health Programme (DMHP) was added to the program in 1985 at Bellary by NIMHANS in collaboration of the Zila Parishad and Department of Health, Government of Karnataka. It demonstrated the need, feasibility, and benefits of integrating mental health care into the general health care. The program was re-strategized in 2003 to include two schemes, namely Modernization of State Mental Hospitals and Up-gradation of Psychiatric Wings of Medical Colleges/General Hospitals. The workforce development scheme (Scheme A and B) became part of the program in 2009.
The objectives of the DMHP are as follows:
- To ensure the availability and accessibility of minimum mental health care for all in the foreseeable future
- To encourage the application of mental health knowledge in general health care and in social development
- To promote community participation in the mental health service development
- To enhance human resource in mental health subspecialties.
As of now, 241 districts have been covered under the scheme, and it is proposed to expand DMHP to all districts in a phased manner.
Although a lot of funds have been invested into the DMHP and program has been expanding, it is yet to be critically documented and audited if this program is making real changes in the population by measuring outcomes, morbidities, and mortalities, capacity building, and decreasing the burden of mental disorders in the community. The NMHP came into being in the early 1980s and used the planning, resources, and technology of that time relevant to its scope and objectives. In last four decades, the delivery of health care and mental health care has undergone a sea change with newer technologies penetrating health sector. What was considered most suitable in the 1980s, perhaps, needed revisions in light of innovations such as e-Health, m-Health, and Digital India.
| Taking the Next Big Step: Digital Technology in Primary Care Psychiatry|| |
It is now being increasingly realized that globally, burden of mental disorders is escalating, and ironically, developing countries are going to face this burden maximally, yet they are least equipped to deal with this burden. One obvious constraint has been the poor workforce resource and lack of infrastructure dedicated to mental health. India will not be able to cope with this easily; there is limit to produce mental health professionals in short period, and developing infrastructure is also resource incentive. In the last few decades, one remarkable progress that has defined low- and middle-income countries, including India, is the rapid penetration of smartphones and digital technology in all sections of society. India would also like to be known as “Digital India.” Digital India is not to be limited to making Wi-Fi services available in airport or shopping malls. It must change the way India's poor have been deprived so far of the benefits of health services. It must help the professionals to deliver the health services to people living in remote areas. People should not be rushing to major health centers or metropolis for any medical morbidity. Fortunately, some steps have been initiated to use digital technology in service of mental health.
Digital technologies including the Internet, mobile applications, sensors, and others have the potential to improve the delivery of health interventions. These technologies are expected to enhance patient outcomes by increasing the reach of existing interventions and by utilizing new technologies to measure health behaviors. Digital technology can allow for real-time data collection and result in immediate clinical interventions based on that data. These technologies offer hope to fill gaps in improving clinical interventions in social work and related professions. In particular, the growth of mobile phone applications for health has grown very rapidly and provides opportunities to expand current care beyond the traditional clinic setting. There are calls to develop innovative ways of improving the quality and reach of efficacious clinical interventions using innovative tools such as mobile phones and smartphones., The use of digital technology in health applications is experiencing a tremendous boom in large part as a result of ballooning health-care costs and the limitations of one-on-one therapy to meet the mental health needs of the population. In particular, mobile phone applications for health have grown very rapidly, which provides opportunities to expand current care beyond the traditional clinic setting.
Basic psychiatric care at primary care is still a distant dream in the developing countries. NIMHANS Bengaluru, a pioneer institute, designed a digitally driven primary care psychiatry program in India focusing on training primary care doctors across India. Two path-breaking innovations such as Clinical Schedule in Primary Care Psychiatry and Tele-On Consultation Training already started showing its effectiveness. Implementation and its evaluation of other modules of primary care psychiatry programs such as Collaborative Video Consultations and Video-based Continuing Skill Development modules, all digital, are underway.
| What Future Should Hold for Indian Social Psychiatry?|| |
With relentless GDP growth and unequal economic boom in the society, Indian society is likely to experience major upheavals in its social fabric. There is going to be a mismatch between the services and privileges enjoyed by groups at the extreme ends of socioeconomic spectrum. If India has to prosper, it has to invest in the mental well-being and mental capacity of its citizens. It must provide adequate health, education, and social services right from the prenatal services to the old age.
Society is a dynamic concept, and the services needed to serve its citizens should also be dynamic in nature. This can go a long way in IASP keeping its objectives. IASP has achieved a lot in the last 34 years of its existence and 24 national conferences so far, through its continuous activities, expansion, journal, collaboration, and advocacy, but it has also stumbled occasionally, which is not surprising given the fact that the epithet “social” tends to raise less attention and attraction in this ever-growing era of “biological” psychiatry. This is unfortunate because eventually there is no direct conflict between biological and social – they differ in their focus but in their ultimate goal of benefiting the mental health of humanity, including those in the community and the rural areas.
Indian social psychiatry must strive to focus on how this can be achieved. It should take up the role of advocacy and provide practical guidelines to the government, public sectors, and nongovernment organizations on such issues. The IASP must also examine how use of modern technology can bring a revolution in the DMHP with not only in extension of mental health services but also of its proper monitoring, auditing, and requisite changes from time to time.
For this to happen, further collaboration of Indian social psychiatry is a must at various levels – collaboration with the government, media, technology innovations, other institutes (for example, the Indian Institute of Technology), the private sector, business entrepreneurs, and perhaps, most importantly, the public. To survive and thrive, social psychiatry must embrace modernity and diversity in every form, without, of course, losing its main focus. Only then should we be able to celebrate the Golden Jubilee conference of the IASP even more jubilantly!
The author gratefully acknowledges the help received from Prof. R Srinivasa Murthy and Prof. Debasish Basu in preparing this manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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