Mental health practice in private primary care In rural India: a survey of practitioners

An epidemiological study carried out in a rural population in Tamil Nadu, Southern India, reported that about 75% of people with mental disorders had been sick for more than one year and had not had any treatment 1. India has 162 medical colleges, with 17,000 medical students enrolling to be trained every year. However, there are only about 3000 psychiatrists, who are mainly based in urban centres 2. This means that a vast chunk of the work in dealing with mental illness is done by primary care practitioners, espe-cially in rural India.

However, primary care is not well developed in India, and the lines of communication between the private and government psy-chiatrists are very poor. A survey of 86 private practitioners revealed that undergraduate education is not geared up to impart sufficient psychiatric training 3. The outcome of mental disorders can be improved by their early detection in primary care, especially if this is followed by evidence based treatment.

We investigated current psychiatric practice among private primary care practitioners in Satyamangalam, a rural town with hamlets of farmers and weavers in the state of Tamil Nadu, Southern India. The town has 40 doctors, including general practitioners and specialists, with no private or government psychiatric services.

We sent to all doctors a questionnaire consisting of 17 items, subdivided into four sections: a) doctor’s experience of psychiatric symptoms and disorders in adults, children, adolescents and the elderly, of pharmacological treatment for the above disorders, and of patients’ acceptance of a diagnosis of mental illness; b) doctor’s knowledge about availability of mental health services and patients’ use of native treatments; c) doctor’s training in psychiatry; d) information on mental illness in journals read by the doctors, and sugges-tions to improve doctors’ skills and knowledge in psychiatry.

Out of the 40 doctors, 37 responded (92.5%). Eight were general practitioners and 29 were specialist in a discipline other than psychiatry. Eighteen (48.64%) had been practicing for 10-20 years.

Thirty-four doctors (91.9%) reported they had seen patients with symptoms suggestive of mental illness and had diagnosed mental illness. Among symptoms of mental illness, body pain was the most frequently reported (41.8%), followed by depression (25.5%). Depressive disorders were the most frequently reported mental disorders (52.2%), followed by anxiety disorders (20.4%).

Fifty percent of the doctors had seen children and adolescents presenting with behavioural problems and 100% had seen elderly patients presenting with forgetfulness. Eighteen out of 34 (52.9%) had used tricyclics as first line antidepressants, and haloperidol was the only antipsychotic used. Only 18 (48.6%) felt that patients accepted a diagnosis of mental illness.

The doctors confirmed that there was no resident psychiatrist in the locality. The mental health resource largely utilised was re-ferral to a psychiatrist in the nearby city (76.5%). All doctors reported that their patients utilised some form of native treatment.

No doctor had sat through psychiatry as a subject of examination in his undergraduate course. Twenty-six respondents (70.2%) had had a training in psychiatry as house officers.

Twenty out of 37 (54.1%) felt that the medical journals they read had adequate information about mental illness. The sugges-tions to improve their practice included the organization of continuing medical education on psychiatric topics by the local medical so-ciety, an increase in the number of articles on mental illness in medical journals, the production of audiovisual aids, and an improve-ment of undergraduate medical curriculum with emphasis on psychiatry as a subject for examination. Mass education and assertive out-reach to increase the awareness of mental illness among client population were also suggested.

This study confirms that pain is a major manifestation of psychological problems in rural India, as previously reported in the literature 4. Though depression was the commonest diagnosis made by our sample of primary care physicians, the accuracy and the timeliness of such a diagnosis is influenced by the conditions of primary care practice. In view of the reported high prevalence of drug use in both healthy and mentally ill people in the Indian population 5, it is surprising that none of the doctors in our sample had approached drug abuse as an issue within the scope of psychiatry. Also disconcerting is that 8% of the respondents reported to have never identified psychiatric symptoms or disorders in their patients. Old medications clearly continue to be used as first line therapeu-tic armaments by general practitioners in rural India.

It is obvious that a revision of undergraduate curriculum is needed in India, and that continuing medical education on psychi-atric issues for general practitioners represents a priority. Some previous experiences seem to be encouraging in this respect. A train-ing programme for general practitioners based on a year’s exposure to psychotherapeutic orientation had been shown to be successful in India 6. Similar initiatives have had a positive outcome in other developing countries (e.g., 7). Moreover, projects to explore al-ternative strategies to facilitate the identification and management of mental disorders in primary care represent a priority for our country.

Our study is limited by the fact that it was constrained in the geographical area included. Also, we have not endeavoured to seek the patients’ views on psychiatric practice. We have hinted broad outlines on therapeutic interventions, but we are not sure about spe-cific uses of pharmacological therapies. Moreover, we have no data on patients’ compliance with referral to a psychiatrist, although we have reasons to be sceptical in this respect. As Ayurveda continues to be an important tool to traditional healers, it may prove useful if modified to fit within an Indian context of mental illness. Finally, we believe that doctors’ enthusiasm towards assertive outreach is significant and should be capitalised upon.