Is psychiatry intervention in Indian setting complete?

Mental illness (MI) not only afflicts the individual, but it has widespread ramification that affects the families and even the community. Chronic MI like schizophrenia and bipolar disorders can incapacitate an individual to such an extent that even the routine activities of daily living becomes difficult, and in fact, these two disorders together are among the top 10 causes of disability-adjusted life years for the 15–44 years old population (WHO report 2001).[1] Such chronic illnesses also result in an enormous burden on the caregivers as reported by several studies.[2,3,4] In fact, a large part of caregivers’ burden is due to the deficits that persist even after recovery from acute symptoms of MI.[3] Although, antipsychotic medication is effective during the acute phase of MI, these medicines do not have much beneficial effect on cognition and social skill deficits and a large number of such patients, even after recovery from positive symptoms of illness, continue to have cognitive dysfunctions as well as significant social and vocational disability leading to poor functional recovery and poor quality-of-life.[5,6] Thus, all these factors cumulatively make the rehabilitation of these patients a very challenging task.

Where medicines have negligible role, nonpharmacological interventions like cognitive remediation (CR) and social skill training (SST) have shown moderate amount of success in improving the condition of the patients having significant amount of cognitive and socio-occupational dysfunctions. In 25 independent, randomized controlled trials of CR, the majority of the studies have demonstrated positive changes in attention, speed of processing, working memory, and executive functioning in the persons with schizophrenia.5 A review has even reported about the benefits of CR in improving the social and vocational functioning in individuals with schizophrenia.[7] However, one study also reports that there is no benefit of CR on cognition.[5] Taken together, the findings of these studies show a modest level of improvement in the basic neurocognitive functioning following CR in individuals having schizophrenia.[5] SST has been found to be quite promising in rectifying the social skill deficits due to chronic MI.[8] Even in studies on enhancing the vocational skills of people with chronic MI, some amount of success has been reported. Intervention model like “supported employment” have been shown to be effective for people with chronic MI and those who have found long-term placement through supported employment had shown improvement in cognition, quality-of-life, and symptom management.[8]

Although, the initiatives to rehabilitate people with MI have been undertaken in different parts of the world, however, the outcome is not the same. The limitations like lack of trained manpower, inadequate rehabilitation-focused training in psychiatry, poor interest in this sub-specialty, limited resources for research on nonpharmacological interventions, longer duration of interventions before results become apparent, like for example in SST[8,9] and strong advertisement by the pharmaceutical companies to promote a pill for every deficit could be major factors for such a varied outcome. Thus, pharmacological intervention alone may not be adequate treatment, and even the caregivers feel that the majority of mental health facilities lack rehabilitation services and support that could help their patients regain skills for independent living.[10]

In developing countries, psychiatric rehabilitation is still in its infancy, and there are negligible rehabilitation facilities.[9] Like in India, whatever rehabilitation facilities are available, these are being run primarily by nongovernment organizations (NGOs) and these facilities are not readily accessible to the trainees in metal health and most of them charge fees for their services.[11] Hence, the majority of these facilities could be beyond the reach of the common man because of the high cost of treatment. Moreover, the focus of many of these facilities is on residential care with a very little emphasis on correction of deficits. In the private sector, the limited rehabilitation facilities are mostly located in the southern part of India and are being run by the NGOs like the Schizophrenia Care and Research Foundation, Richmond Fellowship Society, etc.[12] Here, the Richmond Fellowship Society deserves special mention as the society was instrumental in opening a Postgraduate College in Bengaluru for providing specialized training in psychosocial rehabilitation, which is perhaps the first in the country.[13] Though the elementary rehabilitation facilities in mental hospitals have increased from 10 to 23 institutions,[14] independent rehabilitation services are available at a handful of government institutions only, like NIMHANS (Bengaluru), LGBRIMH (Tezpur, Assam), Department of Psychiatry (GMCH, Chandigarh) etc., with NIMHANS having separate staff exclusively for this sub-specialty.

Chronic MI are known to result in disability, however, it was officially recognized for the 1^st time when it was included as one of the disabilities in the “Persons with Disability Act (PWD Act),” 1995.[15] Enactment of this act moved the disability initiatives from mere charity based to right based. Another landmark development in the field of disability is the United Nations Convention on Rights of Persons with Disabilities (UNCRPD).[16] The UNCRPD was adopted by the United Nations General Assembly on December 13, 2006 and was opened for signature on March 30, 2007. It came into force from May 3, 2008 and India was the 7^th country in the world to ratify it. By virtue of its ratification, it is obligatory on the part of the Indian government to ensure that the persons with any disability get equal rights and privileges and are not discriminated because of their disability. It is expected that honest implementation of UNCRPD would minimize the chances of neglect, social isolation, and denial of rights including property rights to these persons. Thus, the PWD Act and the UNCRPD are supposed to be a boon for those with disabilities, including those with MI. The convention makes a paradigm shift from current model in which persons with disabilities are treated as objects of medical treatment, charity and social protection, to one in which persons with disabilities are recognized as individuals having the right to equality and nondiscrimination (article 5). The equality here means that all are equal before the law, and no one can be discriminated on the basis of disability.

Despite the enactment of very impressive and comprehensive Act like PWD Act and UNCRPD, there are only a handful of rehabilitation facilities here and there in our country. Psychiatric rehabilitation is still in the nascent stage in India, and much is required to be done. More proactive measures have to be taken by both the public as well as the private sectors. Change in government policies is required as psychiatric rehabilitation is a very complex process. This is further complicated by the fact that while policies related to treatment of MI are governed by the Ministry of Health and Family Welfare, whereas the rehabilitation of persons with disability including mental illness is governed by the Ministry of Social Justice and Empowerment (MSJE). In fact, one of the reasons for the slow growth of rehabilitation facilities in India is probably due to lack of coordination between the two ministries. Since the MSJE lacks the infrastructure and the trained manpower in the field of psychiatric rehabilitation, there has not been any concrete plan to address the issue. It will be almost unimaginable to separate rehabilitation from acute care as the role of mental health professionals cannot be overlooked, and the Ministry of Social Justice cannot afford to set-up a parallel structure for psychiatric rehabilitation. This issue needs to be debated at the national level without which we cannot think of moving forward.

For delivering mental health care, the focus of the Ministry of Health has been on acute care through mental hospitals, Medical Colleges and District Mental Health Programme, and there has not been any focus to set-up rehabilitation facilities like rehabilitation centers, half-way homes, and day-care centers. After de-institutionalization movement,[17] large number of patients have been discharged into the community who require long-term care and rehabilitation. It has been estimated that there are over 2 crores persons with serious mental disorders[18] and many of these would require community-based rehabilitation services. Since the current model of mental health delivery in India is mainly through institutionalized care and is delivered to those who actively reach out to these facilities, homeless people with MI who neither have social support nor the capacity to seek help are left out to wander on streets. In fact, the major reason of stigma related to MI is due to apathetic conditions of wandering mentally ill. Neither the central government nor the state government has any program in place to look after homeless mentally ill patients and the situation is worse in case of homeless mentally ill children and women who are subjected to neglect and sexual abuse.

Another factor which might be responsible for the poor development of psychiatric rehabilitation facilities could be attributed to a dearth of trained manpower in the field of psychiatric rehabilitation. There is very little emphasis on rehabilitation during postgraduate training in psychiatry.[8] Although the Rehabilitation Council of India (RCI, 1992) was set-up with the objective of quality assurance in the field of rehabilitation through quality manpower production and central registry of rehabilitation professionals, however, none of the RCI approved courses is specifically catering to psychiatric rehabilitation. Though, the professionals involved in acute care should also take-up rehabilitation, but the shortage of manpower increased workload, and lack of rehabilitation skills have been the major reasons for inadequate rehabilitation facilities being available.

However, there are some recent initiatives by the government which give some hope of a better future. In the MSJE, government of India, a separate Department of Disability Affairs has been created in May, 2012 which is headed by a Minister of State and full-time secretary.[19] The field of disability and rehabilitation is expected to grow much faster with these developments in the ministry. The MSJE, government of India, is now mulling about setting-up a “National Institute of Mental Health Rehabilitation” and couple of meetings have been held with representatives from NIMHANS and the 11 center of excellence (under the National Mental Health Programme) to work out the detail of infrastructure required and scope of such an institution. In fact, separate officials have been designated by the ministry to address issues related to “right to information in this regard.[20] Recently, a conference on psychiatric rehabilitation was organized by NIMHANS in Bengaluruin March, 2014, where several mental health specialists deliberated on various issues related to rehabilitation. The first online journal on rehabilitation in India called the “Journal of Psychosocial Rehabilitation and Mental Health” is also available now.[21] The Department of Psychiatry, Government Medical College and Hospital, Chandigarh has started a designated facility called Disability Assessment Rehabilitation and Triage for rehabilitation of chronic mentally ill patients with specific focus on assessment and intervention for associated social, cognitive, and vocational deficits and the preliminary findings are quite encouraging.[22] The proposed amendments in Persons with Disability Act, (1995) Mental Health Act, 1987 (now called Mental Health Care Bill) with a specific focus on community living are expected to improve the field of rehabilitation. Noteworthy is the fact that in the “Rights of Persons with Disabilities Bill, 2014” there is a provision for 5% reservation in posts in all government establishments for persons with disability, out of which 1% will be reserved for those with autism, intellectual disability, and MI combined together.[23] All these are, therefore, small steps taken for a much needed bigger goal in the field of psychosocial rehabilitation.

Thus, although a lot is required to be done in the field of psychosocial rehabilitation in India, yet we have made some headway and even the government of India seems to have awakened to this new felt need which was, till a few years ago, hitherto unknown and almost too complex. A new beginning awaits us all, and it is hoped that things will only get better from here.