Closing treatment gap of mental disorders in India: Opportunity in new competency-based Medical Council of India curriculum

Psychiatric disorders are one of the major causes of global burden of diseases. According to the WHO study, the treatment gap (the number of people with disease who are not in treatment) of mental disorders in developing countries was 76%–85%.[1] According to the recently conducted National Mental Health Survey (NMHS), the treatment gap of any mental disorder in India was reported to be as high as 83%.[2] The overall current mental health morbidity was 10.6% of which 10% prevalence was accounted for by Common Mental Disorders (CMDs), which include depression, anxiety, and substance abuse.[2] Literature highlights that child and adolescent age group are severely affected, and suicide is emerging as a major concern with 1% population reported to have high suicide risk.[2] Despite efforts to provide care, huge treatment gap exists for all types of psychiatric disorders. Mental illness results in poor quality of life, decreased productivity, and lower earning potential.

Stigma remains a major impediment in the delivery of mental healthcare. It has been found across various studies that attitudes of doctors of other specialties and other healthcare professionals also contribute to stigma due to their lack of knowledge and awareness about psychiatry and mental health problems.[3]

The District Mental Health Program, which was launched in the year 1996 under the National Mental Health Program, had aimed at the integration of psychiatry services with general health services as one of its key goals. However, it has largely remained a “psychiatrist“-oriented program, and the desirable transfer and integration of care from psychiatrists to general medical officers and other specialists have not been achieved.[4,5,6]

The number of mental health professionals remains abysmally low. According to the recently concluded NMHS, the number of psychiatrists in India remains abysmally low and varies from 0.05 in Madhya Pradesh to 1.2 in Kerala per lakh population.[5] It is very obvious that solution lies in training other healthcare professionals in mental health and utilizing their services to treat CMD which can easily be treated by general healthcare providers. Training in mental health provided after graduation, though highly appreciated, has failed to inspire them to provide mental healthcare, as the District Mental Health Program experience shows. Despite receiving training in mental healthcare, healthcare providers perceive mental health as something not within their domain and this perceived lack of competency in mental healthcare despite adequate training has been a major impediment in expanding the base of mental healthcare.

Considering this prevailing scenario, it has been recognized that teaching psychiatry at undergraduate level is the way forward for integration so that psychiatry gets its due recognition as a medical specialty.[7] Psychiatry teaching in undergraduate was limited to few hours of lectures and clinical postings, and only one short note in examination which led to avoidance of psychiatric training and was given less importance by most medical students. For the most part, it was very uninspiring and laced with the dogma of psychoanalysis which further alienated the medical students. Not only did they find it difficult to comprehend but it was also out of sync with their medical schema of training. The Indian Psychiatric Society has been trying to introduce psychiatry as a separate subject at the undergraduate level for the last few years. This effort is justified because 30% of patients attending general medical clinic are suffering from CMDs.[8]

The Medical Council of India (MCI) has prescribed a new syllabus for MBBS to be implemented from 2019 onward which is competency based and gives weightage to psychiatry which has horizontal and vertical integration with other subjects. This also includes teaching ethics and communication with patients and family members such as breaking news of death.[9] Psychiatry in this syllabus occupies its rightful place, and competencies are required about suicide, Mental Health Act, neurodevelopmental disorders, and several other common conditions. Integration with other subjects will reduce stigma and feeling of “alienation” about psychiatry. Emphasis on undergraduate education of psychiatry and opportunities in new competency-based curriculum of MCI can help narrowing the treatment gap of psychiatric disorders in the country. Onus is now on us to provide quality undergraduate training in psychiatry and understand that it differs significantly from postgraduate training both in conceptualization and delivery. Those teaching psychiatry should understand that training needs of all future doctors should be met and not merely of those who pursue psychiatry at postgraduate level. CMDs which are more common in primary care settings than severe mental disorders such as schizophrenia and bipolar disorder should be given more emphasis.

Visibility of psychiatrists in prominent teaching roles throughout the curriculum promotes positive view of psychiatry[10] and influences the choice of psychiatry as a career for medical students. Thus, the new curriculum provided by the MCI is an opportunity to popularize psychiatry and reduce the existing treatment gap.