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Interview: The current state of mental healthcare in India is nothing short of abysmal — Dr Ashoka Prasad

Dr Ashoka Jahnavi Prasad, the author of a number of books on Psychiatry and Mental Health, has worked as a consultant in countries like Seychelles, Chad, Togo, Somalia, Mali and Burkina Faso before returning to India. He currently runs a charitable clinic, writes columns in newspapers and news portals, and actively campaigns for the human rights of the mentally ill.

Dr Ashoka Jahnavi Prasad
Dr Ashoka Jahnavi Prasad

Dr Prasad graduated from Kanpur Medical College in 1976. Then he specialized in paediatrics / neonatology in Ireland and later got trained as a psychiatrist in Edinburgh. He also procured a PhD from Oxford University and received higher doctorate (DSc) from the University of St Andrews for his research on the use of valproate in bipolar illness.

He has obtained Board Certification in Public Health and another doctorate in philosophy of medicine from the University of North Carolina, US. He has also obtained an LLM from Harvard Law School in Mental Health Legislation and Human Rights and a Masters in Genetic Counselling from Brandeis University.

Dr Prasad has served as a professor at Columbia University and at Drexel University Medical School (then known as Hahnemann Medical College) in Philadelphia. He has also worked as a consultant to the World Health Organisation (WHO) and helped them in preparing two of their reports. He has been conferred an honorary doctorate by the University of Natal and has a syndrome named after him (Prasad’s syndrome – Hashimoto’s when it presents as mania). He has also worked as a consultant to the World Psychiatric Association Presidential Task Force to look into the problem of mentally ill in the prisons worldwide.

In an exclusive interview with India Medical Times, Dr Ashoka Prasad shares his views on the state of mental healthcare in India and why the steps that have been taken so far have not brought about any discernible improvement.

How would you depict the current condition of mental healthcare in India?

The current state of mental healthcare in India leaves an awful lot to be desired. It is nothing short of abysmal. All of us have noted individuals in a floridly psychotic state roaming on the roads not just in the mofussil towns but also in the major metropolitan cities. The apathy that is displayed towards them is shocking. There is no effort on part of the powers that be to address this, which I believe is a national disgrace.

The large mental hospitals, which constituted the mainstay, are mostly in pathetic state and inhumanly overcrowded. The situation is even worse for those afflicted with learning disorders (previously known as mental retardation). Rehabilitation is the mainstay in its management. There are hardly any rehabilitation centres at all in the country; the families are left to shoulder the burden and most, if not all, are in no position to afford optimal rehabilitation. Genetic counselling, so vital in most of these conditions, is almost never available and therefore never stressed upon.

Every so often we come across statements by powers that be that a mental health policy is being worked out, but we never see any credible effort to improve the lot of those afflicted with mental illnesses. Even in the area of addiction medicine, we are pathetically short of centres around the country.

We, as a society, must carry the collective guilt for allowing this to happen and not making any credible effort to bring about an improvement. The sad but inescapable inference is that the mentally ill do not constitute a vote bank and hence can be safely ignored.

We were, as it is said, the first post-colonial non-white independent country to institute reforms in mental health. Yet a large section of our population doesn’t have access to mental health services. Have we been only scarcely successful at ensuring adequate mental health coverage? Where do you locate the problem?

You are bang on! Among the colonized nations, India was the first to enact a very progressive Mental Health Act much before most countries. Some missionary psychiatrists like Stanley Jones and Davies did try to enlighten the population through their stellar work. But the myths that had soofied were just too strong to be rebutted. Additionally, there was unfortunately never any credible effort among the powers that be to address this issue head on! As I have stated mentally ill do not constitute a vote bank!

What do you reckon are broadly the mental health needs particular to our nation today? How far have they been met?

We need a mental health white paper and as far as the abuse of human rights is concerned, I think it is essential that we consider appointing a Mental Health Ombudsman conversant with both mental health and legal needs. Some countries have appointed Mental Health Ombudsman. We still have a long road to travel before we can state that we would be reassured of optimal medical care if any of us or our kins contracts mental illness.

How would you describe the urban-rural divide with respect to mental health needs and their fulfilment?

There is no provision for mentally ill in the rural settings and that should give us room for concern. Most patients from rural areas who visit my charitable clinic have already been through the ritual of consulting witch-doctors. But again this can only be tackled if it is done so in tandem with addressing the general medical needs in the rural settings.

How do we fare at providing a specialist level mental healthcare to our population today?

Whenever there is a discussion on mental health matters, we always harp on shortage of psychiatrists in the country. That is certainly true but anyone with even the most rudimentary insight into mental health matters would concur that increasing the number of psychiatrists is not going to bring about any realistic improvement. Psychiatrists on their own cannot alter the situation. Every mental health setup, in addition to a psychiatrist, requires trained psychiatric nurses, psychiatric social workers, clinical psychologists, community mental health nurses, occupational therapists etc. I find it curious that while there is a half-hearted attempt to increase the number of centres to train psychiatrists, there is no credible effort to address the very real problem of not having enough psychiatric nurses.

How has our performance been at the primary care level? How important is it to focus on mental health at the primary care level?

It is absolutely crucial. Primary healthcare is the bedrock on which the success of any specialist healthcare depends. There is an over emphasis on increasing the number of specialists and a criminal under-emphasis on training family physicians who are needed. I believe there are only two medical colleges that have applied for the postgraduate programme to train family physicians.

The interesting fact is that models for optimal psychiatric care exist not just in the prosperous countries but also in the developing ones. I myself had the good fortune to work in 11 countries, both developed and developing. I can confidently state that among the countries I worked in, Sweden, Norway and Switzerland have the best mental healthcare facilities. The United Kingdom had a great system when the National Health Service was still in a shape it was conceptualized to be. The US healthcare system is not only absurd but amoral, only geared to inflate the physician’s bank balances and the Canadian system has enormous variability.

Clearly we cannot emulate the systems that are there in these prosperous nations. But why can we not emulate the Cuban model, at least partly, which is based on community healthcare provision with emphasis on primary healthcare and preventive medicine. What I am trying to say is that it would be futile to expect a positive change in our mental healthcare provision in isolation. A system of specialist and tertiary healthcare as the primary source of contact is bound to explode. Sadly our policymakers are only concerned with tertiary care and have completely ignored the primary healthcare. Witness the insane scramble to set up new AIIMSs!

Unless we address primary healthcare we cannot realistically expect improvement in the healthcare status. All the successful healthcare systems in the world have primary healthcare as their edifice on which the specialist care relies. In almost all Western countries, a trained family physician is regarded as a specialist.

I have written about this on this very portal. We can only expect realistic improvement when we link psychiatric healthcare to primary healthcare and improve the primary healthcare provision. In addition, we have to make sure that we have adequate paramedical support available with mental health skills.

Your comments on the standards of preventive and rehabilitative mental healthcare that we have today?

As I mentioned, rehabilitative healthcare is almost non-existent. Preventive healthcare in my view is very much a part of primary healthcare and it succeeds; Cuba is a shining example.

How successful have our national and district mental health programmes been? Do you identify any shortcomings?

The proof of the pudding is in eating! I keep on reading about these programmes but anyone in the mental healthcare field would attest that there has been absolutely no change in the ground realities because of the absence of political will and lopsided priorities.

What measures do you think are needed at the government or administrative level to bring mental healthcare at par?

Most political formations claim to represent the most vulnerable section of the society. The claim is rendered hollow when we look at the way they continue to treat the mentally ill.

Above all, we have to launch a massive health education programme to dissipate the myths that surround mental illnesses. This would have to be in conjunction with the state apparatus. I have myself noticed floridly psychiatrically ill patients languishing in prisons. That is a matter of national shame. One of the main reasons for this is the lack of appreciation of the rights the mentally ill enjoy. I have spoken to dozens of lawyers who are completely unaware of the principles of insanity defence and M’Naghten rules that govern it. The courts would have to be involved to take a pro-active stand.

On the positive side, we had a very encouraging development take place on the 1st of July this year when the United Nations Human Rights Council enunciated the rights of the mentally ill. As a trained barrister, I observed that with enormous satisfaction. I am also glad that the current President of the World Psychiatric Association, Dr Bhugra, has decided to set up a Presidential Task Force to look into the scandal of mentally ill in the criminal justice system worldwide.

I am also a strong believer that given the widespread abuse of human rights of mentally ill all over the world, we should campaign for the appointment of a UN Special Rapporteur for Mental Health.

I have also had correspondence with Dr Soumya Swaminathan, Director General of Indian Council of Medical Research (ICMR), and am encouraged by her emphasis on mental illness. Collectively we can bring about a positive change but we have to get rid of the inertia that surrounds anything relating to mental illness.

Additionally, I would like the IMA (Indian Medical Association) to take this issue proactively.

Do you identify a need to bolster mental health education in India, in both the community and the academic sphere?

Indeed there is an acute need. Not just in the medical field but also in the legal field. I was flabbergasted to learn that there are no more than six law schools in the country that run course on mental health legislations.

I would like the Medical Council of India (MCI) to take a more active interest in psychiatric training during the undergraduate years. Most medical schools in India do not take psychiatric training seriously. The MCI could start off by warning the medical schools where psychiatric education of undergraduates leaves something to be desired.

Nearly five decades ago when I was a medical student, the common belief was that India, as a country, is insulated from the ravages of mental illnesses. Most who opted to go in for psychiatric training did so out of compulsion because they did not have any realistic option. In fact, when I declared my intention to train as a psychiatrist, there was resistance all around, including within my own family. I had always felt that psychiatry was the most fascinating and rewarding branch of medicine and persisted. Sadly those prejudices still exist and in order to effect a meaningful change, we would have to address that.

by Dr Soham D Bhaduri

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