Dr M S Reddy is director of Asha Bipolar Clinic, Hyderabad, and president of Indian Association of Private Psychiatry (IAPP). He is also a council member of Asian Network of Bipolar Disorders and editor of Indian Journal of Psychological Medicine. Dr Reddy did his Postgraduation in Psychiatry (MD) from Christian Medical College (CMC), Vellore, and is currently pursuing Healthcare Management course at the Indian School of Business, Hyderabad. He is also a recipient of the Florence Nichols Prize. His mission and vision includes translation of evidence-based psychiatry into accessible, acceptable and sustainable mental healthcare delivery models.
In an exclusive interview with India Medical Times, Dr Reddy discusses the challenges facing the private mental healthcare sector in India, which constitutes the greater part of mental healthcare delivery in the country, and his vision for the future.
Given your rich experience in the field of mental healthcare, please tell us something about the general profile of the patients that you come across as a consultant in the private sector, given also the widespread denial of mental illnesses in the Indian community. Are more people gradually opening up about their mental health issues?
A significant percentage of patients are those with depression and anxiety disorders, say about 30-40%. As I am the director of Asha Bipolar Clinic, with focused interest in bipolar disorders (mood disorder), I see a significant number of patients with mood disorders, i.e. depression and bipolar disorders. Patients suffering from different types of psychiatric disorders, which include severe psychosis like schizophrenia to minor problems like adjustment disorders, visit our hospital for treatment. I am sure that is the experience of every practising psychiatrist. The range includes psychoses, depression and anxiety disorders, obsessive compulsive disorder, drug addictions, sexual dysfunctions, childhood behavioural problems, intellectual disability, learning disabilities, geriatric behavioural problems, including dementia, and stress related adjustment problems in various age groups which include teenage problems, marital disharmony, work related adjustment problems etc.
Yes, there is a significant stigma attached to psychiatric disorders, but it is on a gradual downward slope in the last few decades. Few reasons for lowering of stigma being increased awareness in the general population due to various awareness programmes undertaken in the print and electronic media, opening up of psychiatry units in general hospitals, availability of psychiatric care in the private sector and other associated socio-economic changes in the society like increased literacy, reduction of superstitions and in general improvements in healthcare.
One important factor in the reduction of stigma is the availability of effective treatment methods, especially pharmacotherapy, which helps in significant improvement in the disease symptoms and even allows total recovery from the disease episode in conditions like depression and bipolar disorders. At one point of time, and to a certain extent even now, there was this prevalent belief that “there is no medicine for mental illness” which has been strongly and effectively disproved in the last half a century. When you see your neighbour, colleague, friend getting relieved of abnormal behaviour and getting back to work and also into the social mainstream, the resultant positive effect is immense and optimistic. All these factors put together helped greatly in reducing the stigma of mental illness. But a lot more needs to be done to have a greater penetration of this positive impact in all the different sections and segments of the society.
Professionals have dual responsibility:
1. Translating research into effective clinical treatment delivery that relieves the patient of the “pain”.
2. Spreading this positive message in the “language” a layman understands thereby creating awareness.
The ripple effect of the positive benefit must spread continuously and for this to succeed there is need for public-private cooperative participation, including media as an active facilitator.
How significant do you think is the contribution of the private sector today in dealing with the burden of the mentally ill in India?
As of today there are about 6,000 psychiatrists in India and about 3/4 of them are in the private sector. The private sector psychiatry greatly contributes to the management of all varieties of psychiatric disorders in the out patient setting. The number of inpatient beds for mental health is limited in the private sector as of today, but it surely will improve in the next decade. The rehabilitative care is again well provided by the private sector and also by the NGOs.
Nearly 80% of mental healthcare is currently available with the private sector, making it expensive. Do you think of it as a deterrent in the access of psychiatric services by the general population? Should the equation change for the better?
Keeping aside immunization and other public health programmes, this may be true in the entire healthcare delivery and not just for mental health. In India, the private sector contributes significantly in effective healthcare delivery, especially in high technology care and the growing area of non-communicable and lifestyle disorders. Mental healthcare is certainly not expensive, especially if you consider only the outpatient treatment. Only about 10% of patients with psychiatric disorders may need admission and inpatient treatment. The investigations are minimal; the average cost may be less than Rs 2,000.
The cost of most of psychotropic drugs is on the lesser side; an average patient with depression or psychosis can be treated with medication cost of about Rs 1,000-1,500 per month. The only problem is that it is of longer duration: for a period of at least 6-9 months, and in some cases, may be for years. Health insurance, as the treatment is of longer duration, would greatly help in reducing this burden. We need your help in highlighting this issue and to actively canvas for this. For this help, the psychiatric community will ever be thankful to you.
Your views on the general standards of psychiatric care in private settings? Is there an over-reliance on medications, as is often claimed?
Generally, it is good and satisfactory. The second half of the twentieth century has seen significant advances in the field of pharmacotherapy, in a majority of patients with depression and psychosis (two most common conditions), significant symptom reduction can be achieved in a period of 3-6 weeks and they can get back to their work and the medication cost will be around Rs 2,000. Counselling is important and is done at the basic level. But ‘psychotherapy’ of various types that require 10-15 sessions, each lasting for about 30-45 minutes, is neither cost nor therapy effective. I clearly disagree with the thinking line of “over reliance” on pharmacotherapy. It is the advances in pharmacotherapy that has helped psychiatry in achieving and demonstrating acceptable therapeutic results and thereby helping to reduce the stigma. Yes, I do agree that medicine is not the only answer. Even in a condition like diabetes, medicine is not the only answer, as diet control, foot care, exercise etc are also important. For example, I take a comparison of Depression with Diabetes and conclude that medicines are an essential component of treatment but as are minimizing stress, good sleep, exercise, family support, relaxation etc.
What issues do you identify to be afflicting mental healthcare in the private sector today? Are we also suffering from a shortage of trained and qualified staff as for the public sector?
The shortage of mental health professionals is certainly, and largely, an area of concern. General practitioners (GPs) should be educated and trained in the management of simple conditions like depression and anxiety disorders, which will reduce load on mental health professionals and also help in reaching out to more patients. Training of the local GPs and promoting telemedicine can be two effective channels.
Mentally ill patients in India don’t find insurance coverage. Even the government investment in mental health is a mere 0.06% of the budget. It seems that the skewed perception of mental illnesses is not just a feature of our people but also of our institutions. Your views on how this could be corrected?
Various factors that are contributing to this misdirected concept are:
1. Mental illnesses are not real disorders; some people “unnecessarily overthink” and so suffer.
2. People with “strong will” never develop mental illness.
3. Once you have mental illness, you have it for life and there is no medicine.
4. Often people “fake” mental illness for certain emotional and personal gains.
All mental illnesses are due to psychosocial and economic problems and are often promoted by several sections in the society, which is a major roadblock in getting the acceptance of such conditions as brain disorders with predominant neurochemical disturbance. This is also due to the fact that as of now there is no “diagnostic lab test” to confirm any psychiatric disorder. For almost half a century, the psychosocial factors variously described as “childhood fixations, bad parenting, schizophrenogenic mother, loss of loved object” were thought to be the causative factors of psychiatric disorders and therefore need to be corrected “analytically”, “behaviourally” etc. All these factors contributed to the skewed perceptions! There is requirement of major mental health “campaigns” to correct these, which certainly is going to be a time consuming process.
How important is the role of the government in strengthening the private sector? Do you identify any areas that need to be worked upon?
Depression and Psychoses (Bipolar Disorder, Schizophrenia) are major public health problems and governmental policy decisions play a key and major role. The private sector can guide in framing the policies and also can play a role in their implementation. The public private partnership (PPP) can be an important channel, but considering the mammoth dimension of the problem, governmental initiation is very important. For this, policy makers need to be impressed upon with the economic cost of mental ill-health in the community. Good health is not only the biggest asset for every individual but for the nation too. Health includes very certainly mental health!
Policy makers should be made aware of:
1. Cost of mental illness in the community
2. Gains accrued with early and effective interventions.
What do you think are the prime challenges in the way to making private mental healthcare on par with the mental health needs of our population?
1. Mental health is an essential and, may be, more important component of health.
2. Positive mental health concept to be actively promoted — exercise, relaxation, good sleeping habits, avoidance of drugs of abusive potential, leading a less stressful life etc.
3. Awareness and acceptance that mental disorders are just like physical disorders, which need early and effective interventions.
4. Fighting stigma and creating opportunities for social reintegration of people who suffer from mental disorders.
5. Treatment of mental health disorders to be made accessible and affordable.
6. Effective implementation of current district mental health programmes, which is more on paper currently.
7. Allocation of more budgetary support to these programmes, which require dependable data on pharmacoeconomics of mental disorders relevant and specific to our country.
8. Creating economically viable models of mental healthcare relevant to India’s diversified cultural and socioeconomic background.
9. Affordable quality mental healthcare delivery models — one much cherished dream of mine is ‘adoption of some villages and striving for “zero suicide” status’.
10. Affordable mental healthcare coupled with telemedicine can make India an attractive destination for medical tourism in psychiatry! May sound dreamy now, but I am a strong believer in its possibility!
Your thoughts on incorporating the large private mental health sector into public mental health initiatives for better mental health provision, considering that the public sector covers roughly 20-30% of the population, and is plagued by shortage of human resources? What are the ways this could be achieved?
Following are some relevant points that I would like to mention:
• Involve the local private psychiatrist in the District Mental Health Programme — with clear remuneration and clinical outcome metrics defined.
• Immediately open Health Insurance for patients suffering from psychiatric Disorders — allow the insurance companies to define the categories of illnesses covered and the co-pay percentages — do anything, but extend health insurance to psychiatric disorders.
• Extend the admission facility to the private psychiatrist in the government institutes of mental health. Build and create a better (clean, decent, with better nursing care and accountable staff) private ward in the government hospital and open it for the private sector. In the backdrop of Mental Health Care Bill 2016 that insists on getting licence to start private inpatient mental health facility, this may sound a good alternative. (This may sound illogical; this is just an impulsive and out of box thought that took birth in my brain just this moment and thanks to you for that stimulation! Now that I spelt it out, this sounds attractive and elaboration worthy.)
• Allow more private centres to have postgraduate teaching course (DNB in Psychiatry) and regulate syllabus and examination system on par with medical colleges — it will help in creating more technical manpower in the field of psychological medicine.
by Dr Soham D Bhaduri