Dignity in Mental Health

Every year the World Mental Health day is marked on 10th October.  The theme of this year's World Mental Health day is ‘Dignity in Mental Health'.  Worldwide, various organisations including WHO, celebrate the day to raise awareness to fight stigma.  As per the World Health Organisation, millions of people with mental health conditions are deprived of their basic human rights.  Apart from being discriminated and marginalised they are also subject to emotional and physical abuse in their own homes, community and even mental health facilities.  This is further worsened by the lack of infrastructure, dilapidated facilities, poor quality of staff or lack of an adequate number of professionals.  Failure to treat people with respect and dignity often worsens their condition further, by having a negative impact on the recovery and long-term prognosis.

In Kashmir, the number of people suffering from psychological problems has increased exponentially.  With the ongoing conflict, mass exposure to trauma, worsening socioeconomic conditions and the prevailing day to day uncertainty, people are more prone to develop psychological problems.  Psychiatric Diseases Hospital, Srinagar is the main facility catering to all the districts of Kashmir, Ladakh and adjoining areas like Banihal, and Kishtwar.  The hospital has been under tremendous pressure over the years catering to huge demand due to the absence of other psychiatric facilities in the region.  The department has expanded and developed over the years and has become one of the Centres of Excellence in the country, meaning that increased number of doctors and allied staff are being trained.  This was only possible due to the sustained efforts of doctors working in the hospital, who at times spent money from their pockets to attend meetings around the country, to get the funding and upgradation status, without any help from the State administration.  The psychiatry department has its own facility at the SMHS Hospital, which provides daily OPD services and treatment to drug abuse patients.  Lately, many psychiatrists have joined at various district hospitals though there are still no inpatient beds available.  

The attitude of young doctors has changed towards psychiatry and even toppers in the entrance examination are choosing to become psychiatrists.  This is surely progress when it comes to the acceptance of psychiatry as a career by doctors in spite of opposition from families and society at large.  Mind you, they could easily join other specialities like medicine or surgery.  It is worth noting that psychiatry has improved academically in the Valley compared to many other parts of India. 

When it comes to the stigma and general treatment of people suffering from mental illness, we are not doing any better, both in the community and at the professional level.  There is huge stigma related to any kind of mental illness and often people find it difficult to even talk.  There are various myths and stereotypes associated with it and people prefer to take advice from anyone but a psychiatrist.  People would often go to neurologists and cardiologists and undergo multiple unwarranted investigations and end up on a cocktail of unnecessary medications.  Faith healers are often the first port of call, where few find respite and most get into further trouble.  I am not blaming common people here, it is due to lack of awareness and more so because of the stigma. 

Although stigma is inherent with mental illness in most societies, the delivery of care has made the problem worse in Kashmir.  The Psychiatric Hospital at Kathidarwaza originally a part of the central jail was initially started as an asylum.  Later, it was converted into a Mental Hospital and ultimately became part Medical College Srinagar.  Recently, it was renamed as Institute of Mental Health and Neurosciences.  But when it comes to the perception of common people, probably the status of the place has not changed much and is still considered merely as a mental hospital and often called by derogatory names.  Often, young women would request if the prescription is written on a paper which does not say Psychiatric Hospital.  Sometimes they will carry an additional prescription slip from SMHS to show to their family, fearing stigma, shame, being judged or even fearing that visiting here may cost them their marriage.  Most people are usually comfortable to see a psychiatrist at SMHS OPD but would refuse to go Psychiatric Hospital citing obvious reasons. 

Once accompanying a young man from downtown Srinagar, his old mother innocently narrated how she tried to bribe a policeman to get him arrested, explaining that it is more respectful to be in prison than to be admitted to this hospital.  Sadly, such cases are not rare. Many believe that by receiving treatment from this place, the prospects of future relationship and marriage could be bleak for both boys and girls. 

There are families even from well-educated background who lock up their loved ones, fearing stigma and shame. We still see incidents when people are being chained and treated inhumanely.  There are also some patients who have been admitted to the Psychiatric Hospital decades ago, but for various reasons have never been claimed back.  

With the opening up of new wards at SMHS and open ward at Psychiatric Diseases Hospital, the care and treatment for many patients has improved.  Unfortunately, same cannot be said about the patients treated in the closed wards. The wards are not in good condition and remain locked without any direct nursing supervision.  The hospital has a limited area of land, where ongoing construction has meant that it has lost the only garden space and looks more like a construction site.  There is no place for patients to have some free air or get any physical exercise. 

The Mental Health Act 1987 is in force in Jammu and Kashmir to safeguard the care and treatment of mentally unwell.  Sadly, the Act is on paper only and none of the state machinery including the medical fraternity abides by it.  When admitting or treating patients against their will, no consideration is given to their basic human rights and end up essentially locked up.  Sometimes people are admitted under court orders without a review date meaning prolonged admission.  Police has an integral role in the care and safeguarding of mental health patients, but most families have to either beg or bribe the cops to get help for transferring an uncooperative patient to the hospital.  With no training and knowledge of the mental health legislation, patients are transported in very inhumane conditions, often tied and bundled up. 

The Jammu and Kashmir State Legal Services Authority has published guidelines in 2010 for the care and treatment of the mentally ill persons, which if followed would have greatly improved the services.  It argues that as India is a signatory to the UN Convention on the Rights of Persons with Disabilities (CRPD), 2008, making it obligatory for legal system to ensure the human rights and fundamental freedoms of people with mental illness and mental disabilities are protected on equal basis with others.  It also advises to ensure that they get equal recognition before the law and equal protection of the law.  The Convention further requires ensuring effective access to justice for persons with disabilities on an equal basis with others.  But again this has remained limited to paper.

There is a need for education and awareness of the general public and particularly of professionals involved in care and treatment of mentally unwell. This would include the health professionals, police and legal services.  Mentally unwell people should be treated with dignity and respect as anyone else in the society. This includes treatment of both mental and physical health. Those who have been abandoned by their families or have no families need to be rehabilitated in the community so that they don’t live a life of imprisonment just because they have a mental illness.  

Finally the government should relocate the Psychiatric Diseases Hospital to a suitable location and allocate adequate land so that a world class Institute of Mental Health is developed with appropriate space and wards manned by psychiatric nurses, and separate wards for children and old age patients. Many like-minded psychiatrists tried to get the hospital relocated after it was granted the status of the centre of excellence, but no headway was made due to red tape and unending bureaucratic apathy.  A new hospital will surely ease the stigma and improve the basic facilities so that people are not treated in asylum-like conditions anymore.  

 http://www.greaterkashmir.com/news/opinion/dignity-in-mental-health/198198.html 

Personal reflections of doctor starting psychiatry training in Kashmir

Personal reflections of a doctor starting psychiatry training in Kashmir

 

It was my third year in medical school and we were excited to be out of the classroom and with real patients at last.  My first clinical posting was in surgery and within few weeks I had made up my mind, ‘I am going to be a surgeon, maybe a neurosurgeon’.  

This continued till I passed the final year examination.  During my twelve month internship, I had a ten-day posting in psychiatry.  Apart from a few lectures and a random question in the medicine paper in the final examination, these ten days are the only clinical psychiatry experience most doctors will have during medical training in India.  Hence, psychiatry has no identity of its own in undergraduate training.  I do not remember having much interest in psychiatry during my medical school days that is, until I started the ten-day psychiatry rotation as part of the internship in Government Psychiatric Diseases Hospital, Srinagar.

I think it was early winter, there was a chill in the air and the sky was invisible under a shroud of clouds.  The Psychiatric Hospital is old; historically it has been part of a prison, an asylum, a mental hospital and finally ended up as being part of the Government Medical College Srinagar. This led to the establishment of a postgraduate department of psychiatry in the hospital responsible for training doctors as future psychiatrists.

The hospital shares a wall with the Central Jail of Srinagar, in an area which was once within the confines of an old fort called Hari Parbat. One can still see the huge walls and the entrance to the area, called Kathidarwaza.  To my surprise, most of the hospital was in ruins due to a recent fire, the cause of which remains a mystery to this day.  A few old wards were still standing and the outpatients department was being run from a temporary building.  A new small structure, rather better looking than the rest was the office of the Médecins Sans Frontières (Doctors without borders) who had constructed that recently with their own expenses.

Patients were seen in two small rooms.  In one room, there was a consultant psychiatrist and his registrar and in the other room a few post graduate trainees and SHOs.  The corridor was full of patients, mind you there is no appointment system and patients walk in to be seen.   Each room had a small table, a few chairs and a coal heater in the centre.  There was no room to move and one can see people in a range of moods, holding the hospital cards in trembling hands waiting for their turn. There was no privacy and I was surprised how the psychiatrists were able to listen to personal stories and make sense of it all.  A few helpers were trying to man the door to stop everybody from pushing inside at the same time.  There was a strange aura around probably from burning coal heaters, overdressed patients and their attendants, some silent as if they were not there and some indifferent and lost.  It was rather hard to make sense of it all at the time.

As an intern, I was supposed to shadow and watch the psychiatrists seeing their patients.   I think it was my second or third day when one of the registrars asked me to take a history from a patient.  The patient was probably in his fifties traditionally dressed in Kashmiri Phiran (traditional gown) and a round cap.  He was sporting a short beard and looked like a village elder.  But once he started talking, I could not make much sense and my curiosity increased further.  He told me a long story which is hard to recollect in full detail now, but I still remember that he was on the moon, had attended a wedding there and was planning his next trip.  For a minute, I was confused, not sure any Indian has been to the moon let alone a village elder from Kashmir. But his story fascinated me, he was talking to unknown people and seemed perfectly convinced of what he was saying and I was not sure whether I doubted him.  He was happy and full of energy.

This was the first time I thought about the psychiatry as a speciality and what psychiatrists do.  Within the next seven days, I had changed my mind and decided to be a psychiatrist.  I still did not discuss this with any of my colleagues, friends or family.  After finishing my internship, I again joined Surgery as a house officer and nearly everyone thought I would make a good surgeon, not knowing I had other plans.

In those days, there were only 2 placements for psychiatry training in the entire state of Jammu and Kashmir, despite having four medical schools and dozens of placements in other specialities like medicine and surgery.  Out of the two places, one was reserved for “backward category” (those from impoverished backgrounds) meaning there was actually only one placement on offer and hence competing for this single place was not easy.  Thousands of newly qualified doctors compete with each other; a yearly entrance examination is conducted and merit list is drawn as per the score in the exam.  At the time of counselling, the top scorer is invited first and can cherry-pick any branch and rest of the candidates follow as per their scores, meaning those at the end do not have much choice.  Hence to get to this single psychiatry placement, one has to be at least in the top ten on the merit list.  Fortunately, after working hard for a whole year and revising all that had been taught in the entire MBBS, I scored well and was 6th on the merit list.

At the time the result was declared, I was spending time with my parents and was off work.  It was my brother who called late in the evening confirming my score and place on the merit list.  My father asked if I was going to be a cardiologist or a surgeon. I replied “I am going to be a psychiatrist” without any doubt or ambiguity.  Both my parents went a bit quiet initially, but then said "if that is what you would like, why not".  I have to say I have been lucky when it came to my parents; they always believed in me and let me make my own decisions. But I know other people in my place, whose families opposed their becoming psychiatrists and one doctor was even threatened with divorce by his in-laws if he chose psychiatry.  The stigma was very much there and it still prevails.
 

On the day of counselling, when I went to fill in my preference, there was a noticeable stigma.  I was asked to give two choices and when I mentioned psychiatry as my first choice, I remember all three-panel members stopping in time, with their jaws dropping.  They probably thought that with my score, I can take any branch, surgery, medicine, paediatrics, orthopaedics, why is he asking for psychiatry? They could not resist and finally the Chair asked why do you want to do psychiatry?  Obviously my answer was not for their understanding.  I still remember while I was sitting in the waiting area, all the doctors who were supposed to be there that day, came around to have a look at me. They were also surprised why someone would do psychiatry when he could cherry pick whatever he liked. I am glad; my decision did make a difference as next year, candidates with even better scores than mine decided to join psychiatry creating a positive ripple.

Hence, I started my psychiatry training in May 2004 at the very same burned and gutted Government Psychiatric Diseases Hospital Srinagar. I was awarded MD Psychiatry by the Kashmir University after passing the final examination in 2007.  Later, I worked as programme officer for the National Mental Health programme, trying to take psychiatry to the community and was able to establish psychiatry outpatient services at few district hospitals. I was also organising training programmes for general practitioners and health workers with the help of faculty from Psychiatric Diseases Hospital. 

When I needed to move to the UK, I contacted the Royal College of Psychiatrists London, who advised that I could apply under the MRCPsych equivalence scheme which would help me to gain the GMC registration and allow me to work as a psychiatrist in the UK. Unfortunately, the College decided that ‘I could not prove that my degree was equal to MRCPsych' and advised me to take the examination instead.  Although, it was not good news, I was not disheartened; neither did it change my desire to continue practicing psychiatry.  After passing the PLAB examination conducted by the GMC, I applied to London Deanery and they gave due weightage to my experience and degree from India and I started working at the South London and Maudsley NHS Foundation Trust.   I passed the MRCPsych membership exam and currently I am working as a specialist registrar in consultation liaison psychiatry at the famous Guy's Hospital, London. I am involved in teaching and training core trainees and medical students. I am also an honorary researcher at the Institute of Psychiatry, Psychology & Neuroscience King's College London.

Looking back at over 11 years of being a psychiatrist, I do not think there was ever a dull moment. Every new patient I encounter is different and the curiosity to know the human psyche never ends. Reflecting back on my six months in surgery, where things are fairly similar, i.e.  One tries to avoid the same artery while taking out a lipoma, being a psychiatrist means no two cases are ever the same. I am still fascinated with the same energy and intensity as I was in 2002 when I met that Kashmiri village elder who had just returned from the moon. The value of life is not only in its physical form but what drives us underneath. I am glad I made the decision to choose psychiatry. While I could have been treating organs and systems being a surgeon, treating someone as an individual is far more satisfying and fulfilling and that defines being a psychiatrist to me.

Finally, I am happy to say that the Psychiatric Hospital Srinagar, through the efforts of like-minded doctors has developed as one of the centres of excellence in mental health. It has been renamed as The Institute of Mental Health and Neurosciences Srinagar, with an increased intake of psychiatry trainees and has also trained allied mental health professionals in the last few years. The stigma among doctors is much less and for the first time in the history of Kashmir a few female doctors have qualified as psychiatrists.

http://www.rcpsych.ac.uk/discoverpsychiatry/overseasblogs/psychiatrytraininginkashmir/personalreflectionsofadoct.aspx