Mental hospitals

Ernst (Reference Ernst1987) described the growth of mental asylums in British India as a ‘less conspicuous form of social control’. The city of Calcutta had the first mental hospital in India in the year 1787, followed by Bombay (Mumbai) and Madras (Chennai). There are now 37 mental hospitals in the country with a total bed strength of 18 024 (National Human Rights Commission, 1999). A study of the status of the mental hospitals commissioned by the National Human Rights Commission revealed gross inadequacies in all aspects of care, clinical services and rehabilitation. The subhuman living conditions in some of them were a stark violation of human rights and a painful eye-opener to many. Steps are afoot to allocate more resources to improving these hospitals (National Human Rights Commission, 1999).

General hospital psychiatric units

The establishment of general hospital psychiatric units began in the 1930s and intensified in the 1960s, leading to a change in the quality of care. These units are attached to the medical colleges throughout the country and offer a total bed strength of about 3000 (Reference Sharma, Kala and SahaniSharma & Kala, 1999). However, admission is voluntary and families have to remain with the patients. It became evident that a number of people with minor mental morbidity or psychosomatic disorders preferred to use these facilities because they were less stigmatising. Establishment of these units also paved the way for a more active liaison psychiatry.

Voluntary agencies and non-governmental organisations

The past two decades have witnessed a surge in the voluntary mental health movement in India. There are several nongovernmental organisations (NGOs), many of them in the southern part of the country, for example those offering specialised care to people with chronic mental illness (the Schizophrenia Research Foundation, Chennai, and the Richmond Fellowship Society, Bangalore and Delhi), those with suicidal ideation (Sneha, in Chennai), elderly people (the Alzheimer's and Related Disorders Society of India (ARDSI) in Kerala, with chapters in several other states), children, (Sangath, Goa) and substance misusers (T. T. Ranaganathan Research Foundation, Chennai). Self-help and support groups consisting largely of the families of people with mental illness are also making their presence felt on the national mental health scene (Reference Patel and TharaPatel & Thara, 2003).

Traditional healers

Traditional healers in India make up a large proportion of the private health sector. The use of traditional healers is driven by cultural factors, such as explanatory models of illness and treatments that patients and families understand (Reference Patel, Simunyu and GwanzuraPatel et al, 1997). It is not the case that traditional healers in India always harbour an ‘irrational’, unscientific model of explanation – both patients and healers readily accept psychosocial and biomedical models of mental illness. Even in urban areas, there are many who seek help from both traditional and modern Western medicine simultaneously. ‘Traditional’ healers often employ an amalgam of traditional (e.g. dietary and herbal) and biomedical interventions, some bordering on quackery. However, the easier accessibility of such healers for rural populations and the empathetic nature of their relationship with their clients often determine the effectiveness of the intervention, especially in cases of minor mental morbidity.

Religious treatments

Places of worship – Hindu, Muslim and Christian – are still important centres for the treatment of mental illness (Reference Thara, Islam and PadmavatiThara et al, 1998). Here the locus of control is placed outside the sufferer and problems may be attributed to black magic, a curse, divine wrath, or karma (determinism) of a previous life. The explanatory model therefore largely influences the type of help sought. Treatments at religious centres range from performing a series of rituals such as bathing in the temple tank and circumambulating the temple, to prayers at specified times. Physical restraint by chaining patients to a pole or a tree is not uncommon. Belief in the efficacy of religious treatment has led to the growth of unauthorised shelters housing mentally ill patients around such centres of worship. In August 2001 a gruesome event occurred when fire broke out at one such shelter, in Yerwadi, in which 26 mentally ill people burnt to death because they had been chained to prevent them from escaping. This disaster led to a rethink of the mental health scene and some governmental action followed.

Indigenous medicine

Three distinct indigenous (non-Western) systems of medicine are practised in India: Ayurveda, Siddha and Unani, all of which pre-date Western medicine. Evidence for their efficacy according to Western scientific requirements is not yet forthcoming, but the growing interest of scientists in these disciplines is encouraging formal research into traditional psychiatric therapies. The treatments investigated include varying combinations of drugs, herbal extracts, dietary regulations, physical exercises and lifestyle modifications.

Health service utilisation

In comparison with rural communities, urban areas are usually replete with psychiatric health care facilities in the private and public sector, and it is presumed that these communities will have better rates of use of health services. However, a survey of an urban community in southern India, served by four state-run general hospitals with psychiatric services and a large psychiatric institution, found that a third of people with schizophrenia had never accessed any treatment (Reference Padmavati, Rajkumar and SrinivasanPadmavati et al, 1998). Even after these individuals and their families were offered treatment, a third of them continued in their untreated state (Reference Srinivasan, Rajkumar and PadmavatiSrinivasan et al, 2001). People with schizophrenia who were living as part of an extended family accessed treatment less often, even when it was considered essential to do so. The families, when interviewed on the issue, replied that they were used to their relative's illness and that other family members compensated for the person's non-productivity. Once they had reached this equilibrium they did not want to disturb it by seeking treatment. This underscores the importance of cultural, social and family factors in service utilisation. In a country like India it is not easy or appropriate for a health care service to bypass the family to reach the potential patient; the family may have to be persuaded first of the need for treatment. More positively, however, this situation reflects the intrinsic coping style of the community and the family in dealing with disability, which may contribute to the better outcome of treated schizophrenia in India.

National Mental Health Programme

The National Mental Health Programme (NMHP) was developed with the objective of ensuring availability and accessibility of basic mental health care for all sections of the population. Based on the philosophy of decentralisation and demystification, the NMHP sought to integrate mental health care with primary care, by training personnel at primary health centres, making policy planners and bureaucrats more sensitive to mental health issues and providing basic medicines at the primary health centres. This programme has been operating since 1984 in a few states, but many other states have yet to adopt it in even a rudimentary fashion, despite the expectation that the Yerwadi disaster would give rise to a more concerted effort at its implementation. The good news is that the Government's current 5-year plan has allocated a substantial amount to the implementation of the NMHP in all Indian states.

Community mental health programmes

James Mills, describing the history of modern psychiatry in India (Reference MillsMills, 2001), stated that it was only in the 1990s that an increasing emphasis on out-patient care and more modern facilities was seen. It should be pointed out that in fact community-based programmes were first initiated in the 1980s, the impetus being provided by the NMHP. Some NGOs also embarked on community-based programmes, which although efficacious and cost-effective were always restricted by their dependency on time-limited funding (Reference Thara, Islam and PadmavatiThara et al, 1998; Reference Chatterjee, Patel and ChatterjeeChatterjee et al, 2003). Some programmes have demonstrated the feasibility and cost-effectiveness of such initiatives, but the hurdles they faced have discouraged the process (Reference Srinivasa Murthy, Lopez-Idor, Lie Mak and VistoskySrinivasa Murthy, 1999). Poor allocation of resources, insensitivity to the needs of people with mental illness on the part of both professionals and policy planners, and indifference to mental health in general have all acted as deterrents.

Epidemiology

Prevalence studies of schizophrenia in India report rates of between 1.5 per 1000 (Reference Surya, Datta and KrishnaSurya et al, 1964) and 2.5 per 1000 (Reference Sethi, Gupta and MahendruSethi et al, 1974). After correcting for age at risk, the rates range between 2.6 and 3.4 per 1000. Sample sizes ranged from 674 (Reference Nandi, Mukherjee and BoralNandi et al, 1980) to 101 229 (Reference Padmavati, Rajkumar and KumarPadmavati et al, 1987). There appears to be no consistent difference between rural and urban areas in the frequency of the illness, and no clear pockets of high or low prevalence. Incidence studies are few, with estimates of an annual incidence of 0.35–0.38 per 1000 in urban populations and 0.44 per 1000 in the rural population (Reference Rajkumar, Thara and PadmavatiRajkumar et al, 1993).

Course and outcome

The International Pilot Study of Schizophrenia (IPSS; World Health Organization, 1979) and the Determinants of Outcome of Severe Mental Disorders (DOSMED) study (Reference Sartorius, Jablensky and KortenSartorius et al, 1986) have provided convincing evidence for a better outcome in India (along with other less industrialised countries) than in the West. This finding of a good outcome of treatment also emerged in the Chandigarh studies (Reference Kulhara and WigKulhara & Wig, 1978; Reference KulharaKulhara, 1994). Kulhara et al (Reference Kulhara, Avasthi and Chandiramani1989) showed that regardless of diagnostic definition, the outcome in Indian patients was favourable. One spin-off of the IPSS in India was the multi-site Study of Factors Affecting the Course and Outcome of Schizophrenia (SOFACOS), sponsored by the Indian Council of Medical Research. This was a 5-year follow-up of 386 patients in three centres, aimed at identifying social and clinical factors affecting course and outcome. The 2-year follow-up revealed that among the 423 patients followed up, 64% were in remission, and only 11% continued to be ill (Reference Verghese, John and RajkumarVerghese et al, 1989). Data from the Madras centre also revealed a better outcome for women at the end of 5 years of follow-up (Reference Thara and RajkumarThara & Rajkumar, 1992).

The Madras cohort was followed up for another 10 years and was found to have a better outcome in marital and work functioning than has been reported for similar populations in the West (Reference Thara and EatonThara & Eaton, 1996; Reference Thara and SrinivasanThara & Srinivasan, 1997). Another interesting aspect of the Madras study has been the quality of social support enjoyed by the cohort. All the patients continued to live at home and were cared for by either their spouse or their parents. This can be generalised to other parts of the country, where the concept of patients living alone because of their illness still meets with considerable social disapproval. However, the increase in nuclear families and the reduction in the number of joint families, increasing urbanisation and the changing role of women may all, unfortunately, alter this picture in the years to come.

The occupational functioning of men is still crucial in the Indian setting, where the man is largely the main breadwinner. Unemployment and underachievement act as threats to his social status. Compounding this situation, the social security system in India does not consider patients with schizophrenia as its beneficiaries and people with chronic mental illness are not yet eligible for any welfare measures.

In India, relapse is difficult to ascertain. Rehospitalisation is one of the chief criteria of relapses in the West, but is not so here (Reference Rajkumar and TharaRajkumar & Thara, 1989). This is due to a combination of factors such as lack of beds and personnel, the costs involved and the reluctance of the family in some cases to have the patient repeatedly admitted. Costs also determine the type of medication, and many patients are still given conventional antipsychotic drugs.

Abnormal movements in never-treated schizophrenia

The presence of a substantial number of untreated people with schizophrenia in the community presents a unique opportunity to study the illness in its natural state. A series of studies conducted at the Schizophrenia Research Foundation (SCARF) in Chennai looked into the nature and prevalence of abnormal involuntary movements in never-treated schizophrenia (McCreadie et al, Reference McCreadie, Thara and Kamath1996, Reference McCreadie, Padmavati and Thara2002a , Reference McCreadie, Thara and Padmavati b ). The studies showed convincingly that involuntary movements similar in nature and degree to drug-induced tardive dyskinesia occurred in these patients. This indicates that such movements are an integral part of the disease process and not always induced by medication. The relationship with memory dysfunction, changes in volume of the basal ganglia, increased prevalence of involuntary movements in unaffected first-degree relatives and spontaneous remission and appearance of dyskinesia in previously symptom-free patients during follow-up have all been reported (McCreadie et al, Reference McCreadie, Thara and Kamath1996, Reference McCreadie, Padmavati and Thara2002a , Reference McCreadie, Thara and Padmavati b ).

Phenomenology

Indian psychiatrists still do come across catatonic states, especially in patients living in hospital. In the SOFACOS study, nearly 40% of the 386 patients at inclusion had a catatonic syndrome; this figure fell to 4% after 5 years’ follow-up. The Agra sample of the IPSS was the only cohort with more than 15 patients diagnosed as catatonic. It is, however, likely that the numbers of persons presenting with such a picture are on the decline; this is yet another fertile area of research.

Families in schizophrenia

The role of the family in the Indian scene is all-pervasive, influencing as it does the decision to seek help (when, where and how), the nature of help (medical or nonmedical), the need to continue treatment, and other issues such as employment and marriage. A report by Srinivasan & Thara (Reference Srinivasan and Thara2002) describes the role of the family in dealing with acutely ill patients with schizophrenia who are unwilling to take medication.

The fact that over 90% of those who are mentally ill live with their families and are dependent on them has led to research into family burden, family interventions and expressed emotion, and more recently into support groups. The finding in Chandigarh that Indian families show less expressed emotion than their Western counterparts has not been extensively replicated. The recognition of the importance of families has led to the creation of facilities for families to stay with patients in some centres, such as the National Institute of Mental Health and Neurosciences in Bangalore, and the Christian Medical College in Vellore. This facilitates the extensive participation of families in therapeutic programmes. The burden on families of people with mental illness is emotional, physical, financial and medical. Two instruments have been developed specifically to study this burden (Reference Pai and KapurPai & Kapur, 1981; Reference Sell, Thara and PadmavatiSell et al, 1998). Coping by families has also received some attention, with particular reference to religious coping methods (Reference Rammohan, Rao and SubbakrishnaRammohan et al, 2002). In the past 10 years India has witnessed a degree of growth in the consumer and family movement, resulting in the formation of support groups in major cities. A National Federation of Care Givers has also been formed, and it is expected that families will begin openly to articulate their needs and viewpoints.

Psychotherapy

Psychotherapy is a therapeutic process involving at least two individuals. The participants in the interaction come with their own social backgrounds, individual attitudes, values and stereotypes which are in themselves often culturally moulded. The religious and philosophical background, language, modes of affective expression, moral and social norms, mores, and culturally determined conflicts and defences could have an influence on the psychotherapeutic interaction. Hence there are bound to be differences in the practice of psychotherapy across different cultures. To be popular, psychotherapy must be consistent with the socio-philosophical background of the people (Reference Vyas and AhujaVyas & Ahuja, 1992).

A number of variables may be important in mediating cross-cultural differences between Western and Indian models of psychotherapy. Some of these are dependency v. autonomy, personal responsibility, and social and religious beliefs. Earlier workers in different cultures have identified dependence as an important transcultural variable. Indian men and women are described as being more dependent on others than are their Western counterparts. During the development of an individual in Indian society, the process of individuation occurs more at the material level, less at the emotional level. Dependence, often passive, is accepted and encouraged. The independence emerging around adolescence, often mandatory in Western societies, is strikingly absent in Indian families, where adolescents go through a long period of dependence on their parents. For young women this dependence is almost a rule, especially in rural communities. In the process of psychotherapy, dependence of the patient on the therapist is a common phenomenon; patients look to their therapist to decide what is best for them. This process has been likened to a guru–chela (master and pupil) relationship, in which the therapist functions as the master. This approach would preclude therapies such as client-centred psychotherapy, where the client has a more active role. It may work against a ready understanding and acceptance of Western theories and practices, in particular transference and countertransference phenomena in the therapeutic relationship.

Another construct that merits discussion with regard to psychotherapy is ‘psychological sophistication’ – an ability to view psychiatric problems in terms of intrapsychic processes. Absence of such an orientation would not help the psychotherapeutic process. The Indian psyche focuses the source of problems outside the self, in constructs such as karma (predetermined outcome), fate and astrological influences which are beyond one's scope to deal with. This leaves little to work on for a therapist approaching a traditional Indian scene with the tools and methods of Western psychotherapy. This does not make the Indian psyche ‘unsophisticated’, rather it is working in a different dimension of understanding. This position is bound to influence the model and content of any psychotherapeutic effort for the Indian patient. The application of Western models without such considerations might be difficult, ineffective and possibly harmful. Nevertheless, in view of the present trend towards Westernisation, Western methods of psychotherapy have their place, at least for the more modernised sections of society. Even here, traditional patterns of personality development and family organisation persist, placing obstacles in the path of any meaningful application of Western psychotherapeutic models in clinical practice.

Yoga

Yoga is much talked about as a health practice and is almost a fad in the modern world, where extravagant claims are made about its ability to resolve almost every illness of the mind and body. Yoga can be considered as a form of cognitive–behavioural therapy; it involves many activities, including the exercise of mental control, physical movements and posture, and regulation of breathing (Reference Grover, Varma and PershadGrover et al, 1994). Although the role of yoga in alleviating physical illness has been convincingly established, scientific evidence of its efficacy in major mental illness has not been forthcoming. This may be related to the multiplicity of forms of yogic practice in vogue, and the difficulty of standardising them in terms of ‘dosage’. It is a fertile field for research, as this health practice is in tune with the religious and philosophical outlook of much of Indian society.