Presidential Address 2011:Change in lifestyle:Increase in demand for stress reducing methods:Dr. Kaushik Ramakant Gupte

Whatever is there in front of us now will soon perish and become a thing of the past. Even as we adapt to the present, there are new situations and conditions to be faced the next moment. I mean who can truly say “I was totally free from all tensions at some point of time “ . Our relation to tension or stress has now more or less become like that of human and his shadow . Looking at our daily schedule: Waking up we have tension to reach at workplace on time , reached at workplace, well the tension of work or stress of conflicts with boss and colleagues , tension of the ever increasing competition , and the stress of ever rising prices ; for students the tension of submissions , stress of exams ; for the house wife the stress to run the home in budget and somehow squeeze savings from it and the list never gets an end . Just like our shadows our tensions and stress stay with us from dawn till dusk and sometimes even in our dreams. These all are nothing but the signs of changing lifestyle and the tension which it brings along as a parcel.

“Nothing Is Constant Except Change”. This saying can never have been more apt in any other time except today. In today’s world it is not only important to adapt to changes but to adapt at the pace at which these changes occur. Until and unless one learns to adapt himself to these changes he is more vulnerable to Psychological problems. The increase in the numbers of reports of suicides in India is exponential. The old man hanging himself in the house due to loneliness or the farmers dying due to the draught and debt; situation may be different but the cause of death in both cases being feeling of severe Depression. Looking at the current situation, India is divided into two prominent lifestyles: Rural and Urban. In rural India the things are a bit simple as the people are striving for their daily needs and tend to live with simplicity but in the last decade due to the increasing industrialization and less opportunity for better jobs have increased the patients suffering from STRESS. In urban India the situation is quite complex as compared to rural parts, as there are many factors like status in the society , partying culture, work load , etc. which play a key part in defining the lifestyle of a person . In the race to increase their status in the society people tend to incline towards drinking alcohol, may consume drugs and end up becoming addicts . The ever increasing competition in the multinational companies has lead to progress of the country but has pushed the workers into the darkness of depression and the constant stress to keep, be at the top , I cannot stop myself from recalling the dialogue from the movie 3 idiots “Life is a race if you don’t run fast someone else will thrash you and go ahead” . The rise in consumerism has lead to price hike of many basic necessities causing depressed mindedness to the rural and urban citizens alike. The process of adapting oneself to this ever changing lifestyle is itself quite stressful.

People have started now understanding this and are finding their ways to fight against stress in conventional as well as unconventional ways.

Meditation in the form of Art of living or Vipasyana, Pyramid therapy, Aromatherapy and Music therapy are some of the ways people have chosen to reduce their stress and the laughter clubs and yoga centers have become prominent place in people’s everyday schedule. Some people have opted to go for the spiritual path and have taken shelter under Gurus and Saints, some frequently visit Faith healers and many a times get cheated in the lure of immediate solutions to their stress problems. All of us must be having lots of patients referred by Faith healers too. People are likely to get frustrated by these alternative or complementary therapies as the benefit offered is likely to be short-term in nature like a placebo and there is usually no insight offered into the problems that one is facing. And here, is where we, as Psychiatrists, come into the picture.

So, what role do we have to play then? Even in a country like India, the demands placed on the Psychiatrist go beyond prescribing right drugs in right doses. Many people using the alternate therapies will be having milder problems and the reaction to the suggestion of meeting a psychiatrist is likely to be negative as it is seen as a way for serious problems involving long-term treatment. Therefore, we have to create awareness that the psychiatrist is a friendly person with whom problems can be shared by “talking the things over”. Moreover, majority of the problems coming to our attention arise out of difficulties in interpersonal relationships and these involve the family, school or workplace.

These are amenable to counseling. Counseling is also preferred by persons who are educated, aware, sophisticated and have some definite insight. The psychiatrist also has to do homework and has to give the patients knowledge about the alternate therapies along with prescription of drugs and plan a roadmap for the recovery of the patient.

Sharing with you my personal experience – after suggesting one patient to start light physical exercise and also learn Meditation and do relaxation technique on regular bases apart from counseling and medication, he had very good improvement, and he asked my permission to stay in my waiting room and motivate other patients to be regular in taking treatment and make the appropriate use of alternative therapies. I allowed him and astonishingly after a few days I found out many of my patients in the waiting room had followed his footsteps and had a speedy recovery.

No discussion of the role of Psychiatry can be complete without mention of an omnipresent 24 by 7 entity: Media. Media – print and electronic alike, is an integral part of today’s lifestyle and has a tremendous influence on everything that a person does or thinks. Having Laughter shows daily on electronic media along with the yoga and meditation shows in the morning are proving to be real stress busters for masses. Articles in print media about the increasing level of stress in Indian workers, mental stress in people after natural calamities, interviews of doctors, etc. help the people to identify their problem and offer solution to it. There is no stigma attached to visiting a ‘shrink’ or discussing issues like rehab from drugs in USA. Likewise, we in India have to work towards that time when the role of Psychiatrists will not only be accepted but also be appreciated. I remember a report published in one of the leading news papers of New Delhi, where the Editor discussed a case of Suicide by an old aged man who never consulted a Psychiatrist before as he did not have any such problems due to which his relatives felt a need to consult a Psychiatrist, that was what told by the relatives. Only one matter was found that the old man who committed suicide was remaining disturbed for last couple of weeks after the declarations of price hike, he was constantly thinking about the pace of the change in lifestyle and how his children will face the newer situation. A Psychiatrist was interviewed how this can happen, what reasons can be there, what kind of stress he must have undergone that lead to complete the suicide. Entire matter was published in such a informative way that a lay man can easily make out the earliest signs of increased stress and can start thinking about what to do at the early stage to prevent further serious consequences.

Thus, in present times for proper sustenance of the society it is important for the media and the mental health professional to go hand in hand to reach the masses and make them aware about the increasing levels of stress in society. Hence the theme of this conference is “Media and mental health”. Hope we make most of it.

Dr. Kaushik Ramakant Gupte M.B.B.S., D.P.M.

Clinical Practice For Last 20 Yrs

General Psychiatry and Substance Use Disorders

Attached to multispeciality hospitals of surat-BAPS Swaminarayan hospital and Mahaveer Hospital as Hon.Psychiatrist.

Attached to Shree Sardar Smarak Hospital-Bardoli as visiting psychiatrist and running Taluka Mental Health Program of Govt. Of Gujarat

Past president – IPS, Gujarat State Branch

Past Secretary, IPS, Western Zonal Branch

Contact: “Manoshanti”, 202 & 203, Prime Chambers,

Opp. S. B. I. Nanpura, Surat

Presidential Address 2010: Schizophrenia: a Journey of 100 Years: Dr.Bansi Suwalka

Exactly 100 years back a Swiss psychiatrist, Eugen Bleuler, coined the term “schizophrenia”. With passage of time schizophrenia came to be considered as one of the most dreaded illnesses mankind has ever known. It became synonym of insanity, madness and cancer of mind. Even at times, people would believe that psychiatric illness means schizophrenia.

The illness cuts across barriers of nationality, gender, educational and social classes.

Traditionally foreign books have been maintaining that on an average 1% population at some point of time in their life, suffer from schizophrenia.

The Indian epidemiological studies too have shown a similar prevalence.

What is the status of schizophrenia today, 100 years after the term was coined by Eugen Bleuler?

If we go by the criteria of ICD 10 or DSM IV text revision, then, as of now, in my clinical practice it is 0%. Sounds dramatic, isn’t it? Have we won the battle against schizophrenia? Has schizophrenia been eradicated? Alas, it is not so.

Now we see patients who usually have brief episodes commonly known as schizophreniform disorder, delusional disorder, brief psychotic disorder and many other schizophrenia like disorders in which symptoms remit before 1 month period, the period which is mandatory for labeling the illness as full fledged “Schizophrenia”. It’s because modern treatment modalities have been able to alleviate symptoms very easily. Even symptoms which were resistant to most of the medicines till recently, now give in to newer drugs like clozapine, aripiprazole, etc.

Even patients with negative symptoms respond to treatment if they are detected early and brought to the psychiatric facility. Whether negative or positive, I have seen in my clinical practice that the rural people are more receptive than urban ones. Urban people are more sensitive to stigma. The urban people refuse to accept that their family member can develop psychiatric illness. Negative symptoms, are still less acknowledged. Relatives think that they (the patients) are getting dull and lethargic and they think the change is psychological and unfortunately, by the word ‘psychological’ they mean it is voluntary. So rather than taking the person to a doctor they resort to nagging. And in the process the illness gets chronic and in some cases structural damage starts occurring.

Rural patients too can get chronic because of ignorance, superstition and lack of means to contact psychiatric facility. But once they contact the facility they are more compliant than urban.

The patients who are there in mental hospitals also get chronic and are not properly rehabilitated. In many centres I have found that even newer molecules are not made available to them.

Besides, biological, psychosocial factors also play significant role. In the time of Emil Kraepelin, catatonic disorders were very common but now they are almost non existent. Likewise schizophrenic disorders among Asian people have much better prognosis than their western counterparts.

Now at last I come to the group of people who have mental illness and are wandering on roads. Most of them have schizophrenic illnesses. Some of them also have other psychiatric ailments, mostly bipolar disorders, but then they are also amenable to modern treatments.

Among wandering people with mental illnesses are mostly those who wandered away from home and some of them are those who have been abandoned.

Ironically the problem is most pronounced in two countries. One where the poverty is the least i.e. USA and the other where the poverty is maximum, i.e. India. In USA they are visible because they were not there on the roads before deinstitutionalization and in India they are invisible because they have always been a part of the Indian landscape. Even if their symptoms are manifest, people are habituated to see them and do not pay any heed to them. In USA for such people there are many government sponsored social welfare schemes. They devised community treatment which was called Madison model and it proved hugely successful. In UK county councils are responsible for their shelter, treatment and rehabilitation.

In our country too, people are working in this field but they are very few and far apart. The only exception is Kerala, which has rightly been said God’s own country. There are about more than 50 centres which provide shelter to wandering people with mental illness. These are run purely on benevolence of charity minded people. Many such people are taken in by families, a phenomenon inconceivable in other parts of the country.

At this point of time when emphasis is being given on the treatment in community setting and in least restrictive atmosphere, I too would not recommend old fashioned mental hospitals. Rather I think there should be small shelter-cum-rehab centres in towns which have population of around ten lakh. There should be adequate number of trained psychiatric attendants, occupational therapists and trained psychiatric nurses and one or two medical officers. I think such centres can be run even without a full time psychiatrist. Even a part time psychiatrist will be sufficient, who can guide and train medical officers. And I don’t think such centres would become custodial homes for chronic patients. Most of them will respond to treatment and we would be able to reunite them with their families. And those who do not have families or those whose families are unwilling to take them back, they can be involved in various occupations. I am so definite about what I am saying because I have seen this happen in ‘Ashadham’, a shelter home run by nuns who provide refuge to orphan children, elderly homeless people and homeless people with mental illness. I have had the opportunity of working with them closely for the last three –four years.

The task of placement of such people is not as easy as it appears. As back as in 1997 our respected colleague Dr. R. Srinivas Murthy asserted in his address given in Delhi at IHBAS that “Placement for destitute mentally unwell is human right of such people.” 13 years have passed but nothing has been done so far.

Multi -pronged efforts would be needed. We can not fully depend on the government. Neither can we shoulder the entire responsibility. We have to sensitize the government to support efforts done by individuals in this direction. We have to conduct workshops to sensitize police personnel, social clubs and lay people. Even we have to effectively convey the ground level reality to mental health activist. There are nearly 2000 beds available in the mental hospitals, while at a modest estimate the total bed requirement would be 900,000 at any given time. But Sheela Barse would not like them to live in jails and Amita Dhanda would not even like them to live in mental hospitals. And they would not give any alternative as to where they should go, if they do not have families to get reunited to.

So ultimately the buck stops at our door step. We have to take initiatives. We should pressurize the government through revised Mental Health Act and ensure that shelter-cum-rehab centres are built across the country.

Dr. Bansi Suwalka
Ex.Associate Prof. and Head
M.P.Shah Medical College, Jamnagar

Samvedna Mental Health Facilities
Summair Club Road
Jamnagar 361005
(Gujarat)
Phone: Cell: 09824212496 ; 0288 2554565

Dr.L.P.Shah Oration 2010: Introspection of a Psychiatrist - Dreams Realized: Dr. K P. Dave

Good Morning.

Respected President of the IPS – West Zonal Branch, Dr. Suwalka; Dr. Vankar and the entire Executive Committee; and the Chairpersons. Let me take this opportunity to thank all of you for being here today morning. Let me also thank the IPS –West Zonal Branch for awarding the prestigious Dr. L P. Shah Oration for the year 2010 to me.

I have been in the field of Psychiatry since the last 4 decades and have been witness to tremendous changes in the field. These changes have always made me wonder about the art and science of Psychiatry. Hence I have decided to call my speech “INTROSPECTION OF A PSYCHIATRIST - DREAMS REALIZED”.

The history of Psychiatry in Mumbai is a chronicle of individual endeavor. Stalwarts like Dr. N S. Vahia, Dr. V N. Bagadia and Dr. L P. Shah started and set up comprehensive services in the city in public hospitals. The Department of Psychiatry in KEM Hospital bears testimony to the same. These great teachers have been responsible for encouraging and nurturing the skills and talent of dynamic psychiatrists not only in Mumbai, but also the whole of India. I remember Dr. V N. Bagadia telling me, after I had finished MD, “Keep your expenses low and charge reasonably from your patients, and you will do well.” This has always motivated me in my practice. I have learnt not to be fussy about my fees and I take whatever my patients give me.

Over the years, I have seen many Departments coming up. I have also seen numbers of Psychiatrists being trained in them and going into full time academics or private practice, here and abroad. Most of the Departments, now, are very ably run by women, in all academic posts – Assistant Professors to Professors and Heads of Departments. In my opinion, they have been excellent in their leadership.

In the field of private practice, too, there have been individuals who have done good work and have been advocates of their specialized work. In addition to General Psychiatry, now we have specialized setups viz. Deaddiction Centers, Learning Disability Clinics, Autism Services and Geriatric Clinics available in our Institutes. In spite of these services being available, there are many lacunae in the care being provided to the Mentally Ill. We do not have enough Rehabilitation Centers and Day Care Centers in our city. The ones that are present are not easily accessible or affordable.

The teaching of Psychiatry in the Undergraduate level is limited to a few lectures in the curriculum and a couple of weeks posting in the Departments. It is insufficient to inculcate or develop an interest in the field. Hence we have very few undergraduates who take up Psychiatry as a Post graduate Specialty.

After finishing post graduation, most students enter into private practice since few full time academic positions are available in the institutes. Setting up a private practice is a difficult option in a metropolitan city like Mumbai. There is, already, a large number of practicing psychiatrists to contend with. There is cut throat competition too. There is also the presence of consultants of other specialties, those who merrily eat away into the practice of the General Psychiatrist.

If setting up a Clinic based practice is not difficult enough, then setting up a Nursing Home practice is extremely tough. The high cost of property and maintenance, and labor issues notwithstanding, there are the special provisions of the National Mental Health Act to contend with. Satisfying the terms and conditions laid down by the law, especially the ratio of trained professionals to patients, is extremely difficult, if not impossible.

The attitude of general public towards psychiatric problems, in general, and psychiatric nursing homes, in particular, doesn’t seem to be favorable. I started a Rehabilitation service along with residential facilities, a few years ago, in a suburb in Mumbai in a residential area. The place belonged to a dear friend of mine, who, after his death, had wanted his place to be utilized for the good of the mentally ill. I had started this service in accordance with the wishes of my friend, only to counter the hostility and the unfavorable attitude of the residents in that locality. They complained to the authorities, and after a legal battle I had to relocate these services elsewhere.

As for General Psychiatric patients, we also need to have good inpatient or residential services for those suffering from Dementia. A trend, nowadays, is to start practice in a group. A group of like-minded individuals come together and start various kinds of services – inpatient or rehabilitation and daycare. The foremost example that comes to mind is the endeavor of young psychiatrists like Dr. Vishal Sawant, Dr. Prasanna Tendolkar, Dr. Karthik Rao and Dr. Malik Merchant. These dynamic psychiatrists have pooled together resources to start inpatient services on the outskirts of Mumbai. We need to have another look at the provisions and implementation of the National Mental Health Act.

There have been a number of incidents that highlight unethical practices and abuse of the rights of the Mentally Ill. A study in 1999 showed that the rights of the mentally ill were blatantly disregarded in many mental asylums of our country. Thus we need to be extremely alert so that such incidents are not repeated.

These were some of my thoughts that I felt should be put across to you. Thank you for your kind attention.

Dr.K.P.Dave

Consultant Psychiatrist in Private Practice since 4 decades.

Retired Honorary Professor & Head, Department of Psychiatry, L T M Medical College & Hospital, Sion, Mumbai. (2001)

Professor of Psychiatry, K J Somaiya Medical College & Hospital, Sion, Mumbai.

Past Secretary & President of Bombay Psychiatric Society