| Abstract|| |
Delhi hasn't always enjoyed the status of the India's capital, but it has always played a pivotal role in the history of India as a gateway city. The same way, it received mental health services much later than the rest part of country, but it has witnessed an evolution from colonial era to the birth of state of art modern psychiatry services. Journey started with the landmark inaugural meeting in Delhi University of few visionaries paving the birth of Indian psychiatry society. Subsequently, it witnessed emergence of general hospital psychiatry units & saw their transformation to apex institutes of teaching and research like AIIMS and others. It saw an exemplary worth replicating transformation of hospital for mental diseases into the state of art neuropsychiatry center, IHBAS. Delhi of today represents a microcosm of psychiatry institutes offering entire range of therapeutic, rehabilitative and academic services with equally important share in policy making at national level. This article traces the trends and developments that happened in mental health services in last six decades.
Keywords: AIIMS, Delhi mental health services, IHBAS, mental hospital
|How to cite this article:|
Jiloha R C, Kukreti P. Psychiatry in Delhi: History and current status. Indian J Psychiatry 2018;60, Suppl S1:218-23
| Introduction|| |
The year 1947 did not only witness the independence of India from the British yoke but it also saw the forging of the first link in the chain of events which began with the establishment of lunatic asylums during the rule of East India Company in the initial years and the British Raj later on. The last one in the link was the Hospital for Mental Diseases (HMD) at Shahdara in Delhi established after the independence of the country, in the year 1966.
It was on 24 August 1608 that Captain William Hawkins of East India Company dropped the anchor at the mouth of the Tapti river about 14 miles below Surat and traveled to the Mughal Court to seek formal permission to trade within its dominion.
The East India Company set up hospitals for the care of British insane soldiers in Monghyr, Madras, Bombay, and Colaba between 1795 and 1806. The need to construct these asylums was felt because many Englishmen and the Indian soldiers in the service of the company required custodial care for mental illness. The early institutions were influence by not only the prevailing beliefs of Britain during that period but also there was a close relationship between political developments and establishment of these institutions.
The East India Company set up hospitals for the care of British insane soldiers in Monghyr, Madras, Bombay and Colaba between 1795 and 1806. The need to construct these asylums was felt because many Englishmen and the Indian soldiers in the service of the company required custodial care for mental illness. The early institutions were influenced by not only the prevailing beliefs of Britain during that period but also there was a close relationship between political developments and establishment of these institutions.
After having settled comfortably at these places which were easily connected with sea, they focused their attention toward Delhi, the seat of political power and the capital of the mighty Mughal Empire. From Delhi, the whole of India lies before the would-be conqueror. Control of Delhi represented key to the Indian subcontinent. From Delhi, pressure could be exerted on the plentiful lands of Central and Western India with their access to sea.
This was made possible in the beginning of nineteenth century when General Gerard Lake of Company's army captured Delhi on September 16, 1803, reducing the Mughal Emperor to a mere pensioner of the Company. A hollow symbol of vanished power of Mughal tradition lingered as if in suspended animation for some years. This tranquil decadence was swept away in 1857 when the mutineers once again captured Delhi for the aging emperor Bahadur shah Zafar with the bloodbath of the mutiny, its horror of massacre, siege, and vengeful sack. Delhi was retaken from the rebels when the young British captain, Hudson, summarily shot two of Emperor's sons and a grandson dead. The Emperor was captured and sent to Rangoon as a “state prisoner.” The administration of Delhi was delegated to the Panjab. The capital city of a mighty empire became a district center until the foundation stone of India's new capital – New Delhi had been laid on December 15, 1911, by the King George V and the Queen Mary of England.
Prof Edward Mapother had suggested in the 1930's that New Delhi, the new seat of the Imperial government, could perhaps host a center for training psychiatrists in the future. Other visitors to New Delhi were often shown the site where the new Asylum was to be built. But because of political developments, though a major city of' India, Delhi could never receive the similar exposure to Western influence regarding educational and health-care activities as did Bombay, Madras, and Calcutta. Delhi could not have its own mental hospital during the British rule. It was much later in 1966 the HMD at Shahdara was built. Around the period of mutiny, some hospitals in the close proximity of Delhi came up which catered to the needs of Delhi population. The important ones were, at Agra built in 1858 and Bareilly in 1862.
| Birth of Indian Psychiatric Society|| |
On January 17, of 1947, a group of thirteen dedicated mental health professionals met in the city of Delhi for the first time to chalk out India's future mental health activities as a professional body. TA Munro, the adviser in Psychiatry to Indian Army (1945–1947) invited the eminent psychiatrists and other doctors interested in mental health, mostly from the army background, to constitute an association for the cause of mental health in the country. The meeting was called as an inaugural get-together which took place during the ongoing Annual Conference of Indian Science Congress held at the University of Delhi. Among those who attended this historical meeting were, RB Davis, JE Dhunjibhoy, SA Hasib, RM Lloyd Still, C Kenton, MH Shah, DJ Walterson, NN De, AS Johnson, RS Lal, HP Maiti, RJ Rosie, and ETN Tylor. MV Govindaswami and KK Masani were not personally present during the meeting but they endorsed the proceedings of the meeting later. The professional body formed was named, Indian Psychiatric Society.
Col. Dhunjibhoy was formally elected the founding president of the society, but soon after independence, he migrated to Karachi in newly carved out Pakistan. Later, he resigned as a fellow of the society on 3rd April 1950. NN De took over as president in the First Annual Conference of Indian Psychiatric Society held at Patna on January 2, 1948. Only ten delegates could attend the conference as the English Psychiatrists who were the part of the inaugural meeting had left India after the independence of the country. Col Singh and Bhatt were the new member.
Forty years later, Delhi had its own professional body at the state level conceived in the year 1987. Currently, the Delhi Psychiatric Society has around three hundred members working in the field of mental health in different positions. The society publishes its own journal.
| Emergence of General Hospital Psychiatry|| |
Unlike the presidency cities of Calcutta, Bombay, and Madras, Delhi had virtually no psychiatric services to name before independence. Grossly disturbed and unmanageable patients requiring custodial care or inpatient treatment were sent to the nearest mental hospitals located at Agra, Jaipur, Bareilly, and Amritsar, and the others were treated by the local physicians of various systems of medicine and the faith healers. Whereas Girindrashekhar Bose at Calcutta and KK Masani at Bombay had already taken the lead to establish general hospital clinics in their respective cities in the fourth decade of twentieth century, Delhi had to wait for many other cities in the neighborhood to take their turn before it could have its first general hospital clinic in the year 1957. When Dr S Dattaray was posted as “state psychiatrist” to look after the inmates lodged in a jail located near Delhi Gate where Maulana Azad Medical College stands today, he had no idea that his arrival in Delhi could pave the path for the growth of general hospital psychiatry units (GHPUs) in the city. Dattaray started the first ever GHPU at the nearby Irwin (now Loknayak) hospital once a week, in collaboration with Medicine department. When Maulana Azad Medical College came up in 1958, the jail inmates were shifted to Tihar. Dattaray was redesignated as lecturer in Psychiatry at the college where he taught undergraduate medical students. However, he continued to look after the jail inmates at Tihar. GB Hospital (now GIPMER) came into existence in 1964 where a full-fledged department of Psychiatry was created. The department is currently running postgraduate program in Psychiatry and is actively involved in training of general practitioners under National Mental Health Programme.
After independence, with the urgent need to train specialists, All India Institute of Medical Sciences (AIIMS), the country's premier medical institute established its Psychiatry department, on the arrival of Prof. D Satyanand from Central Institute of Psychiatry Ranchi in 1957. It began with its postgraduate training program in 1962. Apart from establishing a Community Outreach Program and Child Guidance Clinic in 1964, the department launched its deaddiction center in 1976 that later became the National Drug Dependence Treatment Centre (NDDTC) in 1988, the only one of its kind in the country. From 2016, the center has started postdoctoral (DM) program in addiction medicine. The centre moved to its current location at Ghaziabad in 2003. The department had taken the lead in research on epidemiology of substance abuse along with mental health morbidity.
Hoch, a Swiss psychiatrist, who worked at Lady Hardinge Medical College (LHMC) in 1966 established the Department of Psychiatry there. Same year Dr. Austin worked at Safdarjung Hospital to run outpatient department services for the psychiatric patients.
Currently, almost all big hospitals in Delhi run psychiatry services which include 13 government hospitals. There are 42 private psychiatry clinics run in the city of Delhi.
| Psychotherapy Services|| |
Girindrashekhar Bose founded Indian Psychoanalytic Society at Calcutta in 1922, independent of Freudian influence. Later on, the society got affiliated to the International Psychoanalytic Association which was propagating Freudian psychoanalysis. In due course of time, the British School of psycho-analysis had its influence when Owen Berkley Hill came as the medical superintendent of European Mental hospital at Ranch. David Satyanand, who came after Berkley Hill, had received his personal psychoanalysis from him and later came under direct influence of Melanie Klein. When Satyanand shifted to Delhi as chairman of Psychiatry department at All India Institute of Medical Sciences in 1957, he began his work with orthodox Freudian views. His work offers a unique insight into the way 20th century ideas influenced developments. He tried to analyze dreams from Freudian, Adlerian, and Jungian perspective, as well as by extending his tools of understanding mysticism. He used the concepts derived from Indian mythology and Hindu philosophy, particularly the Bhagwad Gita. His total analysis is, “analysis of content and processes of all dimensions.”
He has set forth his views in a series of publications which, on account of stylish opacity, could not become popular reading. However, he retains a multidimensionality, an elusive, hard to categorize quality that distinguishes him from other psychotherapists. Despite his prolific productivity, his influence as a psychotherapist is not visible in Delhi or India for that matter. His ideas were carried further by GG Prabhu subsequently.
Hoch, a Swiss psychiatrist, who worked in India for several decades, delved deep into the traditions and mores of its variegated culture. She worked at Lady Harding Medical College for few years and established the Department of Psychiatry there. Her psychotherapeutic methods are prominently reflected in her book Pir, Faqir, and Psychotherapist. She wrote copiously about her psychotherapeutic experiences with Delhi patients.
Social Psychiatrists like Dhairyam and George Carstairs were of the view that the model of psychotherapy which is widely accepted in Indian patients could be found in traditional concepts of relationship between the religious leader and the follower.
Accepting this concept, Neki, who took over from Satyanand as the chairman of Psychiatry at AIIMS, examined this traditional relationship as a therapeutic paradigm. With the rejection of Satyanand's model by the Delhi subjects, Neki propagated “Guru-Chela Relationship” based on the tenets of religious and cultural beliefs. The Guru (therapist) is the more active of the two parties; he has to assume the responsibility for the decision taken and the inside provided. This model received wide acceptance among patients and is still being practiced by many.
At present, depending on their training background, psychiatrists of the city practice a wide range of psychotherapy including cognitive behavior therapy.
| Postgraduate Training Program in Psychiatry|| |
Like other cities of the country, at the time of independence, Delhi had no postgraduate training program in Psychiatry. The solitary medical college which was established in the second decade of twentieth century for the women students – LHMC did not have psychiatry services at the time of independence, let alone any training program.
MD course in Psychiatry began at AIIMS after the establishment of Psychiatry department in 1962. Although the Delhi University offered postgraduate training program in many specialties in late 60s, MD Psychiatry was approved by the Medical Council of India only in 1983 at the Maulana Azad Medical College with two seats at GB Pant Hospital. Subsequently, the Delhi University started this course at LHMC and the Institute of Human Behaviour and Allied Sciences.
When Ram Manohar Lohia Hospital was elevated to a postgraduate medical institute was accorded the status of a postgraduate teaching institute, MD Psychiatry course began in affiliation with Guru Gobind Singh Indraprastha (GGSIP) University in the year 2009 with two seats every year.
Currently, under the aegis of Delhi University, GGSIP University and AIIMS, five medical colleges offer MD psychiatry course with intake of 19 students per year (8 AIIMS, 4 Institute of Human Behavior and Allied Sciences [IHBAS], 3 MAMC (GIPMER), 2 LHMC, and 2 RML Hospital) in the Delhi region.
Besides MD, Diplomate of National Board (DNB) in Psychiatry also took off in the city since 20002 starting from GIPMER. However, currently 3 hospitals, namely, Sir Ganga Ram Hospital, Base Hospital, and Vidyasagar Institute of Mental Health and Neuro Sciences (VIMHANS) are running DNB Psychiatry course with annual intake of six students.
In 2016, postdoctoral programs were approved. Apart from the DM course in deaddiction psychiatry at the NDDTC, the Sir Ganga Ram Hospital has started postdoctoral fellowship in child and adolescent psychiatry with one seat per year in each hospital.
| State Institute of Psychiatry|| |
Institute of human behavior and allied sciences
Delhi's only mental hospital which was built in the outskirts of Delhi at Shahdara in 1966 was known as the HMD. Like all other mental hospitals of that period, it had a flavor of custodial setting; persons with mental illness were housed in closed cells enclosed by the high walls of the hospital. In response to a Public Interest Litigation filed in 1983 in the Hon'ble Supreme Court, alleging serious human rights violation and prevailing deplorable conditions of the hospital, orders were issued for remodeling of the hospital as a center of treatment, training, and research in 1991. In compliance to the court directive, in 1991, the hospital was registered as a society under Society Registration Act 1860 with the name of IHBAS, which came into existence in 1993. Since then, it has seen tremendous progression and established itself as a benchmark neuropsychiatric institute.
Teaching and training
Institute was initially running DNB course in Psychiatry from 1999 to 2002 and from 2003 onward it runs MD course affiliated to the University of Delhi. It also runs MPhil Clinical Psychology course since 2004. Institute also provides training to psychiatry nursing, psychiatry and social work students., It caters to the one of the largest Psychiatry OPD of 1200–1300 patients per day. Hospital has extensive inpatient wards, including emergency psychiatry (Intensive Care Unit) and indoors. It also runs community outreach clinics.
Community Mental health
IHBAS is the resource center for implementation of District mental health program (DMHP) in North India since 1999 and currently operates at five districts of Delhi, i.e., Timarpur (North), Jahangirpuri (North-West), Chattarpur (South), Dwarka (South-West), and Moti Nagar (West). The DMHP team also visits two residential homes for homeless once a month delivering meta outreach services (reaching beyond outreach clinics).
Community outreach work for homeless mentally ill and mobile court facility
IHBAS in alliance with NGO, Ashray Adhikar Abhiyan launched community outreach service model for providing health intervention for the homeless persons in least restrictive setting. The program is running since 2000 under the District Mental Health Program DMHP. In 2008, to address the issue of providing involuntary treatment in the community for persons with serious mental illness not in a state to provide consent, a new initiative was started as a pilot experience with the aid of Delhi State Legal Services Authority. Under this service, the mobile court facility was made available at the clinic for legal facilitation of involuntary treatment of patients with severe mental illness in need of treatment.,
Mobile mental health unit
The homeless mentally ill, wandering on streets or homebound untreated patients, is a common sight but deplorable, and a sheer violation of right to health. To address this problem, IHBAS and Delhi State Health Mission, under the National Rural Health Mission, initiated a project Mobile Mental Health Unit (MMHU). The team has a mobile van and attached multidisciplinary team which plays an important role in actively identifying homeless persons with mental illness in the community and helping them engage in treatment with legal and social welfare agencies.
Mother child unit
Women with severe mental illnesses requiring hospitalization during crucial peripartum period often pose a clinical challenge. Many a times, they are referred to obstetric facilities with no mental health facility and it also often leads to separation of mother and child on the name of best interest of maternal recovery. To address this unique problem and providing mental health care to such women in a facilitatory environment where comprehensive care package for mother and child's medical as well as psychiatric needs can be provided, IHBAS envisaged the concept of mother and child unit. It is a five bed unit functional in IHBAS since 2010 where multidisciplinary mental health team provides special care to court-referred cases or patients with family member belonging to this unique section, women in advanced stages of pregnancy or with very young children– <7 years, are kept under the same roof as inpatients. Mother and child are provided with trained hospital attendants to ensure safety and security and aid mother to take care of children.
Quality assurance in mental health
Striving for quality assurance in mental healthcare, IHBAS has become the first government-run specialized neuropsychiatry center to receive National Accreditation Board for Hospitals and Health Care Providers accreditation. As per the excerpts from NHRC report of 1999, IHBAS has been a model worth replicating for transformation of a mental hospital into state of the art premier neuropsychiatric institute. As per report of special rapporteur of national human rights commission 2010, “IHBAS has fulfilled an important mandate given by the Supreme Court of achieving balanced combination of teaching, training, treatment, and research.,,
Delhi has taken lead in various other areas of mental health. Private Psychiatry has emerged in a big way during the last 2–3 decades and has shown a phenomenal growth in terms of human-power and infrastructure development. There is the Delhi Chapter of national professional body of private psychiatrist which works for promoting the positive mental health. VIMHANS is exclusively devoted to the cause of mental health. Delhi has provided leadership in creating awareness among masses about mental health and removing stigma of mental illness through mass media. Avdesh Sharma's pioneering work is laudable. Emergency interventions such as “Suicide Prevention Help-line” are actively at work.
| Conclusion|| |
The recent developments of psychiatric care in Delhi seem initially to be part of a jigsaw puzzle. But, despite being a late entrant in the arena of mental health care, Delhi experimented with all the models of psychiatric thinking as reflected in the latter half of the 20th century. Psychiatry services in Delhi saw an upsurge of general hospitals, medical colleges and modernization of neuropsychiatry institute of state (IHBAS). It established exemplary models of community care, rehabilitation, addiction services, and child guidance. This rich array of facilities, complemented by a large number of services in the private sector is likely to translate into better-coordinated services for the mentally ill. Perhaps, a historical analysis of these services needed in Delhi and across India will be needed to set forth a visionary map of higher standards of mental health care in India.
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Conflicts of interest
There are no conflicts of interest.
| Commentary|| |
The recent developments of psychiatric care in Delhi seem to be part of a jigsaw puzzle. Prof Edward Mapother had suggested in the 1930's that New Delhi, the new seat of the Imperial government, could perhaps host a center for training psychiatrists in the future. Other visitors to New Delhi were often shown the site where the new Asylum was to be built. After independence, with the urgent need to train specialists, the AIIMS was newly established, while the AIIMH in Bangalore relied on an older mental hospital. Delhi thus experimented with all the models of psychiatric thinking that exemplified the latter half of the 20th century. Psychiatry in Delhi, as this article points out, grew out the general hospitals and medical colleges. It thus inherently had a closer link to developments in community care, social models, addiction services, and child guidance. The Mental Hospital at Shahdara was left out of the services being developed by the medical colleges and the University for almost three decades. The medical colleges, general hospitals, and the Mental Hospital (now called IBHAS), each of which is making significant contributions, offer a welter of services. Whether this rich array of facilities, complemented by a large number of services in the private sector, translates into better-coordinated services for the mentally ill is still a matter of debate, as the reports quoted in the article point out. This scenario is often repeated all over India and is part of our contemporary life. Perhaps, a historical analysis of these needs to be considered, in the future!
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Dr. R C Jiloha
Department of Psychiatry and Rehabilitation Sciences, Hamdard Institute of Medical Sciences and Research, Jamia Hamdard, New Delhi
Source of Support: None, Conflict of Interest: None