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Year : 2018  |  Volume : 60  |  Issue : 6  |  Page : 258-263
General hospital psychiatry in India: History, scope, and future


Department of Psychiatry, All India Institute of Medical Sciences, New Delhi, India

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Date of Web Publication5-Feb-2018
 

   Abstract 


Background: General hospital psychiatry units (GHPUs) are the major providers of mental health services in India. Unlike in high-income countries, GHPUs in India are also the main training centers for providing postgraduate training in psychiatry and allied disciplines. Aim: This paper traces the history of the GHPUs in India from beginning to the present. Material and Methods: PubMed, old issues of the Indian Journal of Psychiatry and related sources were searched with key words general hospital and psychiatry both electronically and manually to look for the related literature. Results: The history of the development of GHPUs is discussed under 3 phases: beginning to the preindependence period, independence to the year of the launch of the National Mental Health Programme of India, and afterward. Contributions of the GHPUs towards service development, teaching, research, community awareness and reducing stigma, and their future scope are discussed. Conclusion: GHPUs have been a revolutionary development in India with great contribution in the field of mental heath

Keywords: General hospital, GHPU, history, India, psychiatry

How to cite this article:
Chadda RK, Sood M. General hospital psychiatry in India: History, scope, and future. Indian J Psychiatry 2018;60, Suppl S1:258-63

How to cite this URL:
Chadda RK, Sood M. General hospital psychiatry in India: History, scope, and future. Indian J Psychiatry [serial online] 2018 [cited 2021 Apr 19];60, Suppl S1:258-63. Available from: https://www.indianjpsychiatry.org/text.asp?2018/60/6/258/224662





   Introduction Top


Historically, psychiatric services were usually available only from the confines of the mental hospital. During the latter half of the twentieth century, general hospital psychiatry gradually became the main source of mental health services, especially in South Asia. Currently, psychiatric services in India are available in a wide variety of settings including general hospital psychiatric units (GHPUs), psychiatric hospitals, psychiatric nursing homes, polyclinics, and office-based practices.[1] The term “general hospital psychiatry” refers to the existence of psychiatric services as one of the various specialty services being provided by a general hospital. A GHPU is the psychiatric wing in a general hospital or medical school [2] and embodies the idea of integration of mental and physical health care, a concept included as one of the objectives of the National Mental Health Programme (NMHP) of India.[3] Since its humble beginning as an outpatient facility in Kolkata by Dr. Girindra Sekhar Bose on May 1, 1933,[4] GHPUs have come a long way and firmly established as the main resource for mental health care, training, and research in the country.

In the present article, we trace the history of the GHPUs from beginning to the present and examine their achievements, current status, and future scope.


   Materials and Methods Top


We searched on PubMed using the search terms “general hospital psychiatry” and “India.” In addition, the Indian Journal of Psychiatry and its supplements were searched, both electronically and manually, to identify relevant papers on the history of general hospital psychiatry. We also went through the websites of various medical colleges of India to get historical information about the general hospital psychiatry in the respective institutions. Some information was also collected informally from colleagues.


   Results Top


The first GHPU was started in India in 1933 as a result of Western influence, a part of the mental hygiene movement and follow-up to the first liaison psychiatric service at Albany Hospital, New York.[5] Around the same time, an editorial in The Times of India also emphasized the need for psychiatric services outside the mental hospitals (The Times of India, April 1, 1931). A few more units were opened in different parts of the country in subsequent years. However, the postindependence expansion and proliferation of GHPUs occurred because of features specific to India, discussed in subsequent sections.

We can divide the history of GHPUs into three distinct eras: preindependence before 1947, postindependence to 1982 (the year of the launch of the NMHP of India), and post-1982.

Before 1947

As stated earlier, Dr. GS Bose established the first GHPU in Kolkata in 1933 under the aegis of the Calcutta chapter of the Indian Association for Mental Hygiene at the then Carmichael Medical College (now known as RG Kar Medical College). Interestingly, the college provided only a room and some furnishings, and the rest of money came from the association and Dr. Bose. Most of the staff worked on an honorary basis and the clinic functioned for 2 hours, twice weekly. In the 1st year, 174 patients visited the facility.[4] After a few years, in 1938, Dr. KK Masani started psychiatric services at JJ Hospital.[6] This was followed by a once-a-week psychiatry clinic in in the Outpatient Department (OPD) of Patna Medical College Hospital in 1939, under the guidance of Dr. Ghoshal,[7] and another service by Dr. N S Vahia at KEM Hospital [8] in the 1940s in Mumbai. Patna Medical College also has the honor of having Professor LP Varma as its first MD psychiatry student in 1941.

A parallel movement was taking place in the Army Medical Corps with general hospital psychiatry starting in the military hospitals. During World War II, the number of psychiatrists was increased from 4 in 1939 to 86 in 1945. The psychiatrists manned psychiatric units in operational and peace hospitals and delivered services along the same lines as the GHPUs. This increase in numbers was achieved by an in-service short-term training of the medical officers in psychiatry.[9] After World War II, the military psychiatrists spearheaded the task of establishing psychiatric services in India. They went back to their respective places and started psychiatric services in three ways: working in mental hospitals, private practice, and opening GHPUs. Col. Kirpal Singh [10] led psychiatric services along the lines of the GHPU model in the armed forces and Lt., Col. Dhunjibhoy [7] was instrumental in opening a psychiatry OPD and ward at the Patna Medical College. Some of the prominent military psychiatrists who started to work at mental hospitals were Major RB Davis [11] at the European Mental Hospital in Ranchi, Lt. Col. Dhunjibhoy [7] at the Ranchi Indian Mental Hospital, Lt. Col. Banarasi Das [12] in Agra, and Major Vidya Sagar [13] at Amritsar Mental Hospital. Major Vidya Sagar introduced the concept of involving family members in the care of the mentally ill at the Amritsar Mental Hospital. Col. Parasuram [14] started a psychiatric practice at Palakkad in Kerala in 1945, which became a model for starting psychiatric services in general hospitals. Many of these psychiatrists also completed their postgraduation from the USA or the UK. At the time of independence, there were four GHPUs and psychiatric centers in the armed forces.

From 1947 to 1982

Soon after independence, the Bhore Committee (Health Survey and Development Committee) emphasized the need for training in the social aspects of medicine to boost India's meagre mental health resources. Mental health resources at the time of independence comprised of 19 mental hospitals with 10,181 beds and a few GHPUs. The Bhore Committee recommended that psychiatry departments be set up in every general hospital to review and enhance the existing curriculum and training in psychiatry for medical students.[15] In 1955, the first postgraduate courses in mental health – in the form of Diploma in Psychological Medicine (DPM) and Diploma in Medical Psychology courses – were started at the All India Institute of Mental Health (later National Institute of Mental Health and Neuro Sciences [NIMHANS]), Bengaluru.[16] From the beginning, the postgraduate training in psychiatry at NIMHANS (under the guidance of Dr. Govindaswamy, who had worked closely with Dr. W Mayer Gross)[17] included some exposure to neurology, neurosurgery, psychological testing, social psychiatry, laboratory services, pathology, community medicine, and preventive efforts and rehabilitative services. This led to an increase in the number of psychiatrists and clinical psychologists in the country. By this time, electroconvulsive therapy (ECT) and psychotropics such as chlorpromazine and imipramine had been introduced into the country, which helped in the treatment of patients with mental disorders, who could now be treated even on an outpatient basis. With improved training and a definite improvement in the condition of patients, thanks to the use of psychotropics, this fresh crop of psychiatrists could establish themselves in medicine departments in the medical colleges and mental hospitals of the time and later went on to open psychiatric departments in newly opening medical colleges.

At the All India Institute of Medical Sciences (AIIMS), New Delhi, Dr. Luvia Taylor Gregg, an American, was appointed honorary consultant in psychiatry around 1956 when the MBBS course started. Dr. Gregg was instrumental in designing an undergraduate curriculum in psychiatry of about 80–100 hours, which was integrated with medicine. At AIIMS, the exposure to psychiatry was spread throughout the 3 years of the clinical posting. In 1962, first regular MD psychiatry programme was started in India at AIIMS, New Delhi. Community psychiatric services were also started by AIIMS through the Indian Council of Medical Research-funded mental health project at the Comprehensive Rural Health Services Project, Ballabhgarh.[19] The service has continued till date, and currently the service arrangements include one senior resident and one junior resident providing daily psychiatry outpatient services. At AIIMS, a psychiatry ward and OPD were opened in the main hospital building, along with other departments. Around the same time, Dr. Dutta Ray [20] started a psychiatric outpatient service at Irwin Hospital (now GB Pant Hospital), New Delhi in 1957. Dr. NN Wig started a GHPU at the King George Medical College, Lucknow in 1958 and later in 1963 at the Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh.[21] In 1958, Dr. JS Neki [19] started a Psychiatry Department at the Amritsar Medical College, and later in 1965, he started the Department of Psychiatry at the Medical College, Rohtak, in Haryana (then Punjab).

A similar movement was taking place in other parts of the country. Dr. Florence Nichols,[22] a Canadian psychiatrist, started the Mental Health Centre at the Christian Medical College, Vellore. Psychiatric services were also started at the Madurai Medical College [23] in 1957, with Dr. VS Ramachandran as its first Tutor and Assistant Surgeon. The department had 2–4 psychiatric inpatient beds scattered across the medical wards, apart from regular outpatient services. Dr. A Venkoba Rao was appointed Professor of Psychiatry in 1962. Dr. NC Surya started the Psychiatry Department in JIPMER, Pondicherry in 1961.[24] In Odisha, a psychiatry wing was opened in the Department of Medicine of the SCB Medical College Hospital, Cuttack in 1961.[25] In 1967, the first GHPU in Kerala was opened in Kottayam.[26] The period between late 1960s and 1970s saw the opening of GHPUs in various medical colleges in Ahmedabad, Surat, Baroda,[27] Jaipur, Patiala, Pune, and many other places. In the three decades after independence, about 90 GHPUs were functional in India.[28] Some of them, like in Bhavnagar in Gujarat, had psychiatric services manned by a visiting psychiatrist from a mental hospital once a week or fortnight.[27] The Department of Psychiatry in Gauhati Medical College was established in 1974[29] and at Dibrugarh in 1976.[30]

The psychiatric services in general hospitals were initially started under the department of medicine. Gradually, separate psychiatry departments were established in general hospitals. Special clinics were also started in GHPUs to provide better services to specific populations. Dr. Masani started the child guidance clinic in Mumbai in 1952,[6] probably the first in the country. Various other clinics – such as lithium clinic, modecate (depot) clinic, de-addiction clinic, and schizophrenia clinic – were also started in various places. GHPUs contributed significantly to postgraduate training, as after the 1960s, postgraduate training programs in psychiatry were started predominantly in the GHPUs. Many of the psychiatrists trained in the GHPUs opened up new departments of psychiatry in various medical colleges in the country.

In 1978, Dr. Wig, in an editorial, wrote that “with the coming of general GHPUs, psychiatry has come of age in India.”[2] In 1982, in the summary of the NMHP, it was reported that of the 108 medical schools, only half had academic departments of psychiatry, and there were two dozen centers for postgraduate training in psychiatry with a total output of one hundred psychiatrists per year.[3],[31]

In the 1970s and 1980s, GHPUs were also started in the general hospitals opened by public sector establishments such as Indian Railways and the Steel Authority of India for their employees. Many general hospitals in the private sector also started psychiatric outpatient services, with a very limited inpatient facility restricted to an as-needed basis.

Post-1982

The number of GHPUs continued to increase with the Medical Council of India (MCI) making it mandatory that medical colleges have departments of psychiatry. In 1996, under the aegis of the NMHP, the District Mental Health Programme (DMHP) was launched in 4 districts and was later expanded to 27 districts across the country by the end of the 9th 5-year plan period (1997–2002). At present, the DMHP is implemented in >200 districts. The DMHP brought with it the posting of psychiatrists to district hospitals, thus ensuring the availability of psychiatric services, which were earlier available only at the level of tertiary care, also at the level of secondary care.

In the recent past, there has been an increase in the mental health budget in the 5-year plans of the Government of India (especially since the 10th plan onward), with a focus also on upgrading the psychiatric wings of government medical colleges. Under the re-strategized NMHP of 2003, the psychiatry wings of government medical colleges and general hospitals in 88 medical colleges have been upgraded, thanks to a one-time grant of Rs. 50 lakh during the plan period of the 10th and 11th 5-year plans. These upgrades were primarily of infrastructure and equipment, with an aim to strengthen the training facilities for undergraduate and postgraduate students.[3],[19]

Scope of the general hospital psychiatric units

GHPUs have been involved in multiple roles including clinical care, teaching, community outreach services, and research. This section discusses the scope of the GHPUs in their various areas of functioning.

In India, fully functional GHPUs with both outpatient as well as inpatient setups exist mainly in the medical schools. GHPUs in the private sector generally provide only outpatient services, with skeletal inpatient services. GHPUs in tertiary care settings exist in medical schools, super-specialty and multi-specialty hospitals, and hospitals attached to various public sector organizations such as the railways, public sector undertakings (PSUs), and the armed forces. Most of the GHPUs at the district hospital level are manned by a psychiatrist and a nurse (generally not trained in psychiatric nursing). However, GHPUs in medical colleges, PSUs, and armed forces have more staff: consultants, junior doctors, a psychiatric social worker, a nurse, and possibly a clinical psychologist can often be found at these.

GHPUs play a significant role in the provision of comprehensive mental health services in the form of clinical care, training, research, and realizing the aims of the NMHP, that is, the integration of mental health with physical health.

Clinical services

GHPUs are the main resource for mental health care in India, unlike in the west, where GHPUs are a part of the mental health services network; for example, in the west, if a patient becomes acutely disturbed while admitted to a general hospital, he/she is quickly evacuated to the nearest mental hospital. This is in contrast to India, where most acutely disturbed patients are managed in GHPUs. These patients are not referred to the mental hospitals and are provided with comprehensive care (including emergency care, hospitalization, and long-term follow-ups) in the general hospital itself. GHPUs are mostly publicly funded facilities, and patients are hospitalized in open wards for a short duration either for free or at very low cost (10–25 rupees/day).[1] The services they provide include food, essential medicines, beds, bed linens, and basic recreation facilities. Patients are admitted to the GHPUs along with a family member, who also takes care of the day-to-day needs of the patient. Professional care is provided by the doctors and nurses. Some GHPUs also have specialty clinics for child psychiatry, bipolar or mood disorders, lithium, schizophrenia, deaddiction, and many others.[1]

Earlier, it was often believed that a majority of the patients visiting GHPUs suffered from psychiatric illnesses of milder severity [2] as these centers were located in general hospitals. Several studies over the last few decades have reported that the clinical profile of the patients visiting GHPU includes all types of psychiatric disorders: severe mental illnesses, common mental disorders, substance use, psychosexual disorders, and childhood psychiatric disorders.[32],[33],[34],[35],[36],[37] GHPUs, being part of general hospitals, also offer consultation liaison psychiatric services and emergency services. An almost comparable number of patients are seen at GHPUs and psychiatric hospitals – the number of new adult psychiatry cases seen during 2013-2014 at AIIMS, New Delhi (15097)[38] was comparable to that at NIMHANS, Bengaluru (12915).[39]

Teaching

GHPUs in medical colleges serve as the main centers for teaching and training in psychiatry for undergraduates and postgraduates. The MCI recommends that every medical college should have a department of psychiatry. The department should have a minimum of three faculty members and should have outpatient facilities, inpatient facilities with 30 beds, and provisions for various forms of treatment including ECT. Ideally, a clinical psychologist, a psychiatric social worker, and psychiatric nurses should also be available.[40]

For undergraduate teaching, the MCI recommends 2 weeks of clinical posting and 20 hours of theory lectures in psychiatry during the student's 5th semester. There is also a short question in the medicine paper to assess knowledge of psychiatry.[40] Approximately one-third of the medical colleges in India do not have adequate psychiatric services,[41] and the resources and the standards of various services in GHPUs vary widely. Training in psychiatry for medical undergraduates at AIIMS, New Delhi, is significantly different from that recommended by the MCI in terms of time spent in clinical training (4.5 times), keeping a compulsory logbook, the involvement of the psychiatry faculty in teaching, internal assessment, evaluation at the time of MBBS final examination, and integration of training in psychiatry with community medicine.[15]

GHPUs have shown a tremendous potential for growth as facilities for postgraduate training in psychiatry. In the early 1960s, postgraduate courses existed in only three institutions; two of these were psychiatric hospitals (DPM started in 1955 at NIMHANS, Bengaluru,[16] and in 1962 at CIP, Ranchi [42]) and one was a GHPU (MD psychiatry started AIIMS, New Delhi in 1962[19]). However, by 1984, there were about 25 such postgraduate training centers, and all the new postgraduate centers were started in GHPUs.[43] In recent times, GHPUs in medical colleges have contributed significantly to increase in the numbers of qualified psychiatrists in the country. Currently, in 176 medical colleges, 451 MD psychiatry seats exist, and in 59 medical colleges, 135 seats for DPM are offered.[44] However, there are wide variances in training standards across various centers. Some of the GHPUs – such as those at AIIMS, New Delhi; PGIMER, Chandigarh; and KGMU, Lucknow – have recently started DM programs in addiction psychiatry, child psychiatry, and geriatric psychiatry.

Research

GHPUs have also made significant contributions to psychiatric research in India. In addition to research in mental health, psychiatrists at GHPUs have an opportunity to conduct interdisciplinary research with other clinical and basic science departments. There are many more publications from GHPUs than there are from mental hospitals.[21] Authors have reported that about two-thirds of publications in the Indian Journal of Psychiatry during the period of 1989–2013 were from GHPUs. Most of the papers were multiauthored.[45] About one-third of the papers from GHPUs were on psychoses and mood disorders similar to those from mental hospitals. Interestingly, the number of papers on neurotic disorders was greater from mental hospitals, and there were more papers on psychoses from GHPUs. This also means that the differences in the clinical profile of patients seen across different mental health settings are coming down. This finding also challenges the fact that the mental hospitals attend only to patients with severe mental illnesses. Most of the research from GHPUs was self-funded, with very few papers originating from funded research. The reason for this could be due to limited funding for mental health research from different government agencies such as the Indian Council of Medical Research, Department of Science and Technology, and others. It is also possible the researchers who get funding tend to publish their research elsewhere.

General hospital psychiatric units: What is lacking?

Achievements of the GHPUs are manifold. GHPUs have helped make psychiatry a mainstream medical field and have made the mental health services easily accessible. The advantages of services at the GHPUs are also manifold and include making psychiatric services available in the community and the involvement of family members in the care of mentally ill persons possible. They have helped reduce the stigma attached to mental illness and help seeking. Due to inter-specialty collaboration, the physical problems associated with mental illnesses and conversely psychiatric problems associated with physical illnesses are better addressed. Emergency psychiatric services have also been integrated with hospital emergency services. The GHPUs in medical schools play an important role in undergraduate teaching and postgraduate residency training and have made significant contributions in psychiatric research in the basic sciences and interdepartmental research. GHPUs have contributed significantly to an increase in trained mental health power through their training of undergraduates and postgraduates, thus helping realize the objectives of the NMHP such as the integration of mental health into general health care and promotion of community participation.

However, GHPUs in India have generally been ignored by the policy-makers. Many GHPUs lack basic infrastructure and workforce (especially for psychosocial interventions). GHPUs in India attend to a significant number of patients, but the number of beds in general hospitals (10,000; 0.8/100,000 population) is far less than in mental hospitals (17,835; 1.4/100,000 population).[46] This is understandable considering that GHPUs often have shorter admissions compared to the mental hospitals. However, until recently, the GHPUs have been neglected, and the government has not provided adequate funding for their growth. Funds allocated to GHPUs are far less than those to the mental hospitals. Furthermore, the GHPUs have minimal influence on various policy issues. Even within general hospital settings, psychiatric services are ignored and more emphasis in placed on other departments. In the recent Mental Health  Atlas More Details 2011,[46] no information is available about GHPUs except for the number of beds they provide. Thus, there is an increasing need by the mental health policy-makers to enhance the budgetary allocations to the GHPUs and to increase the workforce in the GHPUs. The NMHP of India in the last few years has provided some support to the GHPUs in this direction, but the sector is still a neglected one.

In the last decade, there has been a substantial increase in the number of GHPUs in medical colleges and district hospitals due to the increased commitment of the government under the NMHP.

A number of GHPUs have also come in the private and corporate sectors. Most of the GHPUs lack multidisciplinary teams and care is provided mainly by the psychiatrist. Due to the very limited number of clinical psychologists and psychiatric social workers and a heavy clinical load on the psychiatrists, psychosocial interventions are often overlooked. Another important missing piece is a complete lack of emphasis on public health, where both primary prevention and rehabilitation are ignored.


   Conclusion Top


In the last eight decades, GHPUs have helped bringing psychiatry out of the closet and into the mainstream and have been firmly established as the main setting for clinical care and teaching and research in mental health in the country. However, this important sector of the mental health services needs more focus and resources from the health planners so as to utilize its full potential.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.


   Commentary Top


The article describes the growth of the GHPU in India and gives a sweeping description of the journey of general hospital psychiatry from the 1930s to the present day. It is perhaps necessary to see in this journey to prominence, the counter journey toward oblivion of the mental hospital. As psychiatry has moved more determinedly toward the medical model and the focus on the acute care intervention, the emergence of the GHPU is perhaps completely understandable. What perhaps needs to be set in perspective here, especially when we are focusing on history, is the steadily diminishing spaces either within or outside of the psychiatric institution for the person with a chronic mental illness, the numbers of whom in a country like India will not be small. The authors also comment on the interesting fact that in India, unlike many other places in the world, the GHPU is not systemically connected with other institutions or services. A larger debate on this with an evaluation of the relative advantages of both models and perhaps looking at a multiplicity of models may perhaps be not out of place.



 
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Correspondence Address:
Dr. Rakesh Kumar Chadda
Department of Psychiatry, All India Institute of Medical Sciences, New Delhi - 110 029
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/psychiatry.IndianJPsychiatry_435_17

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