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PROF. J.K. TRIVEDI LIFETIME ACHIEVEMENT AWARD
|Year : 2020
: 62 | Issue : 6 | Page
|Psychiatric practice: Some personal observations
Anil Kumar Agarwal
Retired Professor, Department of Psychiatry, K. G's. Medical College, Lucknow, Uttar Pradesh, India
Click here for correspondence address and
|Date of Submission||23-Mar-2020|
|Date of Decision||30-Apr-2020|
|Date of Acceptance||17-Apr-2020|
|Date of Web Publication||12-Dec-2020|
|How to cite this article:|
Agarwal AK. Psychiatric practice: Some personal observations. Indian J Psychiatry 2020;62:644-9
I am grateful to the Indian Psychiatric Society (IPS) for bestowing this honor. I am primarily a clinician who had been practicing psychiatry both in government institutions as well as in a private psychiatric clinic for nearly half a century. The clinicians in government hospitals are usually overworked due to a large number of patients. The patients and families sometimes feel that they are not getting the kind of attention they deserve. A large number of patients avoid going to government hospitals as they feel that the services may not be up to the mark. The private practitioners are often considered to be greedy and their intentions are considered doubtful. These apprehensions are some of the reasons that induce negative expectations in the patients. We need to neutralize these negative perceptions for developing a trustful relationship. This presentation will reflect some of my personal observations and beliefs. This is an I-centric presentation which is not a normal practice in medical science. I am doing it intentionally to drive home certain personal observations that may not be duplicable but may raise certain questions.
I start this oration by paying homage to Dr. J.K Trivedi who was a dear colleague and an outstanding researcher. He worked with me as deputy editor of the Indian Journal of Psychiatry and later became the editor and president of our society IPS. He was called to his heavenly abode quite early in life. I feel pained to deliver this oration for my own student.
I also wish to pay homage to Prof. N.C. Surya who was my teacher and he had influenced my thinking to a large extent. He emphasized that one should learn to look at each phenomenon in its social and cultural context. Every observation should be recorded in plain language so that others should be able to make their own conclusions. No symptom should be ignored but should be clearly recorded so that its importance could be evaluated later.
Another great Indian psychiatrist whom I wish to pay my gratitude is late Dr. Vidya Sagar who created a new pattern of doctor–patient relationship. He said that patients are “atithi.” Atithi is a Hindi word that means without date. He felt that patients can come without any prior appointment. His doors were always open for patients. Although most of us cannot practice like him, we can imbibe some of his philosophy. We should be able to convey two messages to patients and their families: you are welcome and we care.
| Psychiatric Practice in India|| |
The fundamental concern of mental health care in India is the gap between demand and services. There are nearly five thousand psychiatrists for a population of 135 million. Mental health nurse/social workers and clinical psychologists are even lesser. The available workforce is concentrated in urban areas, and there may be no mental health facility for a large geographic area. This results in a huge workload for psychiatrists and is difficult for patients who may have to travel long distances to reach such centers. Poverty, poor awareness, and stigma are other factors that affect clinical practice [Table 1]. The national mental health survey very clearly reflects the gap between service and demand. The gap in demand and services ranges from 28% to 83% for mental disorders and 86% for alcohol use disorders.
Stigma and prejudice effect treatment approach to psychiatric disorders in India. Mental illnesses are still believed to be because of one's bad deeds, the curse of god, and due to circumstances prevailing in the society. A large number of people still avoid seeking treatment as they feel that they can overcome mental illnesses by personal efforts or by avoiding adverse life circumstances. Two most stigmatizing diseases in India were leprosy and tuberculosis. The stigma in both has almost disappeared as their etiology and treatment have been found. The stigma of mental illness has also decreased remarkably. Patients are openly accepting their illnesses in media and press. Most of these are patients of depression which has effective treatment. Stigma of other mental disorders will also reduce once better treatment options are available. The biggest fear of the mentally ill is that they may not get a job or may not get married due to mental illness. Some of us are perpetuating the stigma by advising the patients to hide their illness in these situations. I firmly believe that disclosure of illness will make patients more self-assertive and their functioning will improve. We should encourage patients and families to reveal the illness to other persons who are significant in their lives. This will empower the patients and families.
| Multiple Treatment Methods|| |
We have multiple methods of treatments for all illnesses which are accepted by people as well as the state. To cite a few: Allopathy, Ayurveda, Unani, Yoga, Chinese acupuncture, and many others. Each method proclaims its superiority as well as the safety profile. Allopathy is said to be most effective but most toxic. Every patient who accepts allopathic treatment is always trying to shift to a safer method like Ayurveda, Unani, or Yoga. This leads to repeated treatment stoppages and recurrences. The difficulties are further complicated when some of us start praising these systems on popular platforms. I do not want to sound dogmatic but being students of science, I believe that every effective treatment should undergo trials before its efficacy is endorsed. We are open to every treatment provided that its effectivity has been produced by trials done at different centers. Till such times such evidence is available we as individuals or as a group should not increase the confusion further by recommending them in a day-to-day treatment or on the public platform. Our stand should be clear that as of today, there is no evidence to prove that most of the Ayurvedic, Unani, and Yogic treatments have any specific effectiveness in mental disorders. Even in conditions such as anxiety disorders and stress disorders, the efficacy of Yoga has not been proved beyond doubt. I would like to state that we may recommend Yoga for healthy people or sick individuals for the betterment of general health and not as a treatment. We are open to accept any treatment that has been proven effective by a scientific method. The premier institute National Institute of Mental Health and Neurosciences, Bengaluru has Ayurvedic research centers, and much work is also being done on Yoga. We are open to use these treatments only when research has proven their efficacy. A clear approach to these issues will improve treatment continuance.
Public view of psychiatrists
The medical community is generally looked at negatively by the general population, and the psychiatrists are even lower in this hierarchy. The psychiatrists are often confused with psychologists or counselors. We need to follow the medical model of psychiatric illnesses and focus on our identity as medical men with special knowledge of psychological processes. The press, Time and Again, continues focusing on various acts of omission and commission by medical men. The medical community should be careful that such allegations are not endorsed by their actions. A Sanskrit Shloka states that doctors are worse than Yama (the god of death), as the later takes away only life, while the former takes away both life and money. The doctors were viewed negatively even in the past. The uncertainty of outcomes leads to such views and we should accept such criticism with humility.
Psychiatric practice in India has been studied by various investigators over the years. Earlier publications revealed that the patients coming to government hospital and private psychiatric clinics were different. Affective disorders were more in private clinics and psychotic disorders were more in government hospitals. Recent reports, show that the prevalence of affective disorders is 40%, schizophrenia is 20%, and obsessive-compulsive disorder (OCD) is around 8% in private psychiatric clinics. Males seek treatment more often than females. This appears to be largely due to economic reasons as the bread earner gets the medical treatment preferentially. High dropout rates had been a common theme in most of the investigations.,,, Dropout rates of around 50% have been reported by different investigators. The dropout rates were dependent on the severity of illness. Minor illnesses had a much higher drop out than severe illnesses. This author compared the dropout rates in his own clinic after a gap of around 20 years [Table 1].
The dropout rates have improved in both the conditions. Among depressives, the continuation rate was 47%, while for schizophrenia, it was 62%. The patients are usually given the next appointment after 1 month. The depressives are more likely to get better in 2 months; therefore, they discontinue treatment. The patients of schizophrenia take long to improve. This explains differential dropout rates in these illnesses. The improvement in the dropout rate over the years could be due to multiple factors, such as more awareness of the disease, lesser stigma, and changes in practice style. The patients in my clinic are now given a fixed appointment for the next visit, and this simple step has brought tremendous change. If we could send reminders for missing appointments, this would further improve.
Every patient who turned up long after their due appointment was asked the reasons for a delayed revisit. Usual responses were the patients were better and they discontinued treatment. The patient did not take medicine, and we did not know what to do. There was health or economic mishap due to which they did not come back. Those patients who did not come back could not be asked this question. In conclusion, dropout should not be taken as treatment failure but could be due to multiple reasons.
Indian psychiatry had been struggling for its identity since the beginning. Many felt that Indian psychiatrists are still a poor copy of Western psychiatrists. Mainly, clinicians working in academic setups used the treatment guidelines; others did not find them useful. Clinicians preferred guidelines that are concise and point wise. Medical prescriptions, use of electroconvulsive therapy (ECT), and psychological methods have been studied.,,,
Most of these studies have been done using surveys. The biggest drawback is that such studies do not cover the total universe but pick a group that is active on social media.
| Qualities of a Successful Clinician|| |
A clinician should remain updated in knowledge. This update must be actively searched. At my age, I do not have access to many journals. However, I actively seek knowledge from all sources. Last few years, Dr. Rajnish Mago's Simple and Practical had been a source of knowledge. I attend almost all CMEs at Lucknow and even travel if the subject is of interest. One must identify specific deficiencies in knowledge in day-to-day practice and seek relevant expertise. The biggest error one can make is to believe that he knows everything. The clinical skills should be improved by identifying the errors one commits and correcting them by seeking help. All of us are not equally competent in every clinical skill. Therefore, we should stick to our strengths and not do things for which we are not trained. Some of us have empathic skills, others know pharmacological treatments better, and some may have psychotherapeutic expertise. One must use his strength and should not try to copy others. Do not treat any condition about which you are not certain or for which better-trained persons are available. Psychiatrists treating physical disorders do the same error that physicians do when they treat psychiatric disorders. The only exception to this rule is that one may treat such disorders if there is no alternative service available in the area (TINA factor).
There is some evidence that some clinicians have a better response rate in the treatment of depression due to their interaction with the patients., This observation confirms the role of psychological factors in the treatment of depressive disorders and should be applicable in other illnesses too. Respect the patient and his relative. Anticipate their needs and expectations and try to fulfill them. Do not do anything that may humiliate them. A good clinician should provide the patients and families a treatment plan that is affordable and acceptable.
Do not unnecessarily investigate. Essential investigations should be done. Less important investigations should be left on the patient's choice. The patients who are referred to other clinicians and investigating agencies should be referred only on merit and for no other considerations. This establishes the clinician's integrity.
Issuance of a medical certificate is a very important factor in establishing a reputation. Many doctors write on their prescription pads that medical certificates will not be issued; others are ready to issue certificates for anything. The correct procedure is to issue only genuine medical certificates for leave from work. Sanity certificates should only be issued by institutions that have admission facilities. Partial fitness certificates and certificates for other reasons like transfer from one place to another should be avoided. Do not issue a false certificate. A medical certificate should be issued only if the patient is present in front of you.
Many doctors write on their prescription pads that these cannot be used for medicolegal purposes. Every prescription can be used as evidence in any court of law and such defensive statements will only reflect your insecurities.
We often change the prescription of an earlier physician, even if it is correct. Once a senior officer consulted me and I found his prescription fully justified and told the patient that his treatment is correct. He told me that you are the first doctor who has endorsed the treatment of other. Respect your colleagues' prescription and it will enhance your reputation.
Psychiatric practice revolves around the assessment of patients and their treatment. All postgraduate teaching programs emphasize on these points and average psychiatrist is quite skillful in both these aspects. The focus is usually on diagnosis and treatment, but often the patient context is lost. One treats a patient suffering from depression and not depression. Each patient is unique. Their constitution differs as well as their psychosocial background. We must focus on the patient, and our treatment will be more effective.
The presenter proposes that our history taking and evaluating techniques require some change. Usually, the receptionist fills in the basic information and the clinician directly focuses on the history and examination. This author prefers to ask the basic information himself and the clerk records. This process lets the clinician learn about the socioeconomic and family background of the patient. One often learns about the illness as well as psychosocial issues during recording of basic psychosocial information. The patient can unburden himself in an indirect fashion. The clinicians can also learn about the support system and what kind of treatment he can afford and what are his preferences. The patients are usually very anxious, and they want to tell about their problems as soon they enter the clinicians' chamber as they fear the clinician may not have enough time to listen to them. These initial few minutes put the patient and family at ease. History taking and recording should be done after carefully dissecting the phenomenon. The standard mental state examination as taught earlier need not be followed as it was meant for patients suffering from psychotic disorders. Majority of patients we come across in daily practice need a modified mental status examination. We need to record observations of patients' behavior and its psychological context. Often, symptoms such as sadness, suspiciousness, irrelevant talk, or odd behavior are accepted without serious attempts on cross-checking. Modern-day examination should include a careful description of signs and symptoms, and each should include negative questions to rule out other possible diagnoses. I would like to cite one instance where serious errors were made.
A young man of around 18 years was brought to me. He was earlier diagnosed as a patient of schizophrenia. The presenting complaints were he kept standing on his bed for long periods of time at night that, would get angry and abusive if someone interfered. He stayed aloof and did not interact with others. I asked the patient why he remained standing. He told me that he had certain blasphemous ideas and he needed to get rid of them before he could lie down. If someone interfered, his solution chain got disrupted and that is why he became aggressive. The diagnosis was changed to OCD.
Another problem in diagnosis is our attempt to fit all patients into predefined categories even when they are not completely fitting into it. Patients suffering from personality disorders, hyperactivity problems as well as some rare conditions are often put in the common categories leading to wrong treatment. Any oddity in the patient should be highlighted and carefully followed. It will often lead to better results.
The treatment is generally by drugs, with psychological help on need base. The drug treatment is usually unfairly evaluated by most of the people including fellow medical professionals. Psychiatric drugs are sleep producing which calm the patients and do no other good. As these drugs effect the brain some common perceptions about psychiatric medication are: they may produce long-term deleterious side effects, for example, Extrapyramidal symptoms (EPS) with antipsychotics or hormonal and weight changes with other drugs. These drugs only control symptoms and are not curative. These drugs are habit forming or addictive.The layman feels that these drugs produce heat in the mind and body, effect memory, and may affect brain functioning in long term. Many of the above are true and are potent reasons for patients to reduce, leave, or change treatment.
The challenge is to overcome these issues in day-to-day practices.
When one prescribes any treatment, we must explain the beneficial effects and the harm they can produce. Many patients ask the clinician will these drugs produce side effects. My answer is always in affirmative and I tell them the drugs which are effective at the place of the disease do act on other parts of the body and these effects are called side effects. Every effective drug would have side effects. I also like to explain that in allopathic medicine, only those drugs are permitted to be used when it is proven that the beneficial effects are more and side effects are minimal. This will prepare the patients to tolerate side effects. They should also be informed when the beneficial effects are likely to appear. The clinician needs to use caution while talking about the beneficial effects. More definite response pattern can be predicted after observing the patient for some time.
There are many treatment guidelines, but the average clinician seldom uses them. A recent review emphasized that simple diagrammatic guidelines are more useful than a detailed one. I feel that we must develop standard operating procedures for common mental disorders which should provide minimal care for each patient. When one prescribes a treatment, his mind should have two regression equations' functioning, one as to what are the best treatment options available and what are practical and affordable. These issues should be discussed with the patient/caregivers before the final treatment is advised. Use only minimal medications that are essential for this illness. Tonics, vitamins, and antacids make treatment unnecessarily expensive.
Communication with the patient is central to all treatments. Unfortunately, the process of communication is seldom discussed. We all know what to inform but do not know whether the message has reached. The patients and their relatives often distort messages not intentionally, but due to stresses in their mind, they interpret messages differently. It is therefore essential that messages should be repeated, and the patient should be asked to state his understanding of the information. Provide written material to the patients about diseases and treatment which will help them to follow your advices properly.
Few observations on usual treatments and prescription
The prescription should be clearly written, and the drug doses and time of next visit should be provided. I have observed that by giving the next date, the chances of missing treatment are reduced.
Many of us use combinations of antidepressants and tranquilizers. I think this leads to drug dependence and many patients find it difficult to stop the treatment. Second, if you want to increase one drug, the second is unnecessarily increased. It is time we tell the drug regulator that this practice is stopped. Unnecessary use of minor tranquilizers and sleeping pills should be avoided. These drugs should be tapered off as soon as possible. This may require more time to be spent with the patient so that the need to reduce drugs could be explained.
The treatment of schizophrenia also needs a paradigm shift. We are using oral antipsychotics initially, and long-acting injection (LAI) are used only in cases of drug default usually after chronicity has set in. There is evidence that repeated relapse leads to changes in brain structure. There is also a strong evidence that almost every patient of schizophrenia stops treatment. Therefore, to avoid chronicity, we must encourage patients to be on LAIs from the first relapse and even in the first episode.
The combination of antipsychotics with trihexyphenidyl is available in this country, and my objection to this combination is the same. However, I often use this combination for poor and illiterate patients so that they continue taking effective medicine. I have observed that when these two medicines are given separately, patients often stop taking antipsychotics and continue taking antiparkinsonian medicine. This combination may be stopped after few more years when there is more awareness.
Drug dosage used for OCD is usually low, and in most cases, one could double them, and better response could be obtained. The drug dosages could be increased to fluoxetine 120 mg, sertraline 400 mg, fluvoxamine 450 mg, and escitalopram 60 mg.
ECT-I seldom use ECT these days. It is reserved for non-responding depression. This treatment is lifesaving in patients who have not responded to drug treatment. Maybe, a common facility can be developed in all cities where this treatment could be given for patients being treated by different psychiatrists.
| Effectiveness of Psychological Treatments|| |
The choice between psychological methods and/or drugs for psychiatric illness has been a source of everlasting conflict. When I learned psychiatry in the early 1960s, we were taught that psychological treatments are the correct treatments for psychological illnesses, and drug treatment was, at best, a close approximation. Thankfully that phase is over and now drugs are the accepted method of treatment in most psychiatric illnesses. However, there are a group of illnesses such as depression where there is conflict regarding the use of drugs/psychotherapy. Most therapeutic guidelines support psychological treatment for mild-to-moderate depression. My impression is that in most mild-to-moderate depression where the depression has an endogenous quality and a hereditary predisposition, treatment with antidepressants is the most effective and economic treatment. Psychological issues could be helped with counseling. There is a need to provide effective delinking of psychological factors that patients and families incorporate in their minds for causation of depression. Especially in India where we have great work pressure due to a large number of patients, we should use our strength and treat them with drugs and large number of patients will improve.
Psychological help is required for most patients for dealing with immediate or persistent psychological issues. Psychiatrist should also have an insight regarding his training and competence in psychotherapy and he should attempt treatments within his competence. Marital counseling and vocational counseling are special areas and should be attempted by those who have developed expertise.
| Rehabilitation|| |
Rehabilitation is often talked about but has not become an integral part of psychiatric practice. The main reason is that most of us have not accepted its utility. Such services are not available in most parts of our country and they are not considered cost-effective. We have started a rehabilitation center at Lucknow. We struggled for clients as well for money. We started in 2005 with no money and no client. The center has a halfway home and a day-care center. This center is unique because the patients and the caregivers are part of every decision-making. The clients coming to the center are diverse and include, long standing schizophrenia, chronic Obsessive-Compulsive Disorder, mild intellectual retardation, chronic bipolar disorders, autistic adolescents, and patients who have no relatives to look after. The patients and relatives have been generally satisfied with the progress made by the clients during their stay. The patients in general had improved social behavior, but their basic problems of poverty of thoughts and delusions persisted. The patients could control these symptoms in social situations. Another major advantage was that the relapses were identified promptly and could be improved by modifying dosage. The quality of life of most patients showed improvement. Rehabilitation centers could also be used as day care facilities for acute psychosis, dissociative disorders, OCD, and other illnesses where patients could stay for some time and later return home. It would reduce costs and social disruptions.
Family members were also empowered by their contact with the day-care center. They could understand the nature of the disease and the disabilities associated with the disorders. They also took interest in the welfare of others, and thus, a cohesive group has been formed who are instrumental in reducing stigma and developing and confidence.
There is a need to develop such centers all over the country so that all psychiatric patients can get optimal treatment. We need to start rehabilitation in schizophrenia early not when chronicity has set in. Every patient who is showing marked withdrawal for few months should be advised rehabilitation.
Friends, I have put some of my random thoughts in this presentation. Neither of them are new nor very exciting, but missing them can affect the quality of one's practice.
| Conclusions|| |
Psychiatric practice as experienced by this author has been presented. The account is not very coherent. The major issue that effects psychiatric practice in India is a large gap between demand and services. The psychiatrists in this country need to develop innovative methods to overcome this deficiency. Each clinician must deal with a large number of patients in a short time. We need to change history taking and examination to suit our needs by developing time-saving yet effective methods. Certain inherent controversies of psychiatric practice have been highlighted. Prevalent beliefs about mental illnesses and their treatment have been described and ways to overcome them have been suggested. This presentation could be considered as an example of loud thinking of issues that affect psychiatry, but they raise more questions than provide certain answers.
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Conflicts of interest
There are no conflicts of interest.
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Dr. Anil Kumar Agarwal
B104/2 Nirala Nagar, Lucknow - 226 020, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
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