| Abstract|| |
Addictive disorders have become increasingly common in India. The health consequences of addictive disorders are immense, and the need for specialized addiction treatment and training far exceeds the capacity and human resources that currently exist. At the same time, increasing demand and treatment gap, need for specialized care, and the emerging sector of medical tourism in the country open avenues for superspecialty training in addiction psychiatry as an attractive career option for Indian psychiatrists. Human resource development and capacity building in the addiction psychiatry field in India is the need of the hour. In the present article, we describe the existing scenario and challenges related to addiction psychiatry training among postgraduate psychiatry trainees and psychiatrists in India and scope for the future.
Keywords: Addiction, addiction medicine, addiction psychiatry, medical tourism, specialty training, superspecialty training in psychiatry
|How to cite this article:|
Tripathi R, Singh S, Bhad R. The need, scope, challenges, and potential solutions for enhancing addiction psychiatry training in India. Indian J Psychiatry 2020;62:728-31
| Introduction|| |
The prevalence of addictive disorders in the Indian population has shown an increasing trend over the past two decades., Recent nationwide surveys, National Mental Health Survey (NMHS) of India, 2015–2016 (NMHS, 2017), and National Drug Use Survey, expose a large mental health gap in the treatment of substance use disorders and recognize it as a major emerging health problem in the country.,
Over the past decades, the medical concept of addictive disorders has become more prominent. Addictive disorders are nowadays considered a chronic relapsing brain disease involving biopsychosocial factors. Moreover, addictive disorders have become one of the world's leading causes of health problems and often complicated by other conditions, including psychiatric disorders and physical complications., Therefore, it requires appropriate training for a psychiatrist in addiction psychiatry to comprehensively manage and treat addictive disorders.
| Current Status of Addiction Training in India|| |
The training of mental health professionals in addiction psychiatry is being carried out at central medical institutes (National Drug Dependence Treatment Center [NDDTC], All India Institute of Medical Sciences [AIIMS], New Delhi, National Institute of Mental Health and Neuro-Sciences [NIMHANS], Bengaluru, and Postgraduate Institute of Medical Education and Research [PGIMER], Chandigarh) for medical professionals and National Institute of Social Defense (NISD) under the Ministry of Social Justice and Empowerment for nonmedical professionals. NDDTC, AIIMS, provides 3-year superspecialty training (Doctor of Medicine [DM]-Addiction Psychiatry) since the year 2016 and PhD (in addiction psychiatry research area) since 2011. NIMHANS, Bengaluru, offers DM (addiction psychiatry) since 2014 and 1-year postdoctoral fellowship in addiction psychiatry since 2013. PGIMER, Chandigarh, offers DM (addiction psychiatry) since 2013. AIIMS, Rishikesh, has also introduced DM (addiction psychiatry) course in 2019. NISD is providing training courses in addition psychiatry through its nongovernmental organization (NGO) partners and regional resource training centers (RRTCs) for social workers, counselors, field workers, peer educators, and allied professionals in the management of substance use disorders for more than 10 years. It offers certificate courses of duration 1–3 months. Some other NGOs and private institutes provide training in addiction psychiatry, which may not be recognized by the Government of India, but focuses on the skill development of professionals working in addiction psychiatry. The Indian Psychiatric Society (IPS), the largest professional body of Indian psychiatrists in the country, has recognized and adopted addiction medicine specialty section for more than 10 years now. It is noteworthy that the IPS is actively engaged in developing publications and continuing professional development activities for psychiatrists in the field of addiction psychiatry.
| Expanding Focus on Addiction Psychiatry Training in India|| |
The need for quality treatment
Addictive disorders lead to significant morbidity, mortality, and dual diagnosis (both physical and psychiatric comorbidities). The treatment approach needs a comprehensive management strategy to reduce relapse rates. Among the available treatment options, pharmacotherapeutic options are limited. Psychosocial approaches have an unparalleled role in management. Recovery is a long process and frequently requires multiple courses of treatment. Considering the complexities of these disorders and the need for long-term treatment, there is a need for extensive training of psychiatrists for quality treatment in the field.
Demand for specialized clinical care
When we look at the postgraduate training of psychiatry in India, there is very limited exposure to addictive disorders. Most of the medical colleges offering postgraduate course in psychiatry in the country give 3–6 months' training in addictive disorders in a 3-year course, which may not be sufficient to understand the must-know aspects of addiction and its management.
It is true that addiction psychiatry draws its recruits from general psychiatry in India, which itself has unprecedented challenges such as shortage of skilled workforce, unlike other developed countries such as the USA and Canada where addiction is managed separately. In the USA, there are two disciplines practicing addiction – addiction medicine and addiction psychiatry. In fact, there is a separate board for certification in addiction, the American Board of Addiction Medicine, since the year 2007 besides the existing American Board of Preventive Medicine, American Board of Psychiatry and Neurology, and American Osteopathic Association for certification in addiction medicine. Taking cues from the USA, one can understand the level of clinical attention and specialization required to handle addiction treatment and training.
Medical tourism can be defined as the process of traveling outside the country of residence for the purpose of receiving medical care. A change in environment by the way of residential addiction treatment can optimize the chances of recovery. Perceived stigma could prevent a person suffering from addictive disorders from seeking treatment at a local health-care facility. Medical tourism in India is a growing field for various specialties, but drug dependence treatment facilities have not yet found mention among the popular specialties. What might be hampering the inclusion of addiction treatment in medical tourism is the lack of a long-term support system. Telemedicine could help here, as it has proven to be a successful strategy to provide consistent follow-up care if used in evidence-based manner. Thus, an increased demand for addiction treatment services can be anticipated and met by increasing training opportunities.,,
Improving the attitude of professionals involved in patient's care
An addiction psychiatrist is more likely to have a nonjudgmental and optimistic attitude for patients and could be efficient and confident in treating patients with addictive disorders. There is also an increasing demand for personalized medicine which can be fulfilled by specialists.,
Catching up with advance technology and research
There has been significant advancement in technology and research related to the diagnosis of substance use disorders such as brain imaging, biomarker testing, and drug abuse screening using novel techniques and in treatment such as brain stimulation technology, neurofeedback, and gene therapy. Moreover, while digital technology can lead to addiction, it can be used for the treatment of addictive disorders. Postgraduate training may not be adequate to learn and practice this advance technology, which necessitates superspecialty training.,
| Barriers and Challenges for Addiction Psychiatry Training|| |
There are several challenges in imparting addiction psychiatry training in India.
It is difficult to introduce separate addiction psychiatry training in MBBS curriculum when there is not enough space and emphasis on psychiatric training itself and revision of curriculum for medical graduates is long due. However, the recent push by the IPS for more coverage of psychiatry subject in curriculum is likely to benefit all subspecialties in future.
Lack of infrastructure and skilled workforce
Most psychiatry training departments in the country do not have dedicated addiction clinics or treatment facilities, thereby automatically limiting the extent of exposure and training in addiction psychiatry. Moreover, the budget for medical training under the Drug De-Addiction Programme (DDAP) of the Ministry of Health and Family Welfare is very small.
In India, drug use disorder patients are mostly treated through general health services, on a voluntary basis. State-level hospitals also offer rehabilitation facilities for indoor treatment through their psychiatry departments. Besides state-run treatment centers, addiction treatment in private sector is mostly imparted by counselors, recovered patients from addictive disorders, family members, untrained medical professionals, etc. The treatment given in the private de-addiction centers (DACs) is largely involuntary, inhumane, and not evidence based. There is serious lack of evidence-based treatment and training facilities for addiction psychiatry in India. Lack of clinical skills and understanding about addictive disorders of medical graduates and postgraduates combined with increasing demand strengthens the need for specialized training in addiction psychiatry to guide the existing treatment providers and improve clinical management and outcome. As there is shortage of psychiatrists in our country, hence drawing out a “sub-cadre” of addiction specialists for training of trainees is a challenge.,
The acceptance of addiction as a medical illness also varies. There is stigma associated with addiction which is reflected in medical teaching as well either overly or covertly. Not all medical practitioners consider substance use disorders a medical condition, and as such do not consider treatment of these patients as their domain of treatment. Changing the negative attitude of psychiatrists toward addiction psychiatry is also challenge.
| Potential Solutions|| |
First of all, the whole medical fraternity should be primed for addiction as a disease. This can be done by the addition of addiction training in MBBS curriculum by concerned authorities. As mentioned above, shortage of number of psychiatrists is also a problem. The government should take a step for it and increase the seats for MD (psychiatry) so that services of general psychiatry are adequately managed. Change in attitude will take time and can be done by the organization of workshops, seminars, and symposia on addiction psychiatry for undergraduate students and other postgraduate specialties. Provision of dedicated addiction clinic and ward in every medical college is the need of the hour. The budget allocated for DDAP program should be increased by the ministry. Webinars, online courses, and live online discussions can also be used for training for professionals in remote areas. The IPS should also organize online addiction programs, conferences, and workshops dedicated to addiction for training of psychiatrists and postgraduate trainees.
| Career Prospects After Completion of Addiction Psychiatry Training in India|| |
There is a serious lack of trained professionals working in the field of addiction psychiatry despite enormous demand in India. However, with the expanding focus of addiction psychiatry and increase in the availability of trained professionals, there is likely to be increased demand, as well as opportunities for trained psychiatrists in the private sector. International agencies such as the United Nations Office on Drugs and Crime and the World Health Organization have taken note of the rising problem of addiction in India and funding various research and capacity building projects in the country with addiction psychiatrists as consultant and program officers. In the government sector too, there has been a change in health policy in response to the increase in the prevalence of substance use disorders which has resulted in increase in the number of drug treatment clinics, addiction treatment facilities, and enhancement in the capacity of the existing government treatment facilities. The National AIDS Control Organization (NACO) and various state AIDS control society are keen to engage addiction psychiatrist in capacity as a trainer and consultant in order to establish Opioid Substitution Therapy centers across the country. The DDAP under the Ministry of Health and Family Welfare of India envisages plan for DACs in government hospitals for fifty districts run by government by 2020, which is likely to be extended to other districts in the near future.
| Conclusions|| |
The rising addiction problems in India demand urgent clinical attention. It requires dedicated and trained psychiatrists to manage these problems, which can be achieved by adequate training in the field. In the current Indian scenario, the number of psychiatrists is less than what is desirable, and drawing addiction psychiatrists from that pool further strains the existing human resources. It is imperative and is the need of the hour to address the menace of addiction before it is too late.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Roshan Bhad
Room No. 4096, Department of Psychiatry, National Drug Dependence Treatment Centre, All India Institute of Medical Sciences, 4th Floor, Academic Block, Ansari Nagar, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None