Training and National deficit of psychiatrists in India – A critical analysis

India is the second most populous country in the world, with an estimated current population of 1.17 billion. This article aims to estimate the deficit of psychiatrists in India in relation to epidemiological burden of mental illness, propose short-term and long-term strategies to tackle the deficit and emphasize the importance of modifying the curriculum of undergraduate medical education to enable the proposed strategies. With 6.5% prevalence of serious mental disorder, the average national deficit of India is estimated to be 77%. More than one-third of the population has more than 90% deficit of psychiatrists. The authors estimated that the undergraduate medical curriculum devotes only 1.4% of lecture time and 3.8-4.1% of internship time to psychiatry, thereby leaving the general practitioners and the non-psychiatrist specialists unprepared to competently deal with mental illness in their practice. We propose short and long-term strategies to manage this deficit of psychiatrists.


INTRODUCTION
"A chain is only as strong as its weakest link" -English Proverb.

THE DEFICIT
While the burden is in catastrophic proportions, the soul annihilating issue is the deficit of psychiatrists. Using the data sourced from National Survey of Mental Health Resources [1] carried out by the Directorate General of Health Services in 2002, we calculated the estimated deficit of psychiatrists in India, based on the available number of psychiatrists and the ideal number required (,1.0 per 100,000 population). We further categorized the states and union territories (UT) based on the amount of deficit of psychiatrists, as seen in Table 2 and Figure 1.
As often is the case with India, there was a huge diversity across the Indian terrain, even in the deficit of psychiatrists. On one hand, four states, namely, Chandigarh, Delhi, Goa and Pondicherry had a surplus of psychiatrists, ranging from 244% surplus in Chandigarh to a 13% surplus in Pondicherry. In all the other states/UTs, there was a deficit, with only two states having a deficit of less than 50%. Nine states had more than 90% deficit. As per our estimation from the 2001 Census, these nine states amounted to 37.6% of the Indian population and 41.1% of the rural population of India. Lakshdweep had a 100% deficit, implying that more than 60,000 Indians living nearly 200-300 km off the west coast of the subcontinent had no psychiatrists.
We calculated the average national deficit of psychiatrists to be 77% and 17 states/UTs were below this average. It is to be duly noted that most of the above estimates were made from the census data from 2001, and the situation now in 2010 is probably far worse, given the continuing expansion in population and nil perceivable expansion in psychiatrist output in the last decade.

THE PLIGHT
In India, such a deficit of specialists may be present in other fields of medicine too. But our model of medial education  Psychiatry, as a subject of study, is offered only a minimum of 20 hours of clinical lecturing. [3] This constitutes to only 1.4% of the total amount of lecturing hours. When realistic aspects of lecturing are taken into account, this miniscule amount of time devoted to psychiatry seems to appear more like a ritual for the achievement of political correctness in adequacy of training, than an honest willful attempt to educate the medical students.
Philosophically, the lack of knowledge in medicine or the attrition of gained knowledge is pardonable, but the lack of skill is not. For example, every doctor is not expected to always possess full knowledge of the physiological aspects of anemia or jaundice, but he/she is expected always to effectively diagnose them and act accordingly. Unfortunately, in psychiatry, our MBBS graduates are not only insufficiently imparted with knowledge, but also suffer from a profound lack of the basic psychiatric skills to not only confront psychiatric diseases, but even to be able to pick up psychiatric manifestations of physical disease and the physical manifestations of psychiatric disease. This is because of the lack of sufficient clinical work experience during internship. As per the regulations of Graduate Medical Education of 1997, [3] psychiatry experience during house internship for MBBS students was a part of the parent general medical rotation, wherein the students were exposed to an exclusive psychiatric rotation, only as deemed fit by the department of medicine or the institution. In essence, psychiatry was not mandatory for the successful completion of house internship. However, in the latter half of 2008, MCI released its 'Regulations on Graduate Medical Education (Amendment), 2008', wherein some changes were made to the distribution of times allocated to different specialties for the interns.
[3] They can be summarized as shown in Table 3.
Hence, by the amendment of 2008, interns need to rotate exclusively through psychiatry for two weeks. Also, psychiatry is offered as one of the options for the elective rotation available for interns for two weeks. The authors, as would many psychiatrists, welcome this change; however, this is still not good enough. This time constitutes about 3.8-4.1% of the total internship time of 365 days or 12 months, depending on administrative situations. Two weeks, the authors contend to be disproportionately less for the attainment of sufficient skills in psychiatry [ Figure 3]. Two weeks of clinical experience is in reality a minimum of 10 working days, wherein administrative duties, orientation and acclimatization would by themselves consume the intern and rob him of fruitful applicable experience.

CONFRONTING THE PROBLEM
The crux of the problem here is that our model of medical education and training is not adequate to meet the demands of the rising burden. The psychiatrist community is aware of the problem, but the problem has not been addressed seriously. Table 4 is a list of publications in the Indian Journal of Psychiatry in the last few decades that have addressed the issue of training in psychiatry.
It is notable from the list of publications that 90% of them (18 out of 20 publications) were aimed at training medical students and/or general practitioners. From this observation, it is probably safe to assume that most of the academia of the Indian psychiatrist community is almost unanimous in the idea that the training of non-psychiatrists is at least as important, if not more, than the training of psychiatrists with respect to dealing with the burden of psychiatric illness in the community. However, only 45% of these publications   [4] General hospital psychiatry and undergraduate medical education 1984 Medical students Editorial P. Kulhara [5] General hospitals in postgraduate psychiatric training and research 1984 PG/Residents Communication Shiv Gautam [6] Development and evaluation of training programs for primary mental health care 1985 General practitioners Original article Rajeev Gupta et al. [7] Psychiatric training and its practice: A survey of 86 practitioners 1987 General practitioners Original article K. Praveenlal et al. [8] Capitals not needed 1988 Medical students Original article C. Shamasundar et al. [9] Training general practitioners in psychiatry -A new venture 1988 General practitioners Original article C. Shamasundar et al. [10] Clinical vignettes for assessment of training general practitioners in psychiatry 1989 General practitioners Original article C. Shamasundar et al. [11] Training general practitioners in psychiatry -An ICMR multi-center study 1989 General practitioners Original article K. Bhaskaran [12] Undergraduate training in psychiatry and behavioral sciences -the need to train the trainers 1990

Medical students Editorial
Anna Tharayan et al. [13] Undergraduate training in psychiatry. An evaluation 1992 Medical students Original article Satyavati Devi [14] Short term training of medical officers in mental health 1993 General practitioners Original article K. Kuruvila [15] A common minimum program needed in post-graduate training in Psychiatry 1996 PG/Residents Editorial J.K Trivedi [16] Importance of undergraduate psychiatric training 1998 Medical students Editorial K. Kuruvila [17] The future of psychiatry: The need to return to the field of medicine 1998 Medical students Presidential address R.K Chadda et al. [18] Awareness about psychiatry in undergraduate medical students in Nepal 1999 Medical students Original article C. Shamasundar [19] "Whither training in psychiatry and psychosomatic medicine!" What need to be done?

Medical students Communication
Indla Ramasubba Reddy [20] Undergraduate psychiatry education: Present scenario in India 2007 Medical students Communication A.B.Ghosh et al. [21] Why should psychiatry be included as examination subject in undergraduate curriculum?

2007
Medical students Communication R. Srinivasa Murthy et al. [22] Undergraduate training in psychiatry: World perspective 2007 Medical students Communication M. Thirunavukarasu [23] Psychiatry in UG curriculum of medicine: Need of the hour 2007 Medical students Communication (9 out of 20 publications) were original articles. The rest were monologues, communications or editorials where its authors were simply blowing off their steam. This also means that there needs to be more objective evidence to support the claims of ineffective training among medical students. Except for the National Mental Health Program (NMHP) and a few isolated task force-propelled training activities of general practitioners, less has been achieved in terms of concrete action.

SHORT-TERM STRATEGY
It is important to understand the dynamics of patient accrual for treatment, in order to tackle this problem in the short term. The authors would like to approach the current issue from the patient's perspective. Patients with mental disorders (with or without other co-morbid conditions) who seek medical care end up in the hands of one of the three following groups of physicians [ Figure 4].

Psychiatrists (through self referral) 2. General Practitioners (GPs) 3. Other specialists
Those who seek the psychiatrist's help are cared for accordingly.
Those who end up in the care of GPs or non-psychiatric specialists may not, in most cases, receive adequate attention to their mental disorder. The patients need to get diagnosed and appropriately referred to the psychiatrist at this stage. This can be achieved in one of two ways: A. Training the practicing GPs and specialists in basic psychiatric skills necessary to identify mental health disorders and refer them for specialist care. B. Introducing strict policies wherein the GP/specialist must document presence or absence of psychiatric symptoms, which will lead to mandatory notification of the patient and/or referral to a psychiatrist to ensure that appropriate care is available.
The comparative advantages and disadvantages of these two approaches are summarized in Table 5.

LONG-TERM STRATEGY
The only long-term solution to this problem is to train undergraduate medical students to provide a strong fundamental basis in psychiatry, so that they are trained to routinely look for psychiatric illness in all the patients that they care for. However, this would mean a basic architectural reform in the curriculum of medical education to include all of the following: 1. Education in the basic fields required to learn psychiatry such as psychology, behavioral sciences, sociology, psychopharmacology, etc. 2. Clinical Psychiatry rotations with proportionate time allocations. 3. Exclusive examination (theory and clinical) to assess achievement of learning objectives. 4. Exclusive clinical internship experience (out-patient and in-patient) for the successful completion of MBBS.

THE BEST STRATEGY
The authors strongly feel that the best strategy to tackle this problem of huge burden and deplorable deficit is to  Requires organizational support Requires large funds to conduct these sessions Attendance may be poor The prime target trainees (those with high volume practice) may be especially low in attendance Effect may not seen quickly Strict Policy decisions for routinely documenting psychiatric symptoms, which will lead to mandatory notification to patient and/or specialist referral Less expensive in the long run Very effective in the short term May prevent grossly missed psychiatric mortality or morbidity such as suicide, homicide, etc Such policies may meet with friction amongst the specialists before its widely accepted Requires legislation actually train the general public! We feel that increasing awareness about mental illness, removing the myths and misconceptions of mental disorders and educating the general public of the scope and importance of mental health care will probably work more quickly, more effectively and will be long lasting. This could mean educating school children about the basics of mental health and well being, just like teaching them about the basics of hygiene and physical health. In the authors' opinion, if this approach is followed, this might prevent stigmata and misconceptions of mental illness in future and to our surprise may even become non-existent in the next generation. This could also prevent problems in childhood, which if left unattended could lead to more embarrassing situations where we might need to implement measures like sex education, drug abuse and alcohol education, behavior modification, etc among school children. While the latter may well be effective, it just seems more intelligent and wise to teach the basics of mental health to children (and parents and teachers) which might prevent the need for such problem-specific interventions.

SUMMARY
The burden of mental illness is in himalayan proportions and the deficit of psychiatrists is large, with an average national deficit of 77%. The problem is expected to increase in an unabated fashion and we are clearly not prepared to deal with the situation. The long-term solution would be a strong training in psychiatry at the undergraduate level. However, it could take several decades to see the effect of such a measure. The short-term solutions would include either or both of two measures, namely the training of practicing non-psychiatrist physicians and the implementation of strict policies to enforce guideline-oriented examination of all patients to look for psychiatric problems leading to mandatory patient notification and/or psychiatrist referral. The best, most effective, fool-proof and long-lasting solution, in the authors' opinion, would be the education of the general public.