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    Abstract
    Introduction
    Indian Psyche
    Indian Family
    Indian Coping Style
    Clinical Syndromes
    Treatment
    Psychopharmacology
    Psychotherapy
    Conclusion
    Acknowledgments
    References

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 Table of Contents    
AWARD PAPER  
Year : 2011  |  Volume : 53  |  Issue : 2  |  Page : 111-120
Indianizing psychiatry - Is there a case enough?


Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Click here for correspondence address and email

Date of Web Publication30-Jun-2011
 

   Abstract 

Psychiatry is different from all other branches of medicine as it pertains on "psyche" which is intangible, effervescent and indefinable. It is influenced by interviewer and client's communication skills, personality, socio-cultural beliefs and interpretations. The inference of "normal" and "abnormal" varies across cultures and understanding of the cultural nuances is an integral part of understanding psychopathology. Knowledge gained in one culture cannot be extrapolated completely to another culture. Indian psyche is distinct as it is has been influenced by various invaders into the country, collectivism and interdependence. Because of all these factors, presentation of mental illness is different in the Indian culture and many a times it is difficult to fit patients into the categories developed by the Western world. Similar factors also influence attitude towards treatment seeking and visit to magico-religious healers and those practicing alternative system of medicine. Moreover, the principles of Western psychotherapy cannot be applied to the Indian subjects. Compared to West, family plays a vital role in all major decision in an individual's life including his treatment and care. They bear the major burden and take up the responsibility of care of the persons with mental illness and dampen the effect of limited resources. These families cope by trusting and passing on the responsibility to almighty. Hence, there is a need for Indianization of psychiatry.

Keywords: Psychiatry, India, Culture

How to cite this article:
Avasthi A. Indianizing psychiatry - Is there a case enough?. Indian J Psychiatry 2011;53:111-20

How to cite this URL:
Avasthi A. Indianizing psychiatry - Is there a case enough?. Indian J Psychiatry [serial online] 2011 [cited 2019 Sep 17];53:111-20. Available from: http://www.indianjpsychiatry.org/text.asp?2011/53/2/111/82534



   Introduction Top


The thought that becomes paramount in our mind is that after all what is so special about Psychiatry amongst medical sciences, that one may consider something as fantastic as Indianizing it. The answer lies in the core concept of Psychiatry, that is, it is the study of abnormal human psychology or the human mind. The psyche, unlike the different parts of the human body, is intangible, effervescent and indefinable. When one tries to detect abnormalities in it, the age-old medical tradition of inspection, palpation, percussion and auscultation becomes inadequate. Diagnosis of disorders in Psychiatry depends mainly on "listening" to clients instead of the physical examination and investigations which form an integral part of medicine in general. Thus, diagnosis in Psychiatry cannot remain uninfluenced by the interviewer and client's communication skills, personality, socio-cultural beliefs and interpretations. We must remember that no man is alike and man's search for sameness in this diversity has led to the development of different cultures, traditions and religion in this world. People from different socio-cultural and religious backgrounds tend to interpret the human psyche differently and the label of "abnormality" is influenced by the definition of "normality" decided by these cultures. We will not enter into the controversies of what is "normal" human psychology as this is a never ending debate. It may suffice to say that this definition varies across culture, religion and customs and therefore recognition of psychiatric disorders can be different across these cultures. If we look at the Major Depressive Disorder, touted as one of the commonest psychiatric morbidities all over the world, its core concept of "excruciating psychological pain" is undoubtedly a vague expression leaving a lot of scope for individual and group variation in its manifestation. To further illustrate the difference of Psychiatry from other branches of medicine, I draw upon one of my favorite analogies - Diabetes Mellitus. Like many psychiatric disorders, it is chronic, treatable but not curable, requiring lifelong monitoring and personal adjustments. However, despite all these similarities, it is a "physical disorder", the reason being the presence of a tangible and demonstrable cause which renders uniformity in diagnosis and treatment, irrespective of the person's socio-cultural background.

Biological psychiatrists will argue that there is sufficient evidence today regarding mental illness being brain disorders. But the question is "Can we see or feel any of those proposed changes in neural circuitry with even the most advanced techniques available today?" The answer is an emphatic no! The etiology of mental illness, although much clearer today, still remains a conceptual understanding unlike Diabetes Mellitus. Having made a case for the uniqueness of Psychiatry, I now would like to illustrate why there is a need for "Indianizing" and not "Globalizing" Psychiatry. Psychiatry, as we practice today, is heavily influenced by Western findings, which however, is limited to only a few European countries like France, Germany, England, and more recently, the United States of America (USA). This has mainly resulted from the fact that although the practice of managing mentally ill patients has been undertaken by almost all countries over the centuries, systematic studies and publications have emerged mainly from these very countries. Currently, even amongst these countries, the USA has become the leader in all fields, including Psychiatry, due to various reasons. I shall not embark upon enumerating these possible reasons but the point that I am trying to make is that Psychiatry, as it is practiced in India today, depends on trying to fit our clients into the "diagnostic criteria" sets and treatment options prescribed for people of these nations, particularly the USA. Hence, Psychiatry today considers the average Caucasian as the model of diagnosis and treatment and the rest of the races are considered "ethnic" or "culture bound' if their psychological problems are inexplicable to the Caucasians. Attempts to include inputs from Asian countries had been made during development of the International Classification of Mental and Behavioural Disorders (ICD 10), [1] a commonly followed diagnostic system all over the world. But their contributions have been limited by the scarcity of "systematic, controlled studies", financial constraints and the heterogeneity of the population. Nearly two decades have elapsed after development of the ICD 10 and we can expect more literature from the Asian continent, especially from India, to make a case for or against Indianizing Psychiatry. With the advances in treatment options, both pharmacological and psychological, the variations in race and culture have assumed a greater importance, as acceptability of treatment and attitude toward the mentally ill are heavily influence by these factors.

The first question that arises in one's mind when one thinks of "Indianizing Psychiatry - Is there a case enough", is that whether Indians are in any way distinct from the rest of the world. This distinction may be in their individual personality as well as in the family, the smallest collectivist unit in the society of any nation. With this in mind, we shall first try to identify the distinctive nature, if any, of an average Indian and his family.


   Indian Psyche Top


It is very difficult to illustrate the characteristics of the Indian personality in general, given the diversity not only in the landscape but also in the races that have made India their home. From the time immemorial, India has been invaded by people of different races, culture and religion. However, the uniqueness of India lies in the fact that most of these "invaders" have over time become a part of the local population accepting India as their homeland. They have uninhibitedly contributed to the development of Indian culture and have also accepted the indigenous culture of the "conquered" nation. This has led to intermingling of different personalities which in turn has led to the development of what I would like to describe as the "Indian psyche".

It has been proposed that for an average Indian, the inner self is lodged in a "circle of intimacy" [2] or the family. Unlike the Western man whose selfhood is confined to his own body, the Indian self diffuses into this intimate circle, with bond, bondship and kinship becoming the fulfilling elements of life. Within these close ties, Indians can communicate without the fear of rejection, depend on sympathy, comfort and support without considering them as charity. From childhood, social relationships in Indians are spread over several people like grandparents, parents, uncles, aunts and siblings, and hence, parents are not the sole guardians or regulators of the child. With the growth of the individual, a series of similar relationships of varying intensity and duration develop and at no point of time do Indians assume full individual responsibility. Even marriage marks the development of a new set of relationship instead of independence. Hence, unlike the singularity, self-sufficiency and independence of western selfhood, the core Indian psyche is based on intimacy, family security and stability. Under these circumstances, the boundaries between "me" and "not-me" tend to get blurred, and for Indians, "we" rather than "I" becomes important. [3] Under these circumstances, likening the Indian "bondship" to "dependency needs" from which the Western psychotherapeutic practice aims to free the individual would be fallacious. [4] The fallacy lies in considering "independence" of psyche as acceptable but not "interdependence". The question is who decides this; those who believe in independence of self or an ancient culture that has prospered on interdependence!

The early Indian psyche is also based on the fear of separation from the Cosmic One which is integral to the Hindu philosophical beliefs of transmigration of soul, re-birth and fatalism. As mentioned earlier, the inner self of Indians has been enriched through the ages by the integration of different religions, language and culture, as the invaders sooner or later mingled and became one with the Indians. Therefore, it was only at the time of British colonialism that the greatest challenge to the Indian self was posed by an "invader", who, for the first time in Indian history, made no efforts to integrate with the ever expanding Indian psyche. Under this onslaught, instead of undergoing a radical change in the inner self, Indians sought to resolve the conflict by postponement and avoidance. Identity models were compartmentalized and behaviors conformed to as per the demands of the situation making us appear as "hypocrites" to outsiders. The other model used to resolve the identity crisis was identification with the victor by internalizing them, in this case the Western belief of self. However, the original Indian self remained as before, making its presence felt time and again. Till date, this fragmented, multifaceted representation of the Indian self persists without creating any significant inner turmoil or crisis. [2] Understanding this dualism is useful not only in conceptualizing mental health problems and their management in the Indian context but also to throw light upon the coping, resilience, attitude toward mental illness and treatment seeking behavior of Indians.

Attempt to understand the Indian personality will always be incomplete until we look at the distinct genetic composition of Indians and its influence on our mental set. Although genetic studies in Indian population are almost absent, studies in the Asian population have shown a greater prevalence of the short(s) allele of the serotonin transporter promoter gene linked polymorphism (5HTTLPR) as compared to the Western population (40-45%). [5] The "s" allele of the 5HTTLPR has been found to be associated with an increase in negative emotions, including anxiety, [6] harm avoidance [7] and increased risk of depression, [8] if exposed to environmental stress. On the basis of these findings, the prevalence of affective disorders is expected to be higher in the Asian population. In contradiction to this hypothesis, the prevalence of these disorders in the Asian population is lower. It has been suggested that the predominance of "l" allele in the Western population promotes bias toward positive words and pictures, thereby facilitating individualistic cultural norms. This is in contrast to the Asians, who, due to the "s" allele, demonstrate greater attentional bias toward negative words and pictures, and this has been proposed to facilitate maintenance of collectivistic cultural norms and interdependence, thereby reducing the incidence of mental disorders in this population. [9] Therefore, genetic studies point toward the beneficial effect of interdependence in Asians and hence may be applicable to Indians too. By trying to free them from the same, modern Psychiatry might actually destabilize the Indian psyche, leading to more harm than benefit.


   Indian Family Top


Unlike the West, the Indian society is a collectivist society that emphasizes on family unity and integrity. For an average Indian, his family is all that matters as they are included in the "we" and "circle of intimacy". The family, being almost inseparable from the individual, considering managing patients especially those with mental illness without taking the family into account is almost impossible. In addition to this, despite the large population, India has few mental health professionals, and the few that are present are mainly concentrated in the urban areas. [10],[11],[12] Two cross-cultural studies have shown that 98.3% of the patients live with their families in India compared to 50% of the patients in the Western world. [13],[14] The family has to bear a greater responsibility than the state in caring for patients. Also, presence of family members is mandatory for the inpatient treatment and they invariably accompany the patient during the hospital visits. It has been reported that in India, there is greater cooperation and involvement of the family members in the treatment decision, career choice and marriage of patients. [15] The families, especially the rural ones, are usually quite tolerant to persons with mental illness. It has been shown that the joint families help in dividing the burden of care for the mentally ill and this in turn results in better course and outcome of mental illness. [16],[17],[18],[19],[20],[21] Despite the higher involvement with regard to schizophrenia, the caregivers of patients were found to have similar needs as those of the West, but unfortunately, unlike in the West, most of them were not met. [22]


   Indian Coping Style Top


The close relationship between stress and psychological distress has been accepted with respect to almost all types of psychiatric disorders. Coping strategies are therefore important predictors and modulators of mental illness. The ways of coping are in turn affected by culture and the culture-specific buffers. Indian culture has a fixed hierarchy in which God has a higher value as compared to individual responsibility. Hence, Indians seek sustenance from religion, visit temples and shrines and seek blessings of the Gods and Goddesses, when confronted with life stressors. They feel contented in handing over the responsibility to a higher authority, namely God, and thus relieving themselves from the burdensome responsibilities. This external locus of control, so integral and acceptable to Indians, is in stark contrast to the Western world where the autonomous individual has to bear the responsibility of his own problems and seek their solution without depending on others. [23]


   Clinical Syndromes Top


Having enumerated the salient differences between the Indian psyche, family and coping styles with the Western standard, it becomes even more imperative to look closely at the psychiatric syndromes commonly diagnosed in India. It would not be absolutely foolish to expect that a population so different from the population used as reference in our diagnostic systems may have different modes of expressing and manifesting psychological distress. This is further evident from the high percentage of "Not Otherwise Specified" (NOS) diagnosis made in our Psychiatry outpatient when we try to fit "Indian patients" in the ICD 10 diagnostic criteria.

Several studies have suggested that the prevalence of mental illness in India is lower as compared to the West. [24],[25] Although some Indian researchers have refuted this claim, [10] the lower prevalence of mental illnesses has often been attributed to the differences in the biological, social and cultural factors or due to the failure of Indian studies to truly measure the psychiatric morbidity or due to the combination of both these factors.

If we concentrate on psychotic illness first, we see that there is little evidence that culture distorts the form of psychoses significantly [26] and the first rank symptoms of schizophrenia appear to be culture free. [27] Some, but not all forms of hallucinations, are more prevalent in patients from India as compared to those from America. [28] The differences in presentation of schizophrenia across cultures can therefore be attributed to the variations in accessory symptoms and in content of delusions and hallucinations rather than the form. [29],[30] In India, delusions and hallucinations are often colored by cultural influences in terms of paranormal phenomena, irrespective of the educational and residential backgrounds of patients and caregivers. [31] Catatonic states, especially in hospital-based patients, are still quite common in India in direct contrast to the current trends in the West. Finally, the irrefutable better outcome of schizophrenia in Indian as compared to the Western population stands out as a beacon of the veritable difference of our patients from those in the West. [17],[18] Acute and Transient Psychosis, a diagnosis mentioned in ICD 10, has mainly emerged through the contributions of Indian research. The florid psychotic symptoms in Acute and Transient Psychosis, unlike Schizophrenia, have a sudden onset, episodic or periodic course, and most importantly, a good prognosis. [17],[32],[33],[34],[35],[36],[37],[38],[39] This new diagnostic entity, so commonly seen in India, added a new dimension to the spectrum of psychotic illness enumerated in ICD 10. [40],[41]

With respect to affective disorders, there are subtle differences in the clinical presentations of patients from India as compared to those from the West. Indian patients often present with somatic symptoms unlike those from the West as this is a culturally accepted manifestation of psychic distress. [33],[42],[43],[44],[45],[46],[47],[48],[49] This type of presentation is also associated with an unconscious desire to undermine the psychological distress. Under these circumstances, it often becomes difficult to elicit depressive cognitions which form an integral part of the current diagnostic system. Guilt, often considered as a core concept of depression, is less commonly seen in Eastern population due to the religio-cultural influences. [33, 43, 50-58] However, according to Dr. Varma, ideas of sin or guilt are not uncommon in India, although they are often attributed to karma or to the deeds of a previous birth, which in turn may render them less distressing. [3] The same influences render delusions of persecution and reference more common than hypochondriacal, guilt and nihilistic delusions in Indian patients. [58] Depression also has an overall better outcome in India than in the developed countries. [59]

Indian patients with Bipolar Disorder tend to have higher proportion of manic episodes, [60],[61],[62] unlike the western data which suggest toward a preponderance of depressive episodes in Bipolar Disorder. [63],[64],[65],[66] A study by Chatterjee and Kulhara has revealed that Indian patients with mania are more likely to present with distractibility, embarrassing behavior and early resolution of episode following treatment as compared to the Western population. [67]

As we proceed toward neurotic and stress related disorders, one of the glaring distinctions between Indian and Western patients is embodied in the higher prevalence of possession states, trance states, fugues and hysterical fits in Indians as compared to the Western patients. On the other hand, multiple personality disorder, a common problem in the West, is rarely seen in our patients. [68],[69],[70],[71],[72],[73] It has been hypothesized that religious beliefs in polytheism and reincarnation contribute to the documented high prevalence of hysterical possession in India, while the social approval of role playing in the West has led to higher prevalence of multiple personality disorder in these parts. [69] Similarly, pseudoseizures and other motor manifestations of dissociation are also more common, [74] while dissociative amnesia, fugue and depersonalization-derealization syndrome are rarely seen in our clinical practice. Indians with somatoform disorders commonly report "burning hands and feet" and "hot, peppery sensations in head" which is considerably different from the somatic symptoms (gastrointestinal complaints and abnormal skin sensation) suggestive of immunologically based disorders reported from the Western countries.[75] Despite the paucity of data, epidemiological study on Obsessive-Compulsive Disorder (OCD) has suggested considerably lower rates of OCD in India than that reported in the European and North American studies. Studies have also hinted toward a better outcome with lesser morbid course in Indian patients as compared to the Western literature. [76],[77]

Although there has been a recent spurt in diagnosis of anorexia nervosa in India, this is mainly due to the Western influence on the media and the boom in the fashion industry. It has also been suggested that in India, anorexia is less commonly accompanied by a "fear of fatness" or a desire to be thin, but is motivated by the desire to fast for religious purposes or by eccentric nutritional ideas. [78]

In the realm of sexual disorders, "Dhat syndrome" (a term coined by Dr. Wig) is often regarded as a culture-bound syndrome specific to the Indian subcontinent and has been included amongst "other specific neurotic disorders" in the ICD 10. It is used in reference to those male patients who attribute their fatigue, weakness, and multiple somatic complaints to the loss of semen through nocturnal emission, urine and masturbation. [79] The syndrome subsumes hypochondriacal, anxiety and depressive symptoms under the major visible "pathology" of semen loss [80] and can be classified into Dhat alone, Dhat with comorbid depression and anxiety, and Dhat with sexual dysfunction. [81] The idea of semen loss and consequent anxiety has been reported from Sri Lanka and China, and there is ample evidence of the same in the 19th century Western literature, indicating that Dhat syndrome is not an exclusive product of the Indian psyche. [82] It has been proposed that the anxiety centered around semen loss has diminished in the West due to industrialization and urbanization and the same can be expected in South Asia. [82] However, till date, Dhat syndrome continues to dominate the psychosexual life of Indian patients and its management poses a challenge to Indian psychiatrists. Clinicians in India rarely encounter females with sexual dysfunction per se as the social taboos generally prevent them from approaching physicians and hence it is often masked under somatic and dissociative symptoms.

Personality disorders are less commonly seen in the clinical setting. One possible reason behind this is that they are viewed more as "habit" or "nature" rather than illness requiring clinical help. [3],[83]

Data on childhood onset disorders are generally scarce in India forcing us to depend on case reports and case series. This limits our ability to recognize distinctive features in these disorders. However, case reports have suggested toward shorter lived episodes of mania, higher rates of recovery, lower incidence of rapid cycling, less psychosis and mixed symptoms in Indian children with juvenile onset bipolar affective disorder as compared to Western patients. [84],[85]

Thus, we can safely conclude that although the clinical picture does not differ tremendously between the Indian and the Euro-Americans, there is sufficient evidence for subtle differences in the manner in which they manifest. However, we must keep in mind the possibility of bias in the studies quoted above. The bias can mainly be attributed to the attempts to fit our patients into the accepted diagnostic systems. By this I mean that when we label a person with say "Major Depressive Disorder", can we say with certainty that the criteria used are applicable for our populace? Could it be that we are forcibly applying foreign labels on our so-called "patients"? These impudent questions come to my mind whenever I think of the dearth of efforts on our part to validate the diagnostic systems including the ICD 10 in the Indian population.


   Treatment Top


Attitude toward mental illness and treatment seeking

Treatment can be provided only to those who seek the same and this treatment seeking is heavily influenced by the individual's perception of illness and belief system. The traditional Indian family values consider family members capable of solving all problems and seeking help from "outsiders" as disgusting and shameful. However, when they need to turn to outsiders for help for any illness, especially behavioral and affective changes, the sine qua non of mental illness, the religious bend of the average Indian leads them first to the doorsteps of temples and religious leaders. The belief in the supernatural causation, that is, the curse of God, evil spirits is even more predominant in mental illness as compared to physical illness. Indians believe in magical cure resulting from eradication of these evils through the goodwill of the Almighty. These magico-religious leaders employ various methods of healing like facilitating improvement of interpersonal relationship and encouraging adherence to social norms. [86] In addition, these healers also practice alternative systems of medicine. It is quite humbling when we read reports stating that a good proportion of individuals do believe that these visits have helped them. [87] A large proportion of people also tend to attribute their psychiatric ailments to physical problems and consequently visit the general physicians before reaching the mental health professionals. It is quite disheartening to see reports claiming that even medical students do not view psychological distress as an illness and attribute them to poor diet or loss of semen. In a study, nearly 10% of the medical interns and residents believed that psychiatric illness is untreatable, and a similar percentage believed that treatment is more disabling when compared to the psychiatric illness per se. [88] Hence, most of our clients reach us only after exhausting all these options. Even those who do seek treatment consider it to be more relevant for psychotic disorders. Disorders like major depressive disorder are less likely to be considered as psychiatric illness and hence biological treatment is less likely to be sought. [89] However, one of the surveys from South India revealed that larger proportion of patients with schizophrenia were taken to faith healers as compared to other mental illnesses. [87] It is not surprising that patients and their family members continue to visit magico-religious leaders even after contact with the medical fraternity. [90]

Service delivery

The practice of Psychiatry in India is often handicapped by the paucity of manpower and resources, financial or otherwise. This makes it imperative that methods other than institutionalization of mentally ill patients be devised. One such method is the establishment of the General Hospital Psychiatric Units (GHPUs) which became feasible with the availability of antipsychotics which dramatically controlled the agitation, aggression and withdrawal tendencies of patients, making it possible to treat them in general hospitals. The lack of extensive networks of psychiatric hospitals as in Europe or the USA renders the psychiatric services of general hospitals in India more comprehensive than their counterparts. As evacuation of acutely disturbed patients to the nearest mental hospital is not an easy option, the mental hospitals, being few and usually situated far away from the city limits, involve cumbersome admission procedures. GHPUs in India tend to handle almost the whole range of ICD 10 psychiatric disorders unlike their Western counterparts. Thus, GHPUs have made psychiatric services easily available to the community and have increased the involvement of our greatest asset, that is, the patient's family. They have also contributed to destigmatization of mental illness to some extent and increased the acceptance of Psychiatry and communication with the other medical specialities. A unique feature of GHPUs is the availability of consultation liaison psychiatric services and the impetus it has provided to the field of research.

The second method devised to meet the unmet need in psychiatric service delivery is the development of community psychiatry, an area in which the contribution of Dr. Vidyasagar can never be forgotten. It was he, who in the late 1950s began to involve family members in the treatment of mentally ill patients admitted in the Amritsar Mental Hospital. This was started mainly due to practical reasons but surprisingly led to increase in the number of patients who actually went back to their families. This gave birth to the concept of community psychiatry in India. This was furthered by the NIMHANS Crash Programme (1975) and the Chandigarh Experiment under the aegis of the WHO at the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh. These institutes attempted to train the multipurpose workers (MPW) of the Primary Health Centers (PHC) and the school teachers in recognizing psychological problems, followed by training of the General Practitioners and the doctors in the PHCs to treat cases of severe mental illness. Home-based follow-ups of psychiatric patients by nurses and MPWs were also undertaken. The satisfactory results of these training programs in terms of the knowledge gained by the PHC personnel led to the implementation of the highly optimistic National Mental Health Programme (NMHP) followed by the District Mental Health Programme (DMHP) with the ambitious aim, amongst others, of ensuring the availability and accessibility of minimum mental healthcare for all in the foreseeable future. However, these programs have fallen far short of their ambitious goals. Several factors have been blamed including the apathetic attitude of not only the government but also the mental health professionals and the grassroot level workers. On hindsight, the futility of the whole program becomes even more glaring when we consider the dismal situation of health care in general in our country.

Thus, lack of manpower, inability to establish community outreach programs effectively and the belief in supernatural factors as a causal agent of mental illness are some of the many factors that compel our patients to seek help from faith healers, religious groups and indigenous practitioners of medicine. Given India's long history of civilization, one has to consider that it is this group of "healers" who have dealt with "mentally ill" people over the generations, making it imperative to involve and understand these indigenous practices. If the welfare of our patients is our first priority, time has come when "mental health professionals" trained in the Western model of Psychiatry should seriously consider seeking support from this group in order to establish a complementary holistic treatment.


   Psychopharmacology Top


Pharmacokinetics and pharmacodynamics of the drugs vary across cultures. There is a high prevalence of poor metabolizing variants of cytochrome P450 enzymes like CYP2D6, CYP2C19, CYP1A2 in the Asian population, which renders them particularly sensitive to drugs like diazepam and imipramine. [91],[92] In the Caucasian population, the long (l) allele of the 5HTTLPR has been found to be associated with better response to antidepressants compared with the shorter(s) allele which has been found to be more common in the Asians. [93],[94] This finding has been contradicted by exactly opposite results reported in a study from Asia. [95] Again, it has often been seen in clinical practice that most of our patients fail to tolerate the doses of psychotropics commonly prescribed by Practice Guidelines using Europeans as the standard. [96] Hence, it becomes imperative for us to titrate doses of psychotropics, keeping the Indian physique in mind.

As mentioned earlier, the use of indigenous medications and alternative systems of treatment is part and parcel of psychiatric practice in India. [10] Herbal medications have psychotropic properties and may lead to unpredictable drug interaction through induction or inhibition of the various metabolizing enzymes. [91]

When it comes to electroconvulsive therapy (ECT), majority in India consider it to be cruel and barbaric. [97] However, it is heartening to observe that the view toward ECT is changing. In a study from a hospital in North India, three-fourth of the respondents believed that ECT has scientific proof for its utility. Also, just over a third of the participants believed that ECT is an inhuman treatment. [98] In comparison to the relatives of those who have never received ECT, relatives of those who had received ECT were more likely to obtain information from the physicians and were more likely to have the favorable attitude toward ECT. [99]

Given the developing nature of our country with millions below the poverty line, ability to afford biological treatment is at a premium in India. In addition, as the cost of the treatment is not shared by any governmental or non-governmental organizations, the family has to bear the entire burden. [100] This leads to unequal access to treatment, with some individuals receiving the benefit of the newest drugs, while majority of the urban and rural population are deprived of treatment. [101]


   Psychotherapy Top


The uniqueness of Psychiatry amongst the medical sciences is further highlighted by the wide array of psychological treatments that can be offered to the client. Psychotherapy, as recognized by the Western world, received impetus in India through the work of Girindrasekhar Bose, the founder of Indian Psycho-Analytic Society. Despite his unique and unorthodox views, the society soon came under the influence of Freudian and later Kleinian theories. These alien influences appeared to overshadow the original Indian tenor. It was Prof. D. Satyanand who grafted concepts from Indian mythology and Hindu philosophy, particularly the Bhagvad Gita, into the prevailing psychoanalytic practice, paving the way for Indianization of Psychoanalysis. [102] With time, psychiatrists in India have felt the need for modification of psychotherapy techniques in order to render them applicable to the Indian psyche described earlier. [103] In addition to the unique nature of our psyche which renders individual psychotherapy difficult, it is often rendered impossible due to financial constraints of the patient, the lack of trained analyst and the low doctor patient ratio. The physical or medical concept of mental illness prevalent among Indian patients not only influences the expression of mental illness but also leads to an expectation that the therapist would follow a medical rather than a psychological approach toward the management of their problems. The Indian patients expect the therapist to play an active and authoritarian role, making difficult the maintenance of "therapeutic neutrality", an important part of Western practice of psychotherapy. [104] The Western models of psychotherapy encouraging independence is redundant in the Indian population as dependency is a social norm amongst Indians. [102] The Hindu philosophical beliefs of transmigration of soul, re-birth, and fatalism, the different nature and quantum of guilt feeling in the Indian culture, and the differences in the need for confidentiality and inactivity exercised by the therapist, especially with regard to decision-making for the patient, and environmental manipulation render Indian psychotherapy vastly different from the Western model. Indian psychotherapists have therefore modified psychotherapy by using face-to-face seating arrangement, playing a more active role than in the Western model with use of suggestions, sympathy and manipulation of the environment along with teaching and reassurances in most cases. Hence, it has been proposed that psychotherapy in India should be short term, crisis oriented, supportive, flexible, eclectic and tuned to the cultural and social conditions. [103]

The rediscovery and reformulation of indigenous therapeutic paradigms like Yoga, Vedanta and Buddhism which have a distinctive philosophy of their own within the Indian tradition, despite the mysticism and folklore associated with them, have given greater impetus to Indianization of psychotherapy. Therapists have sought refuge in the psychotherapeutic paradigm illustrated in the Bhagvad Gita [105],[106] and in the guru-chela relationship. [102],[107],[108] Shamsundar proposed an integrated approach including experimentation with actual clinical circumstances and innovations dictated by cultural and individual specificities along with incorporation of traditional cultural concepts into the framework. [109] Relatively stringent scientific methods used to test the therapeutic efficacy of Yoga in psychiatric disorders revealed that it is superior to "pseudo-treatment". [110],[111],[112]

The important role played by the family in the Indian context has led to the success of family interventions in the management of severe mental illnesses like schizophrenia. Group meetings of caretakers of patients with schizophrenia and bipolar mood disorders have been demonstrated to improve the monitoring of the functional status of individuals, reduce subjective family burden and family distress, provide a better support system with adequate coping skills and good compliance with treatment program. [113] In alcohol dependence too, family intervention therapy has been seen to significantly reduce the severity of alcohol intake, improve the motivation for abstinence and change the locus of control from external to internal in the patients as compared to controls. [114]

The social taboos surrounding women with sexual dysfunction and toward sex in general, often render conjoint sexual therapy, requiring both partners, impossible to practice. This has led to modifications and emergence of a unique system of treating single males with sexual dysfunction like failure of genital response, premature ejaculation and Dhat syndrome. [115],[116],[117]


   Conclusion Top


From this discussion, one unequivocal conclusion that can be drawn is the distinctiveness of Indians in general. This distinctiveness lies in the ambiguity inherent in their personality and the nature of the society that nurtures them. Under these circumstances, as illustrated above, Indians cope with stress in a manner quite different from societies that preach independence and autonomy of individuals.

However, despite agreeing to this, we are still at a loss regarding whether mental illness in Indians manifests in a manner different from the prototypical Western man. Although there are subtle differences in the manifestation and course of mental illness in Indians, the available research does not point toward distinctive syndromes and symptom complexes specific to Indians. This can be attributed to several factors, namely, the research tools used in these studies. The research tools and methodology used for studying the prevalence and symptomatology of the psychiatric disorders in India are mainly borrowed from the Western literature. So, the home question is: Are such tools valid for a population so different from that which it had intended to study? Are they not ending up detecting only those disorders that they have been designed for and thereby failing to recognize syndromes specific to the Indians? This often makes us ponder whether the Psychiatry that is being practiced in India is actually a foreign notion forcibly imposed on the masses. However, the counter argument to this disturbing idea lies in the findings of the multinational collaborative studies on schizophrenia, which have clearly proved that prevalence and manifestation of this serious mental illness do not vary across cultures including India. But, there is dearth of similar research on other psychiatric disorders, making it difficult for us to reach to any conclusion. I propose that the time has arrived to validate the psychiatric diagnostic systems and research tools in the Indian population involving massive field trials requiring both man power and financial resources. This would undoubtedly be difficult to muster without the assistance from the state and without valiant efforts from mental health professionals.

Next, we move on to the treatment of those with mental illnesses. One can say with sufficient certainty that with respect to medications the Indians often fail to tolerate doses as high as their Western counterparts. It is time that systematic drug trials are conducted to assess both the effectiveness and tolerability of psychotropics in our patients. While doing this, one has to remember the heterogeneity of the Indian population which may affect the pharmacodynamics and pharmacokinetics of these drugs. With respect to psychotherapy, the Western model that promotes independence and autonomy may prove detrimental rather than helpful for Indians as it might further disturb the already disturbed homeostasis by challenging the core foundation of the Indian psyche. In short, attempts to maintain therapeutic neutrality and professional barriers (not allowing clients to touch one's feet or bless the doctor as their own child) might only contribute in increasing the sense of rejection in our clients, thereby seriously jeopardizing their improvement. As suggested by many others before me, psychotherapy in India has to take into account our traditions that inevitably make the therapist a "Supreme Being" who is expected to find magical solutions to the patient's distress and thus resolve their psychological pain. Disregarding this may provoke increased psychic anxiety and worsening of symptoms in our clients. Time has come for us to challenge practices borrowed from alien cultures and seek new methods which would be in keeping with the needs of our people.

Finally, we move on to the psychiatric service delivery in India. As elaborated earlier, given the current lack of resources and manpower and the higher acceptability of alternative systems of medicine amongst our masses, mental health professionals cannot afford to alienate them if they intend to provide comprehensive services. The essential role played by our spiritual leaders and faith healers in helping the family to cope with mental illness as well as in rehabilitation of the mentally ill can be neither disputed nor undermined. If we intend to destigmatize Psychiatry, the role of these indigenous systems becomes even more essential because of their far reaching impact on the minds of the Indians. Collaboration between mental health professionals and the practitioners of alternative systems of medicine has become the need of the hour. Thus, with respect to treatment and service delivery, the term "Indianizing Psychiatry" does not appear to be too farfetched as it might sound with respect to Indianizing diagnostic systems.

We can conclude that although further research is required to clearly state whether the current diagnostic system needs modification before applying it to Indians, treatment and service delivery do need Indianization or at least a serious consideration of the unmet needs of our people. I shall finally end with a hopeful note that this enticing debate would lead to developments in the foreseeable future, the final result of which would be the materialization of our dream - "mental health care to all".


   Acknowledgments Top


I wish to dedicate this prestigious Oration of Indian Psychiatric Society instituted in the memory of the illustrious late Dr. D. L. N. Murthy Rao to my family which has nurtured and supported me, to my teachers Dr. N. N. Wig, Dr. V. K. Varma, Dr. R. S. Murthy, Dr. P. Kulhara, Dr. S. Malhotra and late Dr. R. K. Chaudhary and late Dr. Morris Carstairs, colleagues and students who have only enabled me, and to my patients and their families.

I deeply appreciate and gratefully acknowledge the contribution of my trusted colleague, Dr. Sandeep Grover (Assistant Professor, Department of Psychiatry, PGIMER, Chandigarh), and my brilliant students, Dr. Munish Aggarwal (Senior Resident, Department of Psychiatry, PGIMER, Chandigarh) and Dr. Alakananda Dutt (ex-Senior Resident, Department of Psychiatry, PGIMER, Chandigarh), who came up with their bright ideas and literature support to help me in writing this oration supported by scientific research evidence and suitable for such a solemn occasion.

 
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Correspondence Address:
Ajit Avasthi
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5545.82534

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