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LETTERS TO EDITOR  
Year : 2019  |  Volume : 61  |  Issue : 2  |  Page : 220-221
Psychiatry, mental health, and primary health care


Department of Psychiatry, AIIMS, Rishikesh, Uttarakhand, India

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Date of Web Publication11-Mar-2019
 

How to cite this article:
Das A. Psychiatry, mental health, and primary health care. Indian J Psychiatry 2019;61:220-1

How to cite this URL:
Das A. Psychiatry, mental health, and primary health care. Indian J Psychiatry [serial online] 2019 [cited 2019 May 25];61:220-1. Available from: http://www.indianjpsychiatry.org/text.asp?2019/61/2/220/253828




Sir,

The paper by Manjunatha et al.[1] is indeed interesting and notably different from the past efforts of training primary care doctors (PCDs) on two important accounts, such as the designing of a clinical schedule for “primary care psychiatry” (PCP) thus simplifying the diagnostic process and tailoring it to primary health care (PHC) needs and use of on-consultation training or handholding that focuses more on skill development rather than knowledge. Yet few more issues also need to be understood for integration of psychiatry into PHC. I have been recently associated, though as observer, with this groups' attempt at training PCDs from Uttarakhand and my aim is to clarify some aspects and refine thinking on PHC and the National Mental Health Program (NMHP).

As a starting point, I disagree with the meaning of PHC inferred by the authors as “the provision of healthcare at first contact and for continuity of care which will be nearer to… home.” Though partly correct it conveys that PHC is limited to the provision of only clinical care and dispensing of medications where as preventive and promotive activities, various social care benefits and rehabilitation, and aspects of community participation are outside its forte. Thus, there may be a tendency to conflate the authors' PCP as a template for the district mental health program (DMHP). Although the authors do not claim so, they should explicitly mention this to ensure the audience refrain from doing the same.

Clinical schedule for primary care psychiatry

For the task of training PCDs, the PCP program has developed a brief clinical schedule.[2] The first author was kind enough to have provided me a copy of the clinical schedule on request. While its brevity is its asset, yet it remains a comprehensive diagnostic and management tool for psychiatric disorders. Although the authors are working on a new version, I expect to see a few changes, first the incorporation of the concept of socio-occupational dysfunction in the diagnosis of different disorders, as this concept is often easy to understand/interpret in clinical situations and a standard to differentiate conditions that require treatment from those that do not, thus avoiding inadvertent over-medicalization. Second are the identification, evaluation, and primary management of emergency psychiatric conditions for its obvious importance. Third local variants of the schedule need to be considered depending on the epidemiological or other specific needs. For example, due to the prevalent problem of opioid abuse in Punjab, Haryana, Rajasthan, and North-eastern state,[3] this becomes important for inclusion.

On-consultation training

The training primarily focuses on how to briefly evaluate for psychiatric signs and symptoms and come up with a prescription devoting on an average 5–10 min for each patient. Thus, the focus is primarily pharmacological management as the authors themselves submit. Moreover expecting something more from the PCDs would be lavish. My personal participation with this training has also made it evident that nonavailability of drugs then turn into a major hurdle in the treatment of patients. Considering the PCDs practice in less resourced locales, even private pharmacies do not stock psychotropics. Thus, training in pharmacological management should go hand in hand with ensuring availability of drugs under the DMHP.

Moreover, since the PCDs are usually expected to be a community advocate (including health education),[4] thus a component of mental health advocacy is an important part of the training that should be looked into in the future.

Bottom-line

A PHC program in psychiatry needs to always keep an eye on the NMHP, such as the availability of psychotropics in the PHCs, strategies to manage psychiatric emergencies, attention to locally specific psychiatric needs and components of advocacy and health education among other preventive strategies. Other key issues though outside the ambit of PCP includes addressing psychosocial and rehabilitation needs and the contentious concerns of community participation.

Thus PCP, as conceived, contributes to a small but important fraction of the NMHP, while the name may mislead readers to assume otherwise. I urge the readers not to do so.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Manjunatha N, Kumar CN, Math SB, Thirthalli J. Designing and implementing an innovative digitally driven primary care psychiatry program in India. Indian J Psychiatry 2018;60:236-44.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Manjunatha N, Naveen Kumar C, Suresh BM, Jagadisha T. Clinical Schedules for Primary Care Psychiatry – Version 2.1. Bengaluru, India: Published by Department of Psychiatry, National Institute of Mental Health and Neurosciences; 2017.  Back to cited text no. 2
    
3.
Ray R. The Extent, Pattern and Trends of Drug Abuse in India, National Survey, Ministry of Social Justice and Empowerment, Government of India and United Nations Office on Drugs and Crime, Regional Office For South Asia; 2004.  Back to cited text no. 3
    
4.
Mash R, Almeida M, Wong WC, Kumar R, von Pressentin KB. The roles and training of primary care doctors: China, India, Brazil and South Africa. Hum Resour Health 2015;13:93.  Back to cited text no. 4
    

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Correspondence Address:
Anindya Das
Department of Psychiatry, AIIMS, Rishikesh, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/psychiatry.IndianJPsychiatry_339_18

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