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The public health burden on a population posed by common mental disorders far exceeds that of severe mental disorders,
but it has only been in the past 50 years that this has been widely appreciated.[1] The supply of psychiatrists
in developing countries is very much smaller than that in the developed world (typically below 0.4/100,000 versus
9-25/100,000 [2], and virtually predicates that primary care must be the main provider of mental health care for all
forms of disorder. There is a significant gap between the prevalence of mental disorders and the number of people
receiving care and treatment. While this is a universal problem, magnitude of this is much higher in developing
world including in India.
Why primary care physicians need to know regarding mental health?
The diagnosis and treatment of physical disorders such as cancer, heart disease and
asthma can generate mental health problems in affected individuals, which in turn can adversely affect health outcomes.
Mental health problems range from increased stress and worry about the illness, to disrupted family or work life, through
to diagnosable mental disorders. Depression, anxiety and cognitive impairment are the most common consequences of physical
health problems. Most medical schools throughout the world do not provide enough instruction to future physicians in the
management of common mental disorders, preferring to emphasise the much rarer major mental disorders. Those entering general
medical practice therefore have an unmet need for supplementary training.
What causes underdetection and undertreatment?
Many patients do not recognize they have symptoms of a mental disorder, and
instead focus on physical health problems such as gastrointestinal symptoms, fatigue, headaches,[3] pain, and sleep
disruption.[4] Others underestimate the severity of their problems and mistakenly believe they can manage without the
help of formal health services.[5] Patients might view themselves as morally weak, unable to care for themselves,
unable to handle responsibility, dangerous or unworthy of respect. Concerns about embarrassment from
using mental health services also stop people from seeking help. There may be an underlying reluctance
to suggest diagnoses and treatments that patients will resist. The general population tends
to associate mental disorders with psychotic, irrational and violent behaviour, or alternatively does not regard
mental disorders as amenable to treatment.[6]
Where are we now?
Psychiatric training has undergone major development over the past
decades and scientific developments in the field of molecular biology, neurobiology, genetics,
cognitive neurosciences, neuroimaging, psycho-pharmacology, psychiatric epidemiology and many other
related fields have contributed to the increasing growth of psychiatry as a medical discipline.[7] In India,
the locus of training is shifting to post graduate departments in medical colleges, unlike in earlier times
when the training was concentrated in specialised psychiatric institutions.
What are the challenges?
Lack of quality assurance in teaching and training of Psychiatry coupled with a
nominal representation of Psychiatry in the undergraduate theory examinations and absolutely no representation
in practical examinations. Many medical colleges have no departments of Psychiatry, and even many existing
departments are poorly managed. Attempts are made by Indian Psychiatric Society to sensitize our medical colleagues,
health administrators and regulatory body office bearers, policy makers about the significance of undergraduate
Psychiatric education.
References:
- Goldberg DP, Huxley PJ. Common mental disorders. A biosocial model. London: Routledge, 1992.
- World Health Organisation. Atlas: country profiles on mental health resources. Geneva: World Health Organisation, 2001.
- Hirschfield R et al. The National Depressive and Manic-Depressive Association Consensus Statement on the undertreatment of
depression. Journal of the American Medical Association. 1997;277:333–340.
- Üstün TB, Sartorius N (eds.). Mental illness in general health care: an international study. Chichester,Wiley, 1995.
- Sareen J et al. Perceived barriers to mental health service utilization in the United States, Ontario,and the Netherlands.
Psychiatric Services. 2007;58:357–364.
- Mechanic D. Barriers to help-seeking, detection, and adequate treatment for anxiety and mood disorders:
implications for health care policy. Journal of Clinical Psychiatry. 2007;68(Suppl.2):20–26.
- Rubin EH, Zorumski CF. Psychiatric education in an era of rapidly occurring scientific advances. Acad Med 2003;78(4):351-354.
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