Presidential address at the 19th Annual Conference of Indian Psychiatric Society, Kerala State Branch August, 2003-Kottayam
QUALITY OF LIFE
Dr. P.M. Madhavan
"One person in every 4 will be affected by a mental disorder at some stage ogf life."

Ms. Gro Haarlem Brunftland Director-General, WHO
"When a trout rising to a fly gets hoked on a line.........he begins a fight which results in struggles and splashes....... In the same way the human being struggles with his environment and the hooks that catch him..... His struggles are all that the world sees and it naturally misunderstands them. It is hard for a free fish to understand what is happening to a hooked one".

      Karl Menninger
Quality of Life (QOL)
" The missing measurement in health" (Follofield 1990) - "An individual's perception of their position in life in the context of the culture and value systems in which they live, and in relation to their goals, expectations, standards, and concerns."
Which means it is a subjective construct. The individual's beliefs, values, thoughts, and attitudes, called EMIC influences (Warner 1999), all affect QOL scores.
History
QOL assessment emerged in the late 1940s, after World War II, when Western economics began to prosper. There was a shift in attitude from merely "prolonging life" to "improving the quality of life" (Awad & Voruganti). the West took up the matter in a big way, but, as in most other matters, the Western approach was biased. In an effort to introduce a sense of balance to the concept, WHO evolved the QOL 100 scale, which was later upgraded to QOL-BREF to include spiritually and levels of independence.
But even this did not include QOL in non-Western cultures, where disease and illness are not seen simply in terms of a boundaried individual, but are social and spiritual in nature, manifesting thorough communication and expressions of a collective familial nature. they are not expressed through idioms of embodied and individual pathologies like in the Western world.
Thus the fundamental building blocks, concepts, epistemologies, and thinking space in which QOL originated were not tolerant of all world views, or congruent with indigenous and local variations of disease categories, illness narratives, and sanctioned processes for recovery (Collinge, Rudell, & Bhui-International Review of Psychiatry, Aug.2002).
Why no about QOL?
1. In medical practice, knowledge of QOL helps make the best choice in patient care. It helps bring a holistic approach to health and health care, and to measure QOL over the course of treatment.
2. It is extremely useful in improving doctor-patient relationships, and thereby reducing the chances of unnecessary litigation.
3. It helps in assessing effectiveness and relative merits of different treatments.
4. It is essential to the evaluation of health services.
5. It provides further directions in research.
6. It is an essential part of policy-making.
QOL : Multiple meanings
There is a variety of potential approaches to QOL.
1. A set of "objective" life circumstances.
2. A reflection of the individual's "subjective" appraisal of his life.
3. Overall health status (Health Related Quality of Life, HRQOL).
4. Health economic approaches (QUALYS & DALYS -Salvador & Carulla 1997)- Quality & disability adjusted life Years.
QOL and the Psychiatrist
We psychiatrists have unfortunately been divested of our ability to deal with "normally" even by our own colleagues of other specialist fraternities, Let alone society, media, and the public at large. here is a deluded notion that we can handle only abnormals: handle only by decreasing QOL..... there is a doubly deluded notion that we cannot handle hypnosis; cannot handle various type of psychotherapy: cannot handle "counseling"........ How unfair, untrue ! In the formative years of our learning, we are taught all that is normal and near-normal (if one didn't know a genuine currency note, how would one detect a fake?). We have also unknowingly nurtured this false belief by not involving ourselves in programmes which improve QOL in normals. So much so that this false belief is exploited  by unqualified and sometimes ill-intentioned people, pseudo-psychologists, counselors, faith healers, hypnotists, and so on. It's high time we participated in programmes which increase QOL of normals instead of leaving them to be exploited by so called "business management experts" as a purely lucrative proposition.
Recent research on " spirituality" and its effect on healing has put spirituality, understood as a person's relationship to that which gives him or her transcendent meaning and purpose in life, on the biomedical map (The Doctor's Relationship with Suffering - David B McCurdy). The focus on spirituality as a personal individual phenomenon usually includes a disclaimer about any necessary link to religion: "One can be spiritual without being religious". Traditional religious views of suffering often shape patient's attitudes and understandings, sometimes as explicit beliefs about God, the world, and human nature and destiny, perhaps more often as an internalized (if often theologically imprecise) sense of what their suffering has to do with God and/or their own conduct. Thus patients tend to respond to suffering with their own "theologies" of suffering (Herbert Anderson, Operational Theology), however true or untrue to any tradition, carefully wrought or rough-hewn, closed to new input or open to change these may be.
The post-Freudian era saw a schism - a "divorce" - between religion and psychiatry, and since then, no marital therapy has brought them back together.
This is one area where faith healers have scored over us: their approach is more "qualitative" as far as the 'subjective' response of the patient and his family is concerned. the mushrooming of religious centers that have no set rules or norms, that have no criteria on consciousness, that use guilt as their primary weapon, could all be because of our inability to use spirituality positively. the treatment meted out at some of these centers in inhuman, to say the least: if our government has an iota of "manassakshi" left in it, we would request it to bring in legislation to stop this religiously religious "exploitation of Illness".
QOL  of the care-givers
The stress on the care-giver has not yet been identified. We have to sensitize ourselves more to the needs of care-givers; especially the ones who, day after endless day, bear the burden of tending to the chronic schizophrenics, the mentally challenged, the demented, the children with developmental difficulties, etc. A positive step in this direction as already been made by the Thrissur group headed by Dr. K.S. Shaji, who have designed and standardized scales to identify and measure care-giver distress. They have focused on the following three areas.
a) Emotions
b) Activities of daily living and 
c) Personal freedom
The "prolific fecundity" with which so-called nursing schools churn out half-backed home nurses makes me wonder whether we are "creating" insanity in Kerala in the decades to come.
Pharmaceutical industry and us
If the pharmaceutical industry could liaison with our guilds in forming local "medicine banks", a lot of the poorer sections of society could be taken care of. Relapse prevention would be higher and rehabilitation more effective. Doctors would be enabled to deliver sustained treatment without straining the resources of patients and their relatives. I would appreciate it if the secretaries of our guilds would take this up as a project this year. Our guilds should also take a more active, positive and decisive role in preventing suicides. According to the latest NCRB report published one week ago, Kerala has the dubious distinction of being the state with the highest suicide rates in the country!
 We and the Media
I would like to remind the media that psychiatry works best through teamwork, the team consisting of the PR professional, psychiatric social worker, psychiatric nurse, clinical psychologist, and the psychiatrist. It is the psychiatrist, amongst equals, who is the team leader. I am saying this in particular because I've read columns and seen media shows wherein the psychiatrist has no role at all!
If the stigma of mental illness has to be removed and the QOL of society has to improve, it is the media, let me repeat, the media, who can, who should!
The Consultation - Liaison model
Pasnau, an authority in C-L psychiatry, described it as "the study, diagnosis, treatment, and prevention of psychiatric morbidity of the physically ill, of the psychological factors affecting the physical conditions, and of somatopsychic and psychosomatic interactions".
I Wish to address the whole medical fraternity involved in liaison work to make my point that there is "more to suffering than somatic pain". Do we know what suffering "really" is? What constitutes it ? How can we really learn to "know it when we see it? As Eric Chassell, a physician and medical humanist put it (New England Journal of Medicine, March 1982), the central point is that " suffering is experienced by persons!" This seemingly simple and obvious fact has important ramifications. For one thing, suffering is experienced not by bodies alone but by persons with minds and spirits, feelings and relationships, as well as bodies. Distress in any one of these areas, or in several or all of them together, any cause or contribute to suffering.
The second, because people are different, the way they experience suffering and what counts for them as suffering will vary from one person to the next. One size does not fit all: it is important to pay attention to each person's sources of distress. Chassell notes that, sometimes, even patients who recover physically and appear in every sense to be "doing fine" are inwardly still stricken-and may continue to remain so until identified and treated.
The third, because suffering is personal, it has to do with the meanings that illness (and treatment) may have for this person. As Chassell points out, the meaning of illness for a person is affected by many factors: Prognosis (and its certainty or uncertainty), cause, current (and likely) duration, chronicity, controllability, the losses it inflicts (and their reversibility or irreversibility), its impact on relationships (e.g. creating dependency or causing isolation), its effect on one's sense of self and worth, and resulting hopefulness or hopelessness of spirit. Ultimately, a key ingredient of suffering is the person's experience of a treat to integrity or "intactness"- in any or all dimensions of life, the bodily among them.
The bottom line is that "failure to recognize suffering can intensify it, and new suffering can occur". It is hence important for any professional who seeks to help sufferer to become familiar with the dynamics and dimensions of suffering and how these may emerge in different people. The physician must be adept at conveying diagnosis, prognosis, bad news, death and dying, and such crucial information. We must admit that there is a lack of training at undergraduate levels. Lack of role models compounds the problem.
In this context, we members would vehemently and fervently ask the Government to introduce more teaching hours on psychiatry into the undergraduate medical curriculum and possibly introduce a separate examination on the subject.
QOL of the psychiatrist
With the increasing disparity in the doctor-patient ratio and the demands of society, the psychiatrist is under back-breaking pressure. A quantum shift has to be made from the antique saying, "Physician, heal thyself". To delineate a few stressors:
  • The nature of the psychiatrist's work (Shift of onus from the West)
  • Time constraints
  • Social pressures
  • Family pressures
  • Peer pressures
  • Frivolous litigation
  • Hydra-headed presence of consumer activism
Let me take the privilege of nominating Dr. Shivathanu Pillai, Prof James T. Antony, & Dr. S.Santhakumar to study this in further detail. Let me take the further privilege of nominating the following doctors to study QOLs in the areas delineated and discuss periodically with the President the progress made:
Academics & research :Drs. E Mohandan & N R Arun Kishore
Geriatry : Drs SHaji K.S. & Shaji S.
Child and adolescent : Drs. Seethalakshmi George & Anil Kumar T.V
Legal/Forensic: Drs. Kuruvilla Thomas & Chandrasekharan Nair
Rehabilitation: Drs Ramanan Earat & Jayaram
Liaison: Drs. Roy Abraham Kallivayalil & Varghese Punnose
Anti-quackery : Drs. Sivaramakrishnan & Jerry Varghese
Mental hospitals: Drs. V V Mohan Chandran & Anil Prabhakar
Conclusion
In conclusion, I Have tried to sow the seeds of sensitivity into each one of us so that we, our fraternities, our patients, their caretakers,and the Keralite reap a better quality of life, both in health and in "disease" and develop positive mental health in years to come.

"I Believe that the very purpose of our lives is to seek happiness

Whether one believes in religion or not, we are all seeking something better in life."                                                          - The Dalai Lama

Thank you and God bless