Presidential Address

Role of General Hospital Psychiatry In Medical Education and Health Care
Dr. Roy Abraham Kallivayalil
 M. D. (Psych-PDI), D. P. M., F. I. A. M. S.
 Our country is a signatory to the Alma Ata Ceclaration, Which envisages "Health for all" by 2,000 A.D., W. H. O. Defines Health as positive well - being, physical, mental, and social. 'mental health' thus forms an integral part of total Health, and as such promotion of mental health must be one of the important priorities of the National Health Policy. for the past several years, Indian Psychiatric Society has been taking all efforts to make mental health services a part of the general healthcare delivery system. But mental health always remained a neglected area at the hands of Central and various state Governments perhaps due to the following misconceptions:-
a) Prevakence of mental health illness is low in our country as compared to the western countries.
b) No effective treatment is available for mental illness.
c) Mental illness, once acquired is a life - long illness.
d) Psychiatric treatment is very costly.
 Needless to say, each one of the above arguments is wrong.
General Hospital Psychiatry :- We are in the midst of a historical change as regards psychiatric treatment is concerned. This has been made possible units in General Hospital Psychiatry- the starting of Psychiatry units in General Hospitals. Till the time of independence, psychiatric treatment was available almost only in the various mental hospitals which were only few and far away. There was no facility to treat the disturbed or psychotic patients in general health care. And patients with 'neurotic' or 'psychosomatic' illness, had no place to go. At best they could seek treatment from the general practitioner or a medical specialist, who were almost always burdened with heavy clinical work, and could not spend a prolonged time, listening to a person with psychological ailment. Hence the out look for psychiatry was quite bleak.
 It was at his juncture that general hospital psychiatry arrived, as a lighted candle it darkness. The first general hospital psychiatry unity was established by Dr. Girindra Sekhar Bose (psycho-analyst and disciple of Freud) in 1933, at R. G. Kar Medical College, Calcutta. The next units was started at J.J. Hospital Bombay in 1938 by Dr. k. K. Mosani,. After independence in 1958, Dr. N. N. Gupta started a unit in K. G. medical college, Lucknow and Prof. J. S. Neki in medical College, Amritsar. But it was during the last three decades, that General Hospital Psychiatry witnessed epoch making growth, gaining wide acceptance from the public and providing much needed excellent care to the psychologically ill. To may knowledge, the first General Hospital Psychiatry Unit in Kerala was established at Kottayam Medical College in 1966, and was nurtured by eminent. men like Dr. G.S. Nair, Dr. T. O. Abraham and Dr. James, T. Antony, (the present president of the Indian Psychiatry society) I had the rare privilege to be associated with this unit for 6 years as a student, and now for the last 12 years as a teacher,
Relevance of General Hospital Psychiatry:- What is so special about these General Hospital Psychiatry Units? In fact, these units reflect a silent, yet revolutionary social change. In a state like Kerala, psychiatric services are now reaching the door- steps of ordinary people, providing immediate care in emergencies. General Hospital are now managing almost all psychological problems including the management of psychiatric emergencies, depressive illnesses, neurotic and stress related disorders and emotional problems in children and adolescents. This has led to the following beneficial effects:
1) Psychiatric care has became more accessible and less costly.
2) Family members are involved in the treatment programme
3) Physicians and other specialists are able to readily refer their cases to the psychiatrist.
4) More and more people are able to seek care.
5) Over-crowding in mental hospitals, could be reduced to some extent.
6) There is less of stigma in a General Hospital setting, leading to better patient compliance.
7) Above all, medical colleges are able to provide better and 'in-house' training to medical students.
The Indian Scenario : Contrary to popular belief, mental illness is widely prevalent in our country, and the prevalence id certainly not less than what is reported from western countries. Besides, the figures are as high in rural as in arban areas. Mental illness causes immense suffering to the person, the family and the community. although this suffering may not be highly visible. It is estimated that mental illness is responsible for 20-35% all disabilities. Statistics from our country reveal that nearly 10% of the population will require psychiatric help for emotional problems. And nearly 3% of the population suffer from serious psychiatric ailments. Thus our country has to care for nearly 2.5 crores (25 million) of mentally ill people. To look after them, we have only 2,500 psychiatrists, requiring psychiatrist to look after 10,000 seriously ill persons. Further, we have only 20,000 beds in general and teaching hospitals. For an estimated population of 900 million, there is one psychiatric bed per 40,000 population. This is indeed a bleak state of affairs.
The Kerala Scene : By the earlier estimate, it can be seen that nearly 2.5 million 925 lakhs) people in our state are in need of psychological help. Among them, nearly one million (10 lakhs) suffer from serious mental problems. To face this daunting task, we have barely 250 psychiatrists in our state. Their services, however best is too insufficient.
General Hospital Psychiatry and Medical Education:- Promotion of mental health in now an integral and most important part of medical education and health care delivery system all over the world. To meet this huge challenge, our undergraduate medical students, undergoing MBBS course, should be given adequate and thorough training in psychiatry. This is also envisaged by the National Mental Health Programme for India (N. M. H. P.)(1982). The following two are among the eleven out-lined as time-bound targets by the N. M. H. P. (11982).
1) Enhancing mental health training in undergraduate medical education.
2) Improvement of psychiatric teaching units and mental hospitals.
 Similarly the Central Council of Health and family Welfare91982) recommended that :-
1) Mental Health must from an integral part of the total health programme and as such should be included in all National policies and programme, in the field of health education and social welfare.
2) Realizing the importance of mental health in the course/curriculas for various levels of health professionals, suitable action should be taken to strengthen the mental health education components.
 And the N. M. H. P. Workshop on Mental Health training of undergraduates in Medical College, held in march 1988,. recommended that "Medical education and administrators be motivated to get more involved in integrating psychiatry, into mainstream medicine, and the fields of both teaching and service delivery".
What needs to be done? :- Viewed in the context of above, we can see that psychiatry Departments of the five Medical College of Kerala, has to be expended adn vastly improved to meet this major challenge. Except one, all the Medical College of our State have at present inly one Psychiatry Unit, which is burdened with outpatient services and in-patient care in the collegiate Hospitals, besides, teaching psychiatry to under-graduate and poet-graduate medical students. This is a sad state of affairs. It is worth nothing that other specialities like ophthalmology, Dermatology, E. N.T. And Orthopaedics have more that one unit in all the five medical college. Hence at least one more additional unit of psychiatry with necessary teaching posts has to be established in all the five medical college of Kerala. Similarly Psychiatry Units have to be established in all the District Hospitals as well as Taluke headquarters hospitals inour state, without this integration of psychiatry with general health care becomes impossible. A large number of General Hospital Psychiatry units in the private sector is a special phenomenon in Kerala. These units are doing great service to the public and hence they should be given every possible encouragement and help by the Government.
Conclusion : The value of provision of mental health services and its delivery to the masses from General Hospitals, has been recognised both at the National and State levels. The mere fact that such units are situated in the heart of the community that they serve, making them easily accessible, renders such units more acceptable less threatening to the users. And these units have much less stigmatising effect, too. Undoubtedly, General Hospital Psychiatry has arrived and id going to say. But we have a long, long way to go. Realizing the importance of General Hospital Psychiatry in medical education and health care, the Government and the administrators, must make every effort to expand and vastly improve them.
REFERENCE:
1) AUSTER, B. H. (1972). The pattern of psychiatric referral in a General Hospital, Brit. J. Psychiat., 120, 631.
2) BRIDGES, P.K.KOLLER, K.M.WHEELER,T.K. (1966), psychiatric referral in a General Hospital, Acts Psychiatr, Scand, 42,171.
3) HACKETT, T.P. (1978), Beginnings: Liaison Psychiatry in a general hospital, in handbook of General Hospital Psychiatry.
4) KULAHARA,P. (1984), General Hospitals in post-graduate Training and research, Indian J. Psychiat., 26(3),281.
5) National Mental Health Programme for India (1982).
6) N. M. H. P. For India-Progress Report (1982-88).
7) SETHI, B.B., CHATURVEDI P.K. (1984). National Mental Health Plan and General Hospital Psychiatry, Indian J.Psychiat, 26(3), 253.
* Delivered at the 11th Annual Conference of Indian - Psychiatric Society, Kerala State Branch, at Calicut on 20th August, 1995.
** Address: Department of Psychiatry, Medical College Kottayam-B.