Need to increase psychiatry training in graduate medical education.

Sir,

The article by Bindu et al.,[1] in the latest issue of this journal has dealt with an important area related to teaching of Psychiatry in India. The finding of 1.9/1,000 prevalence of mental disability by medical interns is about 30% more than the finding in a similar large scale survey carried out by National Sample Survey Organization (NSSO) in 2002[2] in which the prevalence of mental disability was 1.48/1,000 population in Karnataka. This may reflect that interns were better trained to detect mental disability than lay persons used in NSSO surveys. However, the result of this study is a gross underestimate of mental disability compared to other epidemiological surveys as the survey was based on the report by head of each household rather than actual direct assessment of the study population using the standard structured instruments on random sampling basis. Stigma attached to mental disability, no clear definition of mental disability in the study and less regard for trainee doctor compared to senior doctors involved in phase II of the reported study also may have contributed to the underestimate. The response rate of the study is also not mentioned. However, it is unlikely that a response rate of 100% would have been achieved in a large population of 15,583. It may be apt to point that need to apply the screening tool Mini International Neuropsychiatric Interview (MINI) Plus to 29 cases identified by the interns is not warranted as 29 cases is quite a small number to be confirmed by three qualified supervisors (who perhaps joined in the study at a later stage only) from the Psychiatry department and could be easily done by detailed psychiatric evaluation without further screening. It would have been more informative if the study stated the diagnostic classification (Diagnostic and Statistical Manual of Mental Disorders, International Classification of Diseases version) used for its phase II. Based upon the study protocol and results it shall also conclude that such population based surveys shall be carefully designed to use standard, validated, and structured tools for assessment of disability. Such surveys shall be carried by personnel trained in the use of the study tools and under the supervision of the concerned specialists’ right from the beginning of the study to maintain validity and reliability of the study findings.

The article reiterates the need to improve the undergraduate training of Psychiatry to medical students to equip them adequately to identify and treat prevalent mental disorders at the primary health-care level. There is no denying the fact that the weight given to teaching of Psychiatry to the undergraduate medical students is grossly inadequate and needs to be beefed up significantly. Neuropsychiatric disorders account for an estimated 13% of the total disease burden.[3] Compared to this huge disease burden the amount of time allotted to theoretical teaching of Psychiatry is only 1.4% (20 h of a total of 1,440 h) of the total theoretical teaching of clinical subjects in the MBBS course.[4] Similarly, clinical posting in Psychiatry is only about 1.4% (2 weeks of a total of 142 weeks of clinical posting) in the MBBS course.[4] Compared to 20 h of theoretical teaching in Psychiatry other specialties with the lesser disease burden such as Ophthalmology, ENT, Orthopedics enjoy 100, 70, and 100 h each respectively. Similarly, the clinical posting for Ophthalmology, ENT, and Orthopedics is 10, 8, and 10 weeks respectively during the MBBS course, which is substantially more than 2 weeks allotted to Psychiatry. Further, Psychiatry is not an examination subject leading to low priority accorded to it by the medical students. In 2008, MCI made provision of 2 weeks Psychiatry posting during internship but the overall training in Psychiatry remains grossly inadequate.[4]

Indian Psychiatric Society has been advocating an increase in the Psychiatry curriculum at the undergraduate level along with an examination to equip MBBS doctors to function effectively as primary care mental-health physicians.[5] A similar recommendation has been made by the Central Mental Health Authority to the Medical Council of India to increase the duration of Psychiatry training to 9 weeks of clinical posting and 40 h of theory classes along with an examination in Psychiatry to be conducted by Psychiatrists in MBBS.

The graduate medical education curriculum is being revised by the Medical Council of India and it is an opportune time to correct the huge gap in the disease burden due to mental disorders and the meager time allotted to its learning in the MBBS curriculum. This will go a long way in achieving the objectives set out for Psychiatry teaching in the graduate medical education and the need of meeting the challenge of providing comprehensive health-care services at primary health-care level by addressing an important and indispensible dimension of health, i.e., mental-health.