Undergraduate psychiatry training in India; past, present, and future looking for solutions within constraints!!

Psychiatric disorders are considered one of the leading causes of morbidity and mortality worldwide.[1] They are closely associated with other medical conditions such as diabetes and hypertension, adversely affecting their outcome.[23] India has more than 1/6th of the global population, and is a rapidly developing country with enormous changes in all spheres of life. Mental health issues are gaining a great deal of importance, in keeping with other health issues, and are likely to play a key role in the diverse indicators of development. Suicide rates in India are reportedly one of the highest in the world and have already attracted political and socio-cultural trajectories in both causation and solutions for the problem, underplaying mental health causes for the same, as well as understating the inadequacy of mental health services in India.[4] Concerns regarding the mental health scenario in India are directly related to a lack of awareness among the public and a lack of the minimal mandatory training in psychiatry for medical undergraduates, which has consistently produced thousands of doctors who are incompetent to diagnose and manage common conditions such as depression and suicide.[5]

Training undergraduates in the field of psychiatry can be considered as one of the most important pathways to improve mental health services in India. That undergraduate training in psychiatry is inadequate has been the contention from the first report of the subcommittee on undergraduate teaching in psychiatry, Indian Psychiatry Society (1965).[6] The emphasis has been on inadequate hours of training in psychiatry as well as a lack of the required trained staff. Painfully, despite the numerous evidences about benefits of undergraduate psychiatry training [789] nothing seems to have changed in this half of the century (1965–2015) as the Medical Council of India is reluctant to make psychiatry a mandatory subject for the MBBS examination,[10] impairing the mental health component of basic health services in India. This great lacuna in Indian medical education is likely to have an adverse effect on mental health services for the next few decades. In addition is the issue that India has a large deficit of psychiatrists with just 0.3 for 100,000 populations, as mentioned in world mental health atlas 2014.[11]

To address this challenge, we may have to look for solutions that enable us to attract medical students to the subject of psychiatry, and build psychiatric knowledge and skill in them through diverse ways. The onus for achieving this lies on each faculty and the department as a team, the policies of the Institution and University to which they belong, as well as professional bodies like the Indian Psychiatric Society, each of whom will have a major role to play. The efforts of Indian Psychiatry Society have been well-summarized by Dr. Roy Abraham Kallivayalil in his presidential address at ANCIPS 2012, Kochi.

The Medical Council of India had made it mandatory for all medical colleges to have a department of psychiatry as a part of teaching hospitals, providing mental health services in a general hospital setting. Needless to say, most nonteaching hospitals in India, public or private, do not have psychiatric services on a regular basis. Hence, medical colleges are crucial centers for providing Mental Health Services. Currently, there are 412 medical colleges in India with 52,325 MBBS seats.[12] The onus of training these medical graduates in psychiatry for whom the subject is not mandatory, as in, not assessed in the current examination system, lies with the faculty in psychiatry, they have to use their knowledge and passion in delivering psychiatric training for these students. Departments that have recognized postgraduate seats must also put in the same degree of effort in teaching the undergraduates. There have been some innovative ways and experiences on undergraduate psychiatry training, including one from the authors of this article.[1314] Looking beyond individual faculty, it is the Department of Psychiatry who as a team should have a unified goal to do everything possible in strengthening undergraduate psychiatry teaching. The efforts need to be customized to the respective institutional realities. For example, it is worth mentioning that Psychiatry postgraduates alumni of KIMS, Bengaluru have instituted an exclusive annual award for best undergraduate in Psychiatry at KIMS and best young teacher award in psychiatry at the Karnataka IPS, such efforts are important in attracting and appreciating the students and teachers at medical colleges.

Sharing successful models of undergraduate teaching would go a long way in improving patterns followed by institutions. Unfortunately, there are very few avenues to share successful models other than through published studies. A platform to enable this is important so as to share certain real world issues, which can be narrated and discussed. To facilitate this process an annual exclusive CME, and/or allocating a session of the annual psychiatry conference, and/or a regular corner in the Indian Journal of Psychiatry can go a long way in improvizing undergraduate psychiatry teaching in India.

The upcoming of numerous deemed universities in India can be an opportunity to teach psychiatry to the undergraduate student, as the University Grants Commission has given them enough flexibility to design their curriculum, resulting in some of them accommodating psychiatry as a mandatory part of their examination system.[15] This needs to be replicated in other universities as well. Professional bodies like the Indian Psychiatry Society can move a step ahead and consider launching exclusive psychiatry journals for undergraduates, catering to their special needs as well as encouraging their interest in research.

The second most important aspect in this challenge is the training of teachers in teaching undergraduate psychiatry. As mentioned earlier, the last few decades have seen a substantial increase in the number of medical colleges in India, and most institutions have recruited fresh postgraduates as regular staff in the Department of Psychiatry. These young staffs have little or no formal training in teaching methodologies. They also have new found responsibilities with respect to patient care, and demand to participate actively in departmental teaching activities. There have been some sporadic efforts in the past, to train these teachers, but details are unavailable.[16] Documenting such efforts as booklets and building archives of such CME/Symposium will benefit future efforts. It may well be the right time to start a forum in India for teachers of psychiatry active in the social media, as well as having an agenda for all teachers to meet annually and make their experiential contributions for strengthening and streamlining this process.[17]

To summarize, mental health services in India strongly depends on undergraduate psychiatric training. The goal can be achieved by working on a diverse and sustained approach to train medical students despite constraints and by actively training and motivating teachers in Psychiatry.