A world-class centre for the treatment of the mentally ill, the Department of Psychiatry of the National Institute of Mental Health and Neuro Sciences celebrates its 50th anniversary.PARVATHI MENON in Bangalore
THE sunlit wards and green inner spaces of the National Institute of Mental Health and Neuro Sciences (NIMHANS) in Bangalore are a reassuring reminder that modern mental health care is a world away from commonly held stereotypes, whether of "mental asylum" environments or of oppressive mental treatment regimes. No padded cells here, or raving patients chained to their beds. Large inner quadrangles in the long-stay psychiatry wards, for example, permit patients to savour the outdoors. The wards are spotlessly clean, the nursing staff cheerful and businesslike, and the patients - even the profoundly disturbed among them - secure in the treatment and humane atmosphere provided for them.
All this is not surprising for those who have been associated with or are familiar with the pioneering role of NIMHANS in the country's mental health care system. The institute's Department of Psychiatry, which celebrates its 50th anniversary this year, is in a historical sense its very raison d'etre.
The origins of the institute go back to 1847, when a ward for the mentally ill was established in the Bangalore General Hospital, the nucleus of the Lunatic Asylum that was set up subsequently. The Department of Psychiatry was formally established in 1954, when the Mysore Mental Hospital became the All India Institute of Mental Health. In 1974, this was renamed the National Institute of Mental Health and Neuro Sciences.
Significantly, the reputation of NIMHANS as a centre of excellence is firmly tagged to its presence in the public health sector. Thus, its vanguard role in mental health care in India - whether in modern treatment practices, teaching and research, policy formulation, or community and outreach interventions - has served those who would normally have never been able to afford such services. Indeed, it is argued that NIMHANS has become what it is precisely because it is a government institution, and that it must continue to be one to retain its character. Funded by both the Central and State governments, and with treatment that is almost free to most sections of the poor, the Institute has been able to reach out to the widest possible sections of society.
On a typical day, for example, 1,000 out-patients seek treatment in the hospital, of which 500 are new patients. There are at least 250 emergency cases each day and approximately 2,000 neurosurgical operations are performed every year. In 2003, the Institute recorded over 3.5 lakh patient visits (out-patients, emergencies, in-patient admissions and screenings), and reached another 22,000 through its community extension services. While 80 per cent of its patients are from Karnataka, the hospital is eagerly sought by people from other parts of the country and abroad.
"Sixty per cent of our patients come from families below the poverty line," said Professor D. Nagaraja, Director of NIMHANS. For those who can produce evidence of their below poverty line (BPL) status, treatment is free. It is this that has allowed, for example, patients such as Manju Kumar (name changed), a 12-year-old whose father is a daily-wage worker from Amlapuram in Rajahmundry district of Andhra Pradesh, to seek treatment at the hospital. Manju Kumar suffers from Friedrich's Ataxia, a form of spinal tract degeneration. He has had daily physiotherapy sessions at the neuro rehabilitation centre of NIMHANS for 45 days. "My son's treatment and stay are free. So is his food. Everything here is very good," said his father. The hospital has about 900 beds, of which around 50 are for long-stay patients. There are facilities for a member of the family to stay in the family ward and in the children's ward. There is also a guest house with 100 rooms, individual and double, as well as a dormitory, where cooking facilities are provided, at costs ranging from Rs.10 to Rs.50 a day.
"We still need to de-stigmatise mental illness, and because mental illness is so common, it requires even greater attention than what is being given," said Professor Nagaraja. The World Health Organisation (WHO) estimates that one in every four persons will be affected by a mental or neurological disorder at some point in life, and that depressive disorders are the fourth leading cause of the global disease burden. The poor bear the greater burden of mental disorders, in terms of both risk and lack of access to mental care. "Unlike other disabilities, mental disabilities are not obviously visible. The mentally ill need advocates, they cannot speak for themselves," said Professor Nagaraja.
Psychiatry is only one of the 21 departments in NIMHANS, which focuses on treatment ranging from neurophysiology and neurosurgery to psychiatric and neurological rehabilitation. Clinical services apart, separate services are provided for children with behavioural and learning disabilities, dementia and other geriatric problems, problems relating to alcohol and drug abuse, and neurological and psychiatric disorders associated with HIV/AIDS (human immunodeficiency virus/acquired immune deficiency syndrome). Training is a core activity of the Institute. Every year, 148 students enrol in 16 post-graduate (M.D.) courses and four diploma courses. A Ph.D. programme is offered in almost all disciplines. In addition to the formal courses and degrees, short-term training is offered to students and faculty from all over the world. As a WHO collaborating centre, NIMHANS has trained candidates from several developing countries in community mental health.
Patients and visitors to NIMHANS never fail to be impressed by the professionalism of the team of doctors that propel the Institute. The average faculty member in the Institute is a person who radiates assurance and calm through the surrounding sea of mental turbulence. Dedication to patient care, commitment to institutional goals, and an avid involvement in broadening the frontiers of their respective specialisation through research appear to be the attributes that drive the faculty of NIMHANS. Many of them are leading professionals in their respective areas of expertise.
"I believe that much of this has to do with our long history, and the traditions established by our founding fathers, who were not just doctors but visionaries," said Professor Shoba Srinath, Head of the Department of Psychiatry, and Chief of Child and Adolescent Psychiatry Services. "A lot of these people looked at human beings in a holistic way and taught us that you cannot practise psychiatry out of an office. You have to work with other professionals if you are treating a whole person," she said. With the mushrooming of the private mental health care sector, there is the very real possibility of faculty leaving for greener financial pastures. But a majority of them have rejected that option primarily because of the combination of professional opportunities unique to NIMHANS. The Institute, of course, can only retain its most precious asset if it perpetuates the tradition of nurturing excellence in an atmosphere that is relatively de-bureaucratised and free of interference.
Research papers and studies coming out of NIMHANS, many of them in frontier areas of neuropsychiatry, have been integral to the reputation and standing of the Institute. "We have a very high citation index for publishing in psychiatry and the neuro sciences, with more than 800 indexed publications in the last two decades," said Dr. Sanjeev Jain, Additional Professor in the Department of Psychiatry. There is, for example, ongoing research in the area of autism and major depressive disorders among children and adolescents under Professor Shoba Srinath. Dr. Jain has been engaged in collaborative genetic research in the field of schizophrenia and bipolar disorders and Dr. Prabha S. Chandra and Professor S.K. Chaturvedi in research on the psychiatric overlays between HIV and cancer. There is research being done in the area of alcoholism and mental disorders under Dr. Vivek Benegal and Dr. Pratima Murthy; in mental disorders of the elderly by Dr. Mathew Varghese and Dr. Srikala Bharat; and on obsessive compulsive disorders by Dr. Y.C. Janardhan Reddy.
But this is only a sampling of the very diverse research being done in the Institute. Professor C.R. Chandrashekar has been the public face of psychiatry in Karnataka, popularising mental care and destigmatising mental illness through lectures and a large body of popular writing in Kannada. Professor Mohan K. Isaac has made fundamental contributions in the area of community mental health, in the development of India's National Mental Health Policy, and in the National Human Rights Commission's report on Quality Assurance in Mental Health.
The Ninth Five Year Plan allotted Rs.1.5 crores to initiate a District Mental Health Plan, which was substantially increased in the Tenth Five Year Plan. The plan has already been implemented in 27 districts and will be extended to 100 districts. NIMHANS created a model for the programme in Bellary district of Karnataka. "This is the only way that mental health care can be taken to rural areas," said Professor Isaac.
NIMHANS had made significant progress in the field of psychiatric rehabilitation well before the passing of the Persons with Disabilities Act, 1996. "We have looked at psychiatric rehabilitation in a more innovative way. We have de-professionalised the area, drawing in greater community participation to generate a people's movement to remove the stigma of mental illness," said Dr. T. Murali, Head of the Department of Psychiatric and Neurological Rehabilitation.
There are, nonetheless, several challenges before the Institute. "The demands on us are diverse," said Professor Nagaraja. "There are only 3,500 trained psychiatrists in the country, a majority of them in the four metros. Our doctors have a huge workload. Then there are the divergent demands: do we focus on community psychiatry, which is not very high-end, or on clinical and research-oriented areas? We would ideally like to do both. We also need to focus on promotional health," he added.
As the Institute meets these challenges, such debates will continue to engage the NIMHANS community, and it is perhaps essential that they do. Should long-term institutional care be phased out, or is the Institute abdicating its responsibility to the poor by doing so? How humane are the community or family structures for psychiatric patients in need of long-term care? Privately-run long-stay homes for such patients have mushroomed in Bangalore, but where do the poor go? Should an institute spread its scarce resources thin so that the maximum numbers benefit marginally, or should it make one-time investments in advanced, though expensive, technology? Has the introduction of user-fees kept out sections of the mentally ill who can now no longer afford treatment?
The core institutional goal of NIMHANS has been to spread mental health care to the widest sections of the population. This goal is centred on its presence in the public, or state, domain. This is perhaps the key condition that will allow NIMHANS to extend its services and activities.