'Mental health is a public health issue'

T.A. HAFEEZ

Interview with Moises Gaviria.

Moises Gaviria, Professor of Psychiatry, University of Chicago, Illinois, United States, an internationally acclaimed expert in neuropsychiatry and the president of the International Neurological Association was in Chennai to deliver the 18th K. Gopalakrishna Endowment Lecture on "Mind, Brain and Music". He spoke to Asha Krishnakumar on the medical, social, economic and cultural aspects of neuropsychiatry. Excerpts from the interview:

What has led to the development of neuropsychiatry as a separate area?

Neuropsychiatry is not a new field. Under the influence of psychoanalysis it split into two fields - neurology and psychiatry. But in the last 20 years it has, again been coming together.

Three things have made this possible: First is the incredible development of neuroscience. We now have a very good theoretical understanding of how the brain functions. Second, we now have new imaging techniques - MRI [magnetic resonance imaging], PET [positron emission technology], and so on - to visualise the brain.

Third, we are now able to understand some brain diseases that express themselves as psychiatric symptoms, or psychological diseases that express themselves as neurological symptoms. The understanding of Parkinson's disease, epilepsy, schizophrenia, developmental disorders, autism, organ transplants, and so on has brought together neurology and psychiatry. So, slowly an area called clinical neuroscience is emerging, bringing together neurologists, psychiatrists, neurosurgeons, neuropsychologists and rehabilitation specialists to work around illnesses. There is a team involved in tackling each disease. All these changes have contributed to the development of neuropsychiatry.

The other reason for the development of neuropsychiatry is globalisation. Earlier, we only had neuropsychiatry societies in Japan, Britain and the U.S. But, now, with globalisation, this is spreading and several countries in Latin America, such as Argentina and Mexico, have set up neuropsychiatry societies. But we have a special interest in bringing countries such as China, India, Indonesia and Pakistan, where two-thirds of the world's population live, into the fold of the International Neuropsychiatry Association so that the body becomes truly representative.

There are well-trained people who are already practising neuropsychiatry in all countries. We are trying to get them all together to share information, to induce the younger generation of professionals to work in this area, and to provide them with information regarding resources to train in neuropsychiatry.

Most important, of course, is to understand from one another the manifestation of the problem in each country and how they deal with them so that it contributes to the overall understanding of the problem.

For instance, in India, the role of infections in brain diseases is important, which is not so in many other countries. Similarly, the fact that people ride two-wheelers without helmets is the main cause of the rising numbers of head injuries in India. This may be another epidemiological component. On the other hand, the strong family network in India, unlike in the U.S. where such people are put in homes and so on, may be a very important aspect in the rehabilitation of the patients that the world needs to know. Thus, I feel, the socio-cultural factors will give a special flavour to the understanding of the symptoms, care and treatment methods. I think we can learn a lot from the way India treats the elderly within the family. Here I find that the elderly are seen as a source of wisdom, and respected. But in some other countries they are seen as a nuisance, creating problems for the younger generation. This kind of cross-cultural difference is very important in understanding and learning from each other.

I think if at all there is a positive side to globalisation it is such sharing of information made possible by the Internet and so on. We are thus trying to take advantage of this by formally launching the Indian Neurological Association.

Do treatment methods vary across countries?

Pharmacological agents vary across different ethnic groups for genetic reasons. Depending on diet and such other factors, the response to treatment may vary. One cannot generalise on dosage and so on. The placebo effect is very important. That gives us clues on how the patients should be assessed and so on. This is as far as pharmacology is concerned.

The psychiatric treatment is very culture-bound. For example, psychoanalysis versus cognitive, or group therapy or meditation may be related very much to culture and people's perception of what can help. In other words, one's perception of the causes of an emotional illness also determines the kind of treatment or help one would be looking for. This is another area of interest.

Culture also determines the rehabilitation effort. For instance, in cultures that have a fatalistic attitude to life people affected with neuropsychiatric problems may never be taken seriously. It may be blamed on destiny and its inevitability.

So, the socio-cultural, religious and political concepts are important in dealing with these diseases. And that changes across countries. We have to learn from the experiences of each other.

Considering that most people in developing countries such as India cannot afford drug costs, what is the role of governments in dealing with neuropsychiatric diseases? And what is the role of international bodies such as yours?

International bodies can be lobby agents and sensitise governments. This is across the board. Mental health is not seen as something that you need to invest in to improve the quality of life and increase the productivity of the people. No matter how much the World Health Organisation says that one of the main reasons for incapacitation is mental health, governments do not consider this in their budgets at all.

Mental health is a public health issue. Governments have a major role to play in dealing with it. It cannot just be left to private initiatives. It cannot also be a business. If health is not considered as a service but is viewed as a business enterprise that follows the ground rules of business accountable to stockholders, then something is wrong.

On the other hand, you cannot also ignore the cost of providing healthcare. You need to be realistic and maintain a balance. You need to look at costs and then carefully decide on the interventions that will give the best results for the money spent. That probably is the pragmatism one system brings to the others. In a socialistic structure, access to health is a matter of right. We need to look at all these things before formulating a public health policy for mental health.

How important is genetics in understanding neuropsychiatry? Is prevention possible in neuropsychiatry?

Genes tell only a part of the story. Even if one is genetically predisposed to be schizophrenic, what is important is how the genes express themselves. This is completely a new territory.

A lot of neuropsychiatry problems can be prevented. Cerebrovascular diseases and vascular dementia are good examples. Just by controlling diabetes and hypertension, the incidence of stroke can be reduced considerably. There is enough data to show that if one stops smoking and controls blood pressure, the incidence of stroke can be reduced by 65-70 per cent. Just by controlling smoking and blood pressure, the savings that can be made for a country like India are unimaginable. Making the wearing of helmets compulsory for two-wheeler riders can go a long way in reducing another set of problems. There is a close relationship between head injury and not wearing helmets. These are very simple, easy measures. You do not need exotic methods to control most diseases. Mental health has to be seen as a public health issue. There is no question about that.