Psychiatry Part One

Today Moriah and I began our last week at CMC, with a posting at the department of psychiatry. The clinic has a large inpatient unit, with 120 beds,

which sounds small when you consider that it is the only inpatient unit serving the million or so people living in the vellore district, and the nearest psychiatric hospital is almost three hours away in chennai. Their outpatient department sees a little over 300 patients per day on average, and there are immense waiting lists for people to be evaluated by their clinic. The hospital as a whole has four units, two general adult patient, one child/adolescent, and a psychosocial rehabilitation unit.

As with every other unit we've experienced, the financial aspect has been very interesting. A consultation, which includes an initial one hour evaluation and weekly follow up appointments, is Rs 570, and most medications are under Rs 100 for a week. Just like the other services,the physicians can agree to offer treatment at half, quarter, or no cost depending on what they think the patient can afford. If the doctor overestimates the patients ability to pay, they can appeal to a social worker.

Most patients that are admitted stay for over one month, and in order to be admitted, at least one member of the patient's family has to agree to stay with them to provide meals, change linens, etc.

We will tour various units during the week, but started out in the psychosocial rehabilitation unit, designed for the care of those with chronic mental illness, most of whom have schizophrenia. Throughout all of our experiences here we have been surprised by the wide array of services provided that we would not typically associate with a hospital, and this unit was certainly no exception. This unit's work begins once the patient has been medically stabilized, when they continue to manage their psychiatric treatment and work on reintegrating the patient into the community, providing some vocational training, and educating family members about mental illness. The stigma of mental illness is very powerful here, and sadly some of these patients have been abandoned by their families. To deal with this, the hospital has a small ward where these patients can live long term, and they work by making paper bags and candles which are sold by the college campus.

We learned about some very interesting differences about schizophrenia in India. Surprisingly, those who are treated for schizophrenia in India have a better prognosis than patients in America. This is thought to be because of two important factors: larger, more supportive families, and lower societal/family expectations of achievement. This seems to contradict the earlier point about stronger stigma, but the family support was very evident when we sat in on the outpatient session in the afternoon.

Every single patient we saw was accompanied by their mother, father, husband or wife. Except of course, for the encounters where the patient themselves were not there, and their parent or spouse picked it up for them. This happened two or three times in 15 encounters. The doctor said this was a regular occurrence, and while certainly not ideal, it did increase patient compliance on medication. The other very striking difference was that the door remained open for the entire encounter, and just like the other clinics we've been to, the other patients congregated outside, well within earshot. Even in psychiatry much less emphasis is placed on patient privacy.

Tomorrow we will go to the inpatient unit, and the unit head has an academic interest in cultural differences in Indian mental illness.

Dave