THE BANGALORE EXPERIENCE

This November, I was fortunate to attend Child and Adolescent Psychiatry (CAP) services under Supervision of Dr M V Ashok at St John's Hospital Bangalore. As a trainee Psychiatrist, I worked for 3 months in St John's and came to know that Dr Ashok was leaving for further training in CAP to the UK. Upon his return he set up this service, which now is approximately 20 years old.

I could see from the numbers and the great distance from which patients arrived, that this service is a great success.

Dr Ashok works with Dr Vijaya Raman (Senior Psychologist), Dr Suhas Chandran (Assistant Professor) and post-doctoral fellows. This core team is embedded in the 'Centre of Hope' which is the facility dedicated to serve children with special needs. The Centre of Hope is a huge building where Developmental pediatricians and other pediatric specialists like Orthopedicians, nephrologists, neurologists, Opthalmologists, ENT specialists and the full range of Specialists work. In addition, there are trained nurses, physiotherapists, speech and language therapists, occupational therapists, specialist psychologist and specialist medical social workers. A CommDeall centre is also included in this team. This the first time I have seen so many specialists work together, cordially, with common goal of giving the best life for children with special needs. St John's hospital also has very good gardens, security and traffic management, tuck shop and canteen with delicious food. Services are offered at very inexpensive rates. This is part of the general hospital and so the whole family can be served. I think this is a very good system for providing healthcare services.

CAP services treat children from infancy to adulthood. Thereafter, they are taken over by the adult Psychiatry services in a smooth transition. Patients are examined thoroughly and unhurriedly. Treatment is intensive and goal- oriented. Patients are seen in outpatient, inpatient and different therapies. Children with Intellectual challenges, autism, genetic disorders, behavior problems, emotional disorders, stress induced disorders and mental illness are treated in this service. Counseling, therapy, medication and ECT are available for children.

Work typically starts at 9am and extends upto 8pm daily. Everyone (including families) work really hard to give good outcomes to children. The CAP unit also liaises actively with special schools, tutors, shadow teachers, vocational centres and employers. I also visited clinic of Dr Yashaswini Kamraju, who is a private practitioner and practises Child and Adolescent Psychiatry in her clinic. In my free time, I also visited Dr C R Chandrasekhar's Samadhana Counseling and Guidance Centre (which will be covered in a later blog). Here too, children are examined and counseled- free of charge. Children requiring further help are referred to dedicated CAP services close to their homes or to NIMHANS.

All in all, I had a good experience during my stay at Bangalore. I was happy to see that every type of service for children with special needs is provided by Dr Ashok's team. I wish such comprehensive care, with easy access is available in all cities. I hope to emulate the method of doing as much as possible, as soon as possible, maintaining team approach and constantly expanding scope of services.

Repeat Prescription

 I have a pharmacist friend who runs a medicine shop. He often dispenses psychotropic medications. As he is very meticulous, he makes sure that the prescription is a valid one, records the required details, checks the patient's identity and then gives the medication. This means he has to turn away patients who come without a prescription or come with an outdated prescription. Patients tell him they do perfectly well on medication and so what is the harm in just giving it to them? And why should they pay the Psychiatrist an exorbitant amount to just have the same particulars copied down with a new date on it? I, too, face a situation where patients send me a text message with a picture of their old prescription and ask me to reply with a picture of a prescription with a 'new' date. I can fully understand that a patient who remains well on the same medication for several years feels that the process of follow up with a Psychiatrist is totally unnecessary. But for the patient's own safety, the matter has to be a bit different than what 'common' sense would suggest.

Psychotropic medications have to be taken on a long- term basis. During this time patient can have other disorders, start other medications, undergo surgery, have changes in weight, attain menopause or menarche (in female patients), develop new sources of stress, have old stress reduced down and so many other factors that will need a change in the dose of medication. Patient undergoes ageing process which changes the medication response. Some psychotropic drugs have to be monitored for side effects. A good number of mental illnesses will progress despite medication and the early signs of progress need to be picked up to prevent a full relapse. For all these reasons, regular follow up is absolutely essential. When the patient is feeling quite ok, there can be early signs of problem or risk factors for a problem- which can only be picked up during examination by a Psychaitrist. During routine follow up these are picked up and larger problems prevented. Psychiatrists also use the opportunity of follow up to educate the patient about proper diet, exercise, stress management and other important subjects relevant to maintaining good general and mental health. 

Legally, no medical advice can be given without adequate examination of the patient. Prescription is a written advice of the doctor. So, no prescription can be issued without proper examination of the patient. Even if the patient, their whole family or anyone gives full assurance that patient is doing well, and the current medication suits him/ her- such reassurance has no value. The only thing that can be the basis of writing a prescription is a thorough medical examination by the doctor writing the prescription.

And it is only reasonable that the doctor (Psychiatrist) who has worked to examine the patient, apply expertise to solve not only the present problems but to foresee and prevent the imminent ones and explained everything to you in detail and then written all that down in the form of a prescription- should be paid the consultation fee!

PS- If you feel the doctor is not giving enough time- change the doctor. Dont do the shortcut of avoiding consultation and continuing medications.

REPAIR A RUNNING CAR

I have often wondered if there is any time that a running car gets repaired? I have seen cars being serviced in record time during races, but they do stop for it to be done. But in mental health, we are expected to treat the patients while they are in action continuously.

A lot has been written about the loss of concept of 'convalescence'. But in psychiatry its worse- patients don't want to stop even when actively and severely ill. Particularly if the patient is a child or adolescent- the parents rarely allow any concessions in their packed schedule or attempt of various exams. Even celebrity sportsmen take a break when injured- but our patients- never do.

I often feel like I am continuously running to catch up with a running car and simultaneously trying to change its tires. When I do any intervention and expect result- instead patient has gone and stressed themselves out further- forget being over the initial problem- now there is a new problem to handle.

If only people would take it a bit easy and allow the body to heal- that would ensure they recover with minimum medication, minimum side effects and it will be a proper recovery. They should go back to work and life slowly and as advised.

When we talk about Juvenile crime.

https://www.hindustantimes.com/cities/mumbai-news/minority-report-why-juvenile-crime-is-on-the-rise-101664128656202.html 

Social and rule- based behavior is a legitimate part of mental health. For ages there has been the question 'Mad or Bad?'. In my work I am frequently required to deal with behaviors that reflect thoughtlessness, callousness, predatory or depravity. A good number of my patients are children and adolescents. When I read the above article- I thought it was a good piece of reporting; in terms of the observations made and impressions collected from experts. But it also carried a bias- it seems that children from certain backgrounds are upto to something and that progresses to Juvenile crime. A few of my thoughts and observations follow.

I observe that children from less disadvantaged backgrounds also show such behaviors. But they get timely help or worse- their folks make sure the matter never reaches the authorities. Parents of these children put up a fight against the world to safeguard their child's right to misbehave- later they start moving homes or schools in the belief that other kids are spoiling them or being unsupportive. The true commonality between these children and those from poorer backgrounds is deprivation- deprivation of close and balanced adult supervision, deprivation of role models, deprivation of emotional structure, deprivation of limit setting and deprivation of treatment for medical issues like hyperkinetic disorders and learning disorders.

Children of all backgrounds need sufficient time and space to explore, take risks, learn social behaviors and expend their energies (both mental and physical). There could not be a single person in the world who did not think of a painful prank, shirk some work, gain some pleasure by pulling down peers or simply be upto something to 'see what happens'. Boredom and unfettered imagination are the key features of a normal child who is capable of thinking and learning. Surroundings catering to such needs must be provided in the community. Which means unstructured space and time- but under the eye of a caring adult who steps in, though just enough for course correction. We adults have failed to provide this to children. For various reasons our children are left free to learn from their mistakes- how to progress and master them not to correct them. And we get into the picture only to indulge and misguide or punish and stonewall. A child with hyperkinetic disorder and learning issues suffers from greater boredom and inability to engage in curricular learning. But parents refuse to treat children based on their false pride and misinformation.

Juvenile offending can be reduced only if children's need for emotional support and exploration is regarded as legitimate and we make space for their needs in society. A large well- patrolled park with free access to kids, a good after school program, adolescent vocational training and robust medical treatment of developmental problems- all these are needed simultaneously. The community should think if they want landscaped garden with expensive shrubs that is 'free of troublesome' children or a large park where youngsters of all ages can grow into useful members of community.

WHAT IF I MISS A DOSE?

 

Medications for mental health are usually 'long acting'. This means that every dose of medication is able to work for several hours, usually exceeding one full day. Yet there are some things that one needs to understand before answering the common question – "What will happen if I miss one dose of the medicine".

If you observed yourself taking medication, you would have noticed that the response is not immediate. In fact, there is usually an adjustment period with some discomfort before the medication begins to work as intended. The adjustment effects are because of the body's response to the 'new' drug and somewhat unfamiliar changes in the body's chemistry. But the intended effects are delayed because firstly the medication has to achieve 'steady state levels' in the body. This means a certain level of medication has to be maintained in the body at all times. This happens after you have taken the medication for 5to7 days. After that the medication begins its work and the symptoms reduce slowly.

So if you miss a dose- the reverse effect occurs. As the steady state is already achieved, your disease symptoms remain under control. If you have any side effects of medication- you will not experience them that day and so feel better than usual. Thus the usual experience on missing a single dose is to actually feel better overall. However, some medications have an additional action to calm you down and this is a sort of 'short term' effect. For these particular medications, you will begin to feel a withdrawal effect 6 to 10 hours after the missing the dose. The withdrawal can vary from mild uneasiness to miserable degree of dizziness and nausea. The withdrawal symptoms also depend on the persons metabolism, state of mind that day and other diseases and medications. The longer term problem with occasionally missing a dose, is that the steady state level becomes reduced overall- so the medication becomes ineffective and symptoms of the disease come back in a 'relapse'.

Thus the best thing to do is to make sure you do not miss a single dose anytime. As a doctor, I find it difficult to respond to the question because you are not SUPPOSED to miss any doses. So its a scenario that I would rather prevent totally than prepare you for.

WHY YOUR GENERAL PHYSICIAN HESITATES TO TELL YOU ITS A MENTAL HEALTH ISSUE?

 

For the last 16 years, I worked with a senior Doctor who is an accomplished Physician. He is a great advocate of mental health and often refers patients to me. But sometimes- even his expertise and authority does not convince the patient that, in fact, the symptoms he/ she suffers, arise from anxiety and depression rather than dysfunction of other organs like the stomach or heart.

Though people commonly think in terms of 'real' and 'psychological' or 'body' and 'brain'; reality is much different. For disease, there is no such thing as separateness. This is particularly true for disorders of the brain such as depression. Symptoms of anxiety and depression are likely to present as chest pain, palpitations, hypertension, aches and pains, indigestion, acidity, diarhoea, dizziness, skin rashes...and so on. This is because the brain is connected to every organ and cell of the body through the neuroendocrine system. Bodily symptoms of depression are not accompanied by any set patterns of disease in that body part. On the contrary they are accompanied by depression and anxiety. When actively suffering, patient is unable to understand this and gets obsessed with establishing the 'cause' and controlling the test report numbers of whatever symptom they think are important. As physicians perceive a certain resistance to hearing the truth, they tell the patient its 'stress- related' which is actually a euphemism for depression-anxiety. If patient shows any interest to explore and deal with this suggestion, they always encourage the patient to meet a mental health professional. In my experience and my discussions with my senior colleague, we noted that most of the patients are not interested in listening to the real diagnosis. Then rather than argue with the patient and make him/ her more miserable or defensive, the only recourse is to prescribe a mild sleeping dose which helps partially and hope for the best.

A number of times, I have gone to meet the patient to examine and been rudely turned away from the ward- "are we mental? Does dr think our illness is fake?". Hence the general and family physician learns that uttering the word 'Psychiatrist' causes a severe reaction that includes anger, aggression and lots of unpleasantness. Considering the high frequency of such events, the doctor learns to be tactful and agree with the patient rather than explain facts.A good number of my colleagues call me and express their total disinterest and helplessness when they continue to encounter patients with multiple bodily complaints. Being the doctor they have to be patient and considerate- but they dont feel satisfied with their work as they know this needs expertise of a mental health professional. For them it is a 'damned if you do, damned if you dont' situation.

Some doctors are unable to detect mental health problems the first time. But eventually, they do figure out. A small fraction of doctors who are motivated by financial incentives will encourage the patient to pursue the search and cure for bodily symptoms- despite knowing that its depression and anxiety. Patients are more than willing to get multiple and expensive tests and treatments. Usually persons with a hefty medical insurance or working in public sector companies (where they get leave and medical costs reimbursements) follow this pathway. But even these doctors, eventually find it difficult to sustain the indulgence of health anxiety. For us mental health professionals, such patients turn out to be very difficult cases too. After years of believing something, suddenly patients are abandoned into mental health care. It is something they dont agree with and do not want. But now there is no money to do further tests and no doctor (non psychiatrist) willing to give them time or sympathy. Its very difficult.

Instead I look forward to a scenario where patients are more accepting and open. So that their doctors can openly tell them whats wrong. Psychiatrists are full medical doctors. If they even suspect that there is a disease other than mental illness, they will refer you back to the appropriate doctor. So there is no worry of something getting missed by going to a Psychiatrist. But depression and anxiety are disorders that can impair your life and worsen other diseases due to the mind-body interactions. So best to check it out. And get it treated in the best possible way from a mental health professional. And return to normal and happy life as soon as possible.

BETWEEN A ROCK AND A HARD PLACE

"Lack of Professionals, Social Stigma: India Has Miles to Go in Establishing Mental Health Infrastructure" https://www9%2Fwww.news18.com%2Fnews%2Flifestyle%2Flack-of-professionals-social-stigma-india-has-miles-to-go-in-establishing-mental-health-infrastructure-4283723.html

The average Indian still thinks of MOdern Evidence based medicine as "Allopathy"- a harsh, mysterious, drastic, dangerous form of treatment with massive side effects and given by callous commercial doctors. They still prefer quacks, charlatans and traditional approaches which have no concept of mental health, let alone an approach to its treatment. This enhances stigma. A complete cure 'from the root' of it, without absolutely any side effects and in total harmony with your religious/ magical/ superstitious beliefs is the promise they fall for. This is the present nature of stigma. It is not about deriding the condition of mental illness, it is come to derision and suspicion of any sane conversation that is scientifically informed. 

A person who seeks help has to therefore do it in secret- for an army of 'well wishers' is waiting among relatives, friends and so-called loved ones to dissuade. From taking poison. From getting 'F*****d' up by the Psychiatrist. From drugging your child. telling you instead to use hemp oil.

Welcome to the new age stigma of 'Mental health is important' but 'beware of proper treatment'.

The other alternative; 'THerapy' is very expensive and not freely available due to shortage of trained therapists.

SO an average Indian person is now caught between a rock and a very hard place.