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14 February 2010

A second opinion

An interesting discussion has kicked-off after the Post’s mental health editorial two weeks ago (“Mind over matter, Jan. 30, Page 6). I hardly take this series as a debate because all of us are in the same boat heading for the same destination: improved mental health in Nepal. Those involved in the discussion have many parallel opinions that I can’t agree with more: mental health is extremely neglected, a lot more needs to be done from all sectors, and that whoever is contributing in any capacity deserves due respect. More people from diverse spheres should join in. I also do not deny the complexity of mental health and the fact that more training and continuous learning is needed for all.

But there are a few places where we seem to be rowing the boat in different directions. And when rowing is not synchronised, the boat goes nowhere. I hope this series remains a healthy discussion—ultimately inspiring more people to work to alleviate suffering. It would be unfortunate if opinions are misunderstood as personal insults and those advocating for mental health awareness begin to row in opposite directions, or worse, take the boat down a different course altogether.

The article “Every voice counts,” (Feb. 6, Page 6) is one example of how psychiatry is often misunderstood and misinterpreted. The article proved my point that minimum training and education are needed to work in this complex field. Personal experience is simply not enough, no matter how extensive.

Training does not just mean medical training. A majority of people, including doctors from other fields, do not know that modern psychiatry is not strictly based on medical theory (disease of the organs). The currently accepted worldwide basis of addressing mental health problems is the bio-psycho-social model—bio, meaning biological (genetics, anatomy and physiology); psycho, meaning individual psychology and personality; and social, meaning the socio-cultural environment. Modern psychiatry has dropped the previous strict aetiology model, primarily concerned with the cause of disease, and has classified mental health problems as disorders (not even illnesses or diseases) on an operational basis. To put it simply: if a situation is creating distress, call it a problem and help to alleviate the suffering—regardless of the cause. On the first page of the preface of modern psychiatric classification, is the definition of mental health problems within a multi-axial system, not as just one disease. It also includes psychosocial/environmental problems and the current level of functioning. Psychiatric diagnoses are quite different from diagnoses in other medical fields. Two people with the same diagnosis may not have any common symptoms. The popular allegation that psychiatry only looks though a medical model is a total misconception. Psychiatry curriculum includes subjects like psychology, anthropology and sociology, along with ‘pure’ medicine. Modern treatment also encompasses multidisciplinary interventions. The team includes a psychiatrist, psychiatric nurse, clinical psychologist, social worker and an occupational therapist. The last three of this team have non-medical backgrounds. They can independently assess the problem (aside from any medical disease) using the same diagnostic manuals and recommend treatment (besides medical intervention) accordingly. Different disorders require different interventions. The team decides which therapy to start based on updated scientific evidence and the skills and resources available to them. For problems with a deeper biological basis (schizophrenia for example) medical intervention like drugs or electroconvulsive therapy may be the first line of approach. And for some conditions, like mental retardation, nothing more than counselling for the parents and tailored training are needed.

At scientific seminars, conferences and workshops, new opinions, concepts and technologies continually emerge, but until these ideas have undergone the scrutiny of international authorities and have been recommended to the standard textbook or journal, they are not used with patients. There is no ‘random experimentation’ with human life.

Until the invention of a drug called Chlorpromazine, psychiatric treatment was predominantly psychoanalysis. With the invention of different drugs and solid scientific evidence of the efficacy of medicine, psychoanalysis has almost been replaced. Whether we like it or not, the current scientific evidence regarding the cause and treatment of mental disorders points more towards biological aspects like genetics and neuro-immuno-endocrinological disorders. Until the existing evidence is proven wrong, it must be followed.

It is unfortunate that Nepal has a long way to go to standardise this practice. The existing workforce can only try a fraction of this. Judgments made against the field of psychiatry and the nation’s psychiatrists after a cursory look at government hospitals and a few busy practitioners are short sighted.

There are scientific ways to draw conclusions. Giving an opinion is one thing, making analyses another and recommending and prescribing treatment yet another. We want to give better service and better access to treatment, but are limited by a lack of qualified people. But how can we deliver anything without trained experts?

People do learn by experience. Our age-old Nepali proverb “ki padhera janinchha, kita parera” (learn by education, or by experience) clearly exemplifies its value. After almost 13 years working with people with mental health problems, I still don’t know everything about one single disorder. With each new development comes new knowledge. Having formal training simply means to be acquainted with the experience and mistakes of others. But learning from one’s experience alone, without any evaluation from an established expert, leaves a greater possibility of holding misconceptions, jumping to incorrect conclusions and making mistakes. Different opinions are generated when there is ignorance of the facts—especially when it comes to a complex topic like mental health. We see how misconceptions about mental health exist in our society. The point of encouraging education is to avoid such mistakes.

Mental health is lagging because of a lack of trained experts and because of the existence of untrained, self-proclaimed experts who hold various misconceptions. When discussing improved road safety we talk about improving the roads, increasing vehicle safety, training the public better and forbidding those without licenses from driving. We need to think in a similar line of preventative and rehabilitative psychiatry: improving education for everybody—school children, adults, teachers, leaders and all health personnel—and increasing the pool of trained manpower. Medical personnel can’t do this alone. But when it comes to deciding illness and treatment, specific qualifications must be mandatory. ‘Experts by experience’ are blessings for those in distress. But we need to define what an expert is. Already in Nepal some self-proclaimed experts, motivated by vested interests, are misleading naïve patients and their families, recommending unscientific remedies like thrashing patients and changing their religion, workplace and lifestyle. Every day we see patients who have wasted time and money on such experts—many of whom relapse into more severe illnesses after stopping scientific treatment altogether.

We need to be very careful in defining an expert. There must be some state mechanism to make it clear. Every opinion certainly does count, but when it comes to risking one’s life, the public must have a way to know who to trust.

Shakya is a consultant at the Mental Hospital , Lalitpur

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