Academic journal article Indian Journal of Psychiatry

Reply to Queries Raised on the Article 'The Pathway to Psychiatric Care'

Academic journal article Indian Journal of Psychiatry

Reply to Queries Raised on the Article 'The Pathway to Psychiatric Care'

Article excerpt

Byline: Jitendra. Trivedi, A. Jilani


We are happy to receive critical appraisals and queries regarding our editorial article 'Pathway to psychiatric care' published in the Indian Journal of Psychiatry in the year 2011, [sup][1] as it gives us crucial opportunity to further elaborate important unexplored issues regarding mental health in developing nations with particular reference to India. While drafting the above article, we did explore the reality about the existence of a pathway of care in developing nations, including India. It was clear that the government has been creating a structural hierarchical system of health care, which provides a pathway from first point of contact within the community to the tertiary level of specialty hospitals. Though the psychiatric facilities are not available in the beginning of these hierarchal health care systems, e.g., sub-center/primary health center (PHC), but they are able to make sound referrals of patients suffering from psychiatric disorders to the higher level of hierarchy where psychiatric facilities are available, e.g., district hospitals and specialty institutions. With increasing emphasis of government on rural hospitals, more and more specialists are available there. In fact, many state governments make it mandatory for medical doctors and post-graduates to work in rural areas after their education is over.

By applying the proposed definition of a pathway of care, [sup][2] a patient getting in the contact with sub-center/PHC being referred to an appropriate place of psychiatric facility without delay will fulfill the concept of a pathway of care, i.e., entry at one point, which gives right directions for getting help at appropriate psychiatric facility significantly reduces the delay in the recognition and initiation of proper management, hence a better outcome. The so-called lacunae in the health care system of developing nations are that unlike gating system in health care of well-developed western countries, [sup][3],[4] a patient suffering with any kind of illness (psychiatric or otherwise) of any severity is free to walk directly for consultation to higher hierarchal level of health care without need of a referral from lower level of hierarchal health care system. This does not mean that pathway does not exist but only that gating is absent. In one aspect, this is better and beneficial not only for psychiatric patients who can easily get help from a specialist health center at the time of emergency without losing the crucial time in getting the referral order from the place of first contact, i.e., sub-center/PHC but also for ease of access where many people still don't use PHCs. Admittedly, this pathway of care where any person is free and permitted to directly consult a specialist, can get overburdened with those patients who do not need emergency care or specialist care and should have been easily managed at a lower level of health care. The way to approach an appropriate place of psychiatric care or other specialist care in developing nations is not always in a sequential manner of hierarchy of the health care system. Hence, the pathway, though not as well-structured or gated as in the West, does exist.

The writer [sup][5] seems oblivious of the major attempts by the Government of India. However, our point was not about what the government does but about whether and how community avails itself of the services provided by the government.

For the past two decades, realizing the prevalence of severe psychiatric disorders (half of which do reside in the developing nations), the World Health Organization (WHO) and National Mental Health Program (NMHP) in India have been promoting the psychiatric services even at the lower hierarchal level, i.e., PHC for easy and early access within community. [sup][6] Majority of developing nations, including India are implementing the WHO guidelines, for example, the Government of India has initiated the District Mental Health Program (DMHP) under the NMHP for remote and rapid access of psychiatric facility. …

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