1 National Institute of Mental Health, Colombo, Sri Lanka.
2 Department of Psychiatry, Faculty of Medicine, University of Kelaniya, Sri Lanka.
Modern psychiatry has its origin in Freudian times. Its practice has evolved, taken diverse forms and changed considerably over time. The advent of psychotropic medicines in the 1950s further changed the landscape of psychiatry. Western psychiatry has thus taken the upper-hand and its practice is well entrenched in both India and Sri Lanka. The challenge however is to ensure that this specialty meets the needs of the population. Training priorities in psychiatry should thus address these needs.
The needs however are diverse and may range from basic counselling and guidance skills to treatment and rehabilitation of major psychoses (Karim, 2005). Traditionally psychiatrists have also taken on the treatment and rehabilitation of alcohol and substance misuse, sexual disorders and others in the neuropsychiatric borderland, such as dementia.
Training has to address skills which are beyond the scope of average psychiatric curricula. The rich cultures of South Asia bring with it, certain attitudes and beliefs in relation to psychiatric illness. Psychiatric practitioners have to deal with these issues sensitively and effectively, with the benefit of the patient in mind. Some traditional practices are indeed harmful to the well-being of the patient and can result in delays in receiving treatment, resulting in an increased burden of morbidity and at times even significant mortality.
Introducing mental health care into primary health care settings is the practical and accepted mode of bridging the ‘treatment gap’ in low and middle income countries with resultant better health outcomes (World Health Organization and World Organization of Family, 2008). In this sense, imparting adequate training in mental health to all medical undergraduates should be a priority. Sri Lanka has perhaps achieved landmark success in this effort with the introduction of psychiatry as a final year specialty in most medical schools in the island. Previously as in most of India, psychiatry was taught in the third and fourth years with all other medical subspecialties with little emphasis on its importance. The teaching and assessment was minimal, and most medical graduates could qualify with little or no knowledge of psychiatry. This led to serious limitation in the knowledge of psychiatry amongst the medical profession in Sri Lanka. Therefore even the doctors in Sri Lanka were prejudiced regarding mental illnesses and mental health services. Their capability of recognizing a psychiatric disorder was greatly limited and they were reluctant to refer patients to mental health professionals due to the prevailing stigmatized attitude towards psychiatric illnesses and their management methods.
The current programmes in all the leading medical schools in Sri Lanka have up to eight weeks or more of full time exposure to different aspects of psychiatry and mental health, and the undergraduates are assessed extensively on par with the other final year specialties – Medicine, Surgery, Obstetrics and Gynaecology and Paediatrics. Most medical schools also have a behavioural sciences strand from the first year of medical training which focuses on holistic care, imparting empathy and sensitive communication with all patients and their carers. In addition to imparting essential knowledge, these measures also contribute to a positive attitude towards psychiatry among most medical graduates qualifying in this new stream with hopeful minimization of stigma within the profession (Sartorius et al., 2010).
Post graduate training
The Post graduate Institute of Medicine (PGIM) of University of Colombo started in 1980 and conducts a 5 year course leading to MD (Psychiatry). Those who successfully complete this programme are certified as specialists in psychiatry.
Any medical officer who passes the selection examination conducted by the PGIM is eligible to enter the training programme in Psychiatry. The training programme that runs for three years prior to the MD (Psychiatry) examination, includes training in general adult psychiatry as its major component and short periods of exposure in subspecialties such as child and adolescent psychiatry, addiction psychiatry, forensic psychiatry and old age psychiatry. Trainees successful at their MD (Psychiatry) examination have to undergo two more years of training as Senior Registrars under direct supervision of a consultant psychiatrist. One year may be in an approved center overseas. A Senior Registrar will be certified as a specialist in psychiatry once they have completed these requirements and also submitted a research dissertation.
Developing the curricula to produce worthy specialists in psychiatry in the context of India and Sri Lanka involves identifying the core components of this training. This should not be confined just to the knowledge of psychiatry as laid down in textbooks or the diagnosis and treatment of mental disorder. It will have to encompass a wide repertoire of skills and all round versatility. It will have to equip the clinician with the necessary knowledge, skills and attitudes that make the psychiatrist in to a leader, teacher, researcher and clinician.
Diploma in Psychiatry
A large proportion of the senior registrars sent for overseas training however never returned to Sri Lanka (Mubbashar and Humayun, 1999). Thus the psychiatrist per population ratio remained low with a presence of 1:500,000 to 1000,000 on most occasions. In this backdrop it was decided to train a middle grade doctor with limited competency who would be less attractive for recruitment in high income countries. The compulsory period of overseas training up to that point was also made optional in the hope that fewer trainees would opt to go abroad and be tempted to stay back in high income countries.
After much deliberation with several stake holders and objection from some mental health professionals themselves on legitimate fears of dilution of the psychiatry training, a one year training course leading to a Diploma in Psychiatry was started by the PGIM. A major portion of the training included was general adult while they were also exposed to sub-specialties such as child and adolescent, addiction and community psychiatry for a limited number of sessions, mainly for the purpose of recognition.
Training ‘fit for purpose’ in establishing community structures
A mental health policy drafted by the Sri Lanka College of Psychiatrist has been approved by the Government of Sri Lanka for the first time in 2005 (Ministry of Healthcare and Nutrition, 2005). The basic objective of the policy is to decentralize the Psychiatric services that have been centralized in large mental hospitals in Colombo and establishment of a community mental health service. According to the policy of Sri Lanka the district has been considered as the basic service unit. A minimum of one Acute Psychiatric Inpatient Unit (APIU) should be based in District General Hospital which is the biggest health impatient establishment in a district. Apart from the acute inpatient unit there should be a rehabilitation unit based in each district. Each district is divided into several Medical officers of Health (MOH) areas depending on the population. There is a small district hospital situated in each of these MOH areas. The Policy is to establish Primary Community Mental Health centers (PCMHC) in every district Hospital in each MOH area.
A community mental health team comprising of a Medical Officer of Mental Health (MOMH), Community Mental Health Nurses and a Community Support Officer will be attached to each PCMHC. A medical officer who successfully completes the Diploma training programme will be usefully appointed as the Medical Officer of Mental Health in the community team.
The Diploma in Psychiatry training programme has been in existence only for the last three years and has not yet produced enough diploma holders to be appointed to all MOH areas. Therefore, steps have been taken to appoint medical officers as Medical Officers of Mental Health after three months of training in Psychiatry at National Institute of Mental Health of Sri Lanka. This programme will be conducted until all the PCMHC is filled by Diploma holders.
Currently the Sri Lanka College of Psychiatrists provides continuous professional development opportunities to those with a Diploma in psychiatry.
Training of allied specialists
As envisaged in the national mental health policy, the training of other mental health professionals has to now take priority in Sri Lanka. Foremost among them is the need to train psychiatric nurses and psychiatric social workers with particular focus on the community. These professionals can play a critical role in timely, effective and appropriate services to those with mental disorders (World Health Organisation, 2007).
Unlike in the West, the ratio of psychiatric beds for the population has always been low. There have not been widespread mental hospitals and most patients have been cared for in the community by their families (Farooq and Minhas, 2001). Therefore a paradigm shift from institutional to community care is not necessary. The services in the community have to concentrate on strengthening the families to care for those with mental disorders (Linsley et al., 2001).
India perhaps has taken the lead in training a significant cadre of allied mental health specialists. Such a move however is just being initiated in Sri Lanka. This no doubt will be a significant step in supporting the carers and bridging the ‘treatment gap’.
The approach to training in psychiatry has to be multi-pronged (World Health Organisation, 2005). Doctors have to be trained adequately from their undergraduate days. Post graduate training should tackle the unique range of skills necessary for a psychiatrist practicing in South Asia. Flexible attitudes to training middle level competencies will have to be adopted. The development of allied mental health specialists should be a priority.
SARTORIUS, N., GAEBEL, W., CLEVELAND, H. R., STUART, H., AKIYAMA, T., ARBOLEDA-FLOREZ, J., BAUMANN, A. E., GUREJE, O., JORGE, M. R., KASTRUP, M., SUZUKI, Y. & TASMAN, A. 2010. WPA guidance on how to combat stigmatization of psychiatry and psychiatrists. World Psychiatry, 9, 131-44.
WORLD HEALTH ORGANIZATION AND WORLD ORGANIZATION OF FAMILY. 2008. Integrating mental health into primary care: a global perspective. [Online]. Available: http://www.who.int/mental_health/policy/services/integratingmhintoprimarycare/en/index.html.