Schizophrenia - Enhancing hope with better care & research

The Indian situation

Some of the earliest descriptions of a condition resembling schizophrenia in India was made by the Ayurvedic physician Charaka over 3300 years ago in the text Charaka samhita. These corresponded closely with the descriptions in Greek medical texts by Hippocrates9.

Subsequently, India's contribution to schizophrenia research has not been substantive. The Madras longitudinal study is a landmark study on course and outcome of schizophrenia. The patients have been followed up from the first onset for 25 years and the study has generated a lot of information on related variables like mortality, jobs, marriage, etc10. The study of the first episode psychoses at the Schizophrenia Research Foundation (SCARF), Chennai, India, when compared with a Canadian study with a similar sample has thrown up some interesting cross cultural findings11. Both the studies have reiterated the need to promote awareness about the disorder which in turn will facilitate early detection and prevention of chronicity and disability.

With very limited human resources and budgetary constraints, community care is really the future. Care in the community is per se not an alien concept in India since over 90 per cent of the severely mentally ill live with their families. This is not only because families are willing to care for them, but also because alternative options for care are practically non existent. The number of mental hospital beds in the entire country is grossly inadequate to provide inpatient care. While some non-government organizations (NGOs) run community based centres of care and rehabilitation, these are only a few. Besides many of these are in the southern States of Tamil Nadu, Karanataka and Kerala12. Community based rehabilitation, essentially an off - shoot of community based medical care was first initiated in the 1980s under the impetus provided by the National Mental Health Programme of India13. Community care strategies involve operating mental health clinics in the community and a focus on mental health literacy in the general population.

In a recently concluded randomized control trial in India where the effectiveness of a collaborative community based care [where a community health worker (CHW) visited the home of the patient to deliver interventions] was compared with facility based care (usual care provided) for people with schizophrenia and their families, it was seen that the intervention of the CHW was acceptable and effective especially among patients who were more symptomatic and had greater disability. The feasibility of an effectiveness of delivering psychosocial interventions through CHWs was also established14.

Critical strategies for rehabilitation have been the use of lay community volunteers trained in recognition, identification and referral of persons with mental disorders performing the first level of rehabilitation15. Rehabilitation has also been facilitated by networking with governmental and non-governmental organisations involved in social and developmental activities. The NGOs also embarked on community-based programmes, which although efficacious and cost-effective were always restricted by their dependency on time-limited funding1516. However, collaborations with NGOs are seen as an important approach to reach out to a wide geographic area, with a shared economic commitment of the collaboration. There have also been some innovations in the delivery of community care. One of these has been the use of mobile tele-psychiatry by the Schizophrenia Research Foundation. A bus fitted with mobile equipment has been delivering mental health care to the population of a part of Pudukottai district17 and widely accepted by the local population.

The community based programmes have suffered from poor allocation of resources, insensitivity to the needs of people with mental illness on the part of both professionals and policy planners, and indifference to mental health in general. Sustainability and continuity of programmes, especially by NGOs are largely limited as most programmes are time-bound projects, contingent upon the funding resources.

The priority in our country is to make the District Mental Health Programme (DMHP) more effective and efficient, promote more community based services reducing the dependence on big hospitals and reducing stigma. Living with schizophrenia is no easy matter for persons with the disorder and their families. Despite the introduction of many new antipsychotics in the last decade, there still remain some patients who do not respond well to medicines. Schizophrenia can also produce wide ranging disabilities and incapacities in persons. Although the mentally disabled are also eligible for welfare benefits like other groups of disabled, this process is yet to gain uniform momentum in all States of the country.

Schizophrenia is a severe mental disorder affecting many human faculties and functioning. Advances in research hold a lot of promise, but until a wonder drug is found, we need to address the social and psychological issues in patients and families. Government policies and programmes need to be geared to enhancing facilities in the community for these persons and improve awareness about this condition which in turn will facilitate early treatment and social inclusion.