“Who will give him a girl?” – A story from my early days of private practice as a Psychiatrist
At the beginning of my practice in 1988-89, I used to consult in a small polyclinic in the evenings for 2 hours. I hardly had any patients those days. There were no mobile phones or computers. It was a small cabin without any air-conditioning. It just had the minimum essential things a doctor’s cabin needs to have- a table, three chairs- one for the doctor and two for patients and relatives; and a bed for examining patients. The room used to feel congested when closed. There was an exhaust fan which was supposed to bring some ventilation. Mostly I would keep the door open and sit there reading a book, hoping that one day some needy patient lands up.
One day, an elderly man entered my clinic and asked me, “Dr., what time is your last appointment in the evening ? I want to come and see you with my son. He is twenty five. I think he is under some stress and I want you to see him.” Making a feeble attempt to hide my enthusiasm, I replied, “Oh, you can come any time between 7 and 9 pm.” He shook his head. “ Not at 7 doctor. I would prefer to come when it is absolutely dark outside. I don’t want to be noticed by anyone walking into your clinic. I have 2 requests to make. First, please allow me in immediately as soon as I arrive into your clinic, and, second, please cover this board of yours which reads- CONSULTING PSYCHIATRIST- so that by chance if someone notices me here, they won’t realise that I have brought my son to a psychiatrist. My son is still young. We want to get him married some time in 2 years. If people come to know that he needs to consult a psychiatrist, who will give him a girl?”
The stigma that has always existed
Psychiatry has always been an enigma in the eyes of people- interesting to look at from outside but worth evading and even condemning when one looks at it closely. Society has looked down upon people with psychiatric disorders as crazy, insane and incapable of living a normal life. Psychiatrists have been labelled “doctors of the insane”, “loony doctors”, “shrinks”and what not.
The early years
The pre-1950 decades were far- from- happy for Psychiatry. Erwin Ackernecht, a historian, wrote in 1959, in his Short History of Psychiatry, “The position of the psychiatrist around 1900 was not a particularly happy one. Although he was better able to classify the psychoses and predict their outcome than his predecessors a century before, he still suffered from the same ignorance of the causes of mental illness and he still had to be content with the same miserable methods of treatment.” Indeed, the understanding about causes of mental illness then was very poor. Supernatural explanations prevailed in abundance. Even the knowledge of anatomy and physiology which was so useful for understanding medical illnesses was futile when it came to mental illnesses. Brutal methods of treatment such as bloodletting, purging, vomiting, digging holes in the skull, throwing people in ice- cold water were rampant. Obviously none of the people suffering from severe mental disorders got better. None of them were capable of living a productive life. They invariably deteriorated over a period of time. They were a huge burden to the family and society at large. They were dumped in asylums which were more like prisons and the psychiatrist treating them was “a prisoner caught up in the difficulties of the field in which he had chosen to work”, in the words of Ackernecht.
Revolutions in Psychiatry
However, the picture changed slowly over the years. ‘Moral treatments’ of psychiatric patients followed by psychoanalysis followed by electroconvulsive therapy brought about some change in the treatment of psychiatric patients. The discovery of an antipsychotic medicine Chlorpromazine in 1952 was a game changer. It worked like a magic bullet in the head and many of the institutionalised chronic patients who were tied to hospital beds started getting better. It is said that their chains were broken. Today we have several effective and selective medicines for different psychiatric conditions. There are newer brief and effective methods of psychotherapy which have been designed for psychiatric disorders. This has remarkably improved the outcome of mental disorders. Even people with severe psychiatric conditions like schizophrenia can now be managed on an outpatient basis and can live a productive life in the community with the help of their families.
“Will you please treat him/her?” ….. Today’s story
And, today in 2021, I get phone calls from people- “Dr., do you remember me? You treated me in 2018 and I am doing well. I am referring a friend to you. I think he is depressed. He wasn’t willing to see you but I gave him my own example. I would be obliged if you treat him .” Or, “I think my wife’s low backache is related to her stress. Will you please see her?” Or,” I got your referral from a friend of mine whose child you had treated. I want to consult you for my child. ” It is heartening to see de-stigmatisation happening all around. People have openly started talking about mental illnesses and their treatment, thanks to the awareness that exists today.
Is it all rosy rosy?
No way. The age- old social perception of “What will people say?” still continues to haunt people. Supernatural explanations continue to dominate the minds of the illiterate ( and even some educated ones). More people are deprived of mental health care than those who seek it. There is a gross dearth of mental health professionals in India, compared to the population. The ratio of psychiatrists to population in India is 0.75 to 100,000 residents. Nearly 197 million Indians suffer from mental disorders, including 45.7 million with depressive disorders and 44.9 million with anxiety disorders, according to a study in Lancet published in 2020. India still ranks very high in suicides. There are several psycho- social- political- economic factors which modify the course and outcome of mental disorders.
Future– From ‘demons’ to ‘molecules’-
Modern medicine is the highest evolved scientific form of medicine because it keeps evolving! The journey of Medicine started from shamanistic medicine; and has progressed through herbal medicine, to pharmacological medicine to the future molecular medicine. Genetics, epigenetics, connectomics seem to be some fascinating words that will often be heard in relation to Psychiatry in years to come. Neuroimaging techniques have revolutionised our understanding of the micro circuits in the brain.
The real challenge is to bridge the gap between the ever- lingering stigma around Psychiatry and the rapidly progressing scientific developments in the field. It has always been a journey full of pain and rewards, and so will it be. There are no rewards without pain!