Goin' Crazy

I'd give you a project update, but there's not much to say yet. I've basically spent this work week learning what's in the REACH database and how to get it out when I need it. This has meant trying to re-learn what little SQL I used to know, complicated by the fact that sometimes it's in an Oracle format and sometimes in a Microsoft Access format. After that, it was just making figures and tables for the 2008 REACH Annual Report, which looks like it's going to be the first time anyone's tried to sit down and give a truly comprehensive history of what the program is, how it works, where it's been, and where it's going. I might put a copy online once it's approved in the next few weeks.

One thing I did do this week is get myself a tour of the psychiatric ward at the Mediciti hospital. I was honestly a bit surprised to find that there was one, but it shows that things are getting more advanced than we'd think. They've got inpatient facilities for about ten patients at a time. Now, this is not quite what we'd think of in the West as inpatient psychiatry. The wards are not locked, as one needs a special license to maintain that kind of semi-voluntary treatment. Furthermore, like most Indian hospitals, it's a single group ward room (well, two, one for each sex), not individual patient rooms. Third, family members usually stay by the bedside most of the time, in part because that's how the patient gets fed and gets their medicines. In the US, if you took six or so psych inpatients and made them share a room 24/7, you'd be calling security and administering extra doses of meds before lunchtime. At least when I visited, it was mostly just a bunch of people lying on beds, some looking at me, many sleeping/resting. Much less of the active disturbance I've come to expect.

Part of this may also be the cultural presentation of mental illness here. As you might imagine, in rural India the depression/anxiety part of the spectrum doesn't quite look the same. Since there's no clear way to express severe emotional distress, you get a lot of somatization (physical symptoms that express the patient's mental pain). Now, that alone isn't odd, because any primary care doc in the US will tell you he sees two of those a day. What's interesting is that it takes a different form. In Pittsburgh, I'm used to seeing it present as headaches, GI pain, or sometimes joint/back pain. Here, it apparently tends to present as convulsions (pseudo-seizures). There are, unsurprisingly, also some very complicated issues involving the gain of being able to take on the "sick role" (I never can remember whether that's primary or secondary gain.)

One of the things I was very curious about was what happened after the acute inpatient hospitalization. Since we can't really cure mental illness in any real sense, follow-up and continuity of care are critical. In the US, this is accomplished (sort of) by a network of social workers, government agencies, NGOs, and community treatment teams. In India, all of the above are lacking and/or minimally functional. However, what is available and strong, especially in rural areas, is family. I've spoken to some of you before about the central place of family in Indian culture (although in truth, I've only ever experienced a mild version, being from the Westernized branch of the Widges). In the US, a semi-controlled chronic schizophrenic is often not living with his family, because they can no longer deal. Instead, he'll be drawing a Social Security disability check to live in a supervised group home or his own modest apartment. He may have a part-time, low-skill job. His meds, if he's often noncompliant, may be managed by intensive community follow-up. At least according to the chief psychiatrist here (n=1 without direct verification, salt recommended), what happens in India is that he goes back to his village and lives in his family's house. (We're talking at least three generations under same roof, assuming they have room. Maybe four if it's a family with good life expectancy.) They make sure he takes his meds. He stays at home and is given small manageable jobs to do around the house. They handle necessary personal care tasks. They bring him for medical appointments if needed. If true, it'd be surprisingly effective. I really hope it's true.

Hardly a deep analysis of the mental health system, I know, but it was still a highlight of the week.