“We sold the buffalo to pay for a brain scan” – a qualitative study of rural experiences with private mental healthcare providers in Uttar Pradesh, India

The majority of persons with mental distress (PWMD) in India do not have access to care, and even those who seek care are pushed to attend private providers, given the weak and largely absent public mental health services framework. The aim of this study was to examine the experiences in help-seeking and with unethical health service provision among persons with mental distress in the Saharanpur and Bijnor districts of Uttar Pradesh. In-depth interviews were conducted with twenty persons with mental distress and their caregivers. Thematic analysis yielded four key findings about help-seeking: first, that it was syncretic and persistent; second, that expenditure for private care was high and often catastrophic; third, that investigations and care provided were pharmacological and predominantly irrational and excessive; and lastly, that help-seeking was abandoned. This study demonstrates that PWMD are particularly vulnerable to exploitation by private providers with illnesses that are stigmatising, poorly understood, chronic, relapsing, and disabling and that often require complex management. Responding to mental distress requires multiple empowering and interacting policy and programme initiatives that must include regulation of private and public providers, resources, and actions to strengthen public and primary mental healthcare and promotion of mental health competence in communities.

Gay rights and bigotry.

Every day heterosexist ideals and norms encourage homophobia and prejudice. We need to be aware of and debate sophisticated forms of bigotry in today’s world. Modern medicine and psychiatry, since the 1970s, have abandoned pathologizing same-sex orientation and behaviour.1 The WHO accepts same-sex orientation as a normal variant of human sexuality.2 The United Nations Human Rights Council values Lesbian Gay Bisexual and Transgender (LGBT) rights.3 Yet, India’s Supreme Court reinstated a law that bans gay sex by restoring Section 377 of the Indian Penal Code.4 The response from the mental health and legal establishment to this manifest bigotry was weak.5–7 It betrayed a poor understanding of the issues and reflected deeply ingrained prejudices.

Post-traumatic stress disorder: Psychiatric management, atonement and justice.

Post-traumatic stress disorder (PTSD), initially described in Vietnam war veterans, is now a standard psychiatric diagnosis and used across cultures, contexts and around the globe. It is incorporated in the American Psychiatric Association’s Diagnostic and Statistical Manual-5 (DSM-5)1 and is to be a part of the WHO’s International Classification of Diseases-11.2 Despite its widespread acceptance as a disease label, there are many unresolved issues related to the category.3–10 Many of the problems of facing psychiatric diagnoses and classification also plague PTSD. Unpleasant feelings (e.g. anxiety, dreams and memory) within the normal range of emotions and purposive responses of people who are stressed (e.g. efforts to avoid thoughts, feelings, conversations, activities, places associated with the traumatic event) are considered pathological.4–6,7 The reasonable reactions to specific contexts (e.g. hyper-vigilance or numbing) are labelled aberrant. The lack of pathognomonic symptoms, marked overlap of symptoms with other categories (e.g. major depression, specific phobia, generalized anxiety disorder, dissociative disorder, etc.) and absence of diagnostic laboratory tests add to the confusion.3,4,6,7 Psychiatry employs symptom checklists for diagnosis and the process discounts the context; the diagnostic procedure does not examine the pre- and post-trauma setting, vulnerability and supports. The ‘atheoretical’ approach adopted by the current psychiatric classifications essentially supports the medical model, which medicalizes personal and social distress.3,4,6,7 The PTSD category is now also used in people who are victims of violence in the civilian settings and who have survived rape, assault, accidents, communal pogroms, industrial disasters, tsunamis, etc. The diagnosis also assumes that the trauma has past and that the current context is safe. While this may be true for war veterans who have come home, it may not be true for other civilian victims of assault, for women in patriarchal cultures, ethnic, religious and sexual minorities in traditional societies, where continued threats and violence are possible.6,7 The concept discounts variation among different people and does not highlight the strength of the survivors or the meaning of the event.6,7,10 Problems in living, when viewed through the medical lens, are construed as mental disorders.3–7 The legal, insurance and compensation implications of the label are complex and influence the category and criteria. However, research evidence for the usefulness of psychiatric treatment after natural and manmade disasters is thin.11 Similarly, the success of prevention and treatment programmes for veterans is limited.8 Nevertheless, recent articles about experience in wars have discussed different conceptualizations, opposed to the medical

The challenge of medical diagnosis: A primer on principles, probability, process and pitfalls.

Arriving at a medical diagnosis is a complex process, which requires clinical skill. However, the need for clear decisions has to be balanced by an acceptance of the ambiguity of many clinical situations. Complex presentations often require probabilistic inferences rather than presumed diagnostic certainty. The demands, logic and process of clinical diagnosis are highlighted. The multiple aspects of clinical reality and the impact of gold standards, nature of evidence and dichotomous disease/no disease categorization are discussed. The importance of population characteristics and context in diagnosis and prediction are emphasized. The statistics of agreement, Bayesian approach, certainty and risk, hazards and pitfalls, common errors, audit and the influence of commercialization on diagnosis are addressed. There is a need to formally teach the art and science of medicine and to transfer clinical skill rather than hope that such skills will be automatically imbibed during training.

Sexual dysfunction among men in secondary care in southern India: Nature, prevalence, clinical features and explanatory models.

Background. Sexual dysfunction, common in general medical practice, is under-recognized and inadequately managed resulting in significant morbidity and reduction in quality of life. We examined the nature, prevalence, clinical features and explanatory models of illness among men with sexual dysfunction in a general healthcare setting. Methods. We recruited 270 consecutive men attending a general health clinic. Participants were evaluated using a structured interview. The International Index of Erectile Function-5, the Chinese Index of Premature Ejaculation-5, Short Explanatory Model Interview and the Revised Clinical Interview Schedule were used to assess sexual dysfunction, explanatory models and psychiatric morbidity. Results. Premature ejaculation and erectile dysfunction were reported by 43.0% and 47.8% of men, respectively. The most common perceived causes were loss of semen due to masturbation and nocturnal emission. Popular treatments were herbal remedies and resources used were traditional healers. The factors associated with erectile dysfunction were diabetes mellitus, financial stress, past history of psychiatric treatment and common mental disorders such as depression and anxiety; those associated with premature ejaculation were common mental disorders, older age and financial debt. Sexual dysfunctions and concerns were under-diagnosed by physicians when compared to the research interview. Conclusion. There is a need to recognize sexual problems and effectively manage them in general medical settings. The need for sex education in schools and through the mass media, to remove sexual misconceptions, cannot be under-emphasized.

Dementia assessment: A review of studies from Vellore and perspectives.

Some recent studies from Vellore, Tamil Nadu, on dementia have been published in international journals as part of international data, analysis and interpretation. They have also been published separately employing local perspectives and analysis. The different results and interpretations of these two approaches to the same data suggest the need for independent work and study of the local reality to inform national public health policies.

Sexual function in women in rural Tamil Nadu: Disease, dysfunction, distress and norms.

Background. We examined the nature, prevalence and explanatory models of sexual concerns and dysfunction among women in rural Tamil Nadu. Methods. Married women between 18 and 65 years of age, from randomly selected villages in Kaniyambadi block, Vellore district, Tamil Nadu, were chosen by stratified sampling technique. Sexual functioning was assessed using the Female Sexual Function Index (FSFI). The modified Short Explanatory Model Interview (SEMI) was used to assess beliefs about sexual concerns and the General Health Questionnaire-12 (GHQ- 12) was used to screen for common mental disorders. Sociodemographic variables and other risk factors were also assessed. Results. Most of the women (277; 98.2%) contacted agreed to participate in the study. The prevalence of sexual dysfunction, based on the cut-off score on the FSFI, was 64.3%. However, only a minority of women considered it a problem (4.7%), expressed dissatisfaction (5.8%) or sought medical help (2.5%). The most common explanatory models offered for sexual problems included an unhappy marriage, stress and physical problems. Factors associated with lower FSFI included older age, illiteracy, as well as medical illness and sexual and marital factors such as menopause, poor quality of marital relationship, history of physical abuse and lack of privacy. Conclusion. The diagnosis of female sexual dysfunction needs to be nuanced and based on the broader personal and social context. Our findings argue that there is a need to use models that employ personal, local and contextual standards in assessing complex behaviours such as sexual function.

Domestic violence as a risk factor for infant and child mortality: A community-based case–control study from southern India.

Background. Violence against women may have an impact on infant and child mortality. We aimed to determine whether domestic violence is a risk factor for infant and child death. Methods. Eighty infant and child deaths (under 5 years of age) were identified from a central register of a comprehensive community health programme in rural southern India; controls were matched for age, gender and street of residence. Results. Domestic violence during the lifetime (OR 2.63, 95% CI 1.39–4.99), which was severe (OR 4.00, 95% CI 2.02–7.94) and during pregnancy (OR 5.69, 95% CI 2.03–15. 93) and father’s smoking status (OR 3.81, 95% CI 1.92–7.55) were significantly related to infant and child death while immunization being completed for age (OR 0.04, 95% CI 0.01–0.19) and having at least one boy child in the family (OR 0.29, 95% CI 0.14–0.59) were protective. These variables remained statistically significantly associated with outcome after adjusting for other determinants using conditional logistic regression. Conclusion. There is evidence for an association between domestic violence in mothers, and infant and child death.

Perceptions about anxiety, depression and somatization in general medical settings: A qualitative study.

Background. The recognition rates of anxiety and depression in general medical settings, despite the significant prevalence of such presentations, are low. Psychiatrists argue that the recognition and management of these conditions by physicians is less than optimal in primary care and general practice. We did this study to gain insights into physicians’ perspectives on anxiety, depression and somatization, the conceptual models they employ and the practical problems they face in managing such patients in general medical settings. Methods. Focus group discussions (FGDs) were conducted with family and primary care physicians. The FGDs for physicians were tape recorded and transcribed, verbatim. The views of psychiatrists working in liaison clinics were also ascertained. Results. Family and primary physicians admitted to a high prevalence of patients who present with medically unexplained symptoms. They noted the co-occurrence of psychosocial stress. All physicians working in general medical settings admitted to difficulty in separating anxiety, depression and somatic presentations because of milder, less distinct syndromes and overlapping symptoms. They argued that it was difficult to use the current three-category division and that a more complex classification would be time-consuming and impractical in primary care. Conclusion. Psychiatric classifications for use in primary care should consider the different context and employ physicians’ perspectives rather than push specialist concepts and criteria.