Friday, 14 October 2016

Bechara Mein: I want to be a mental care provider but……….?

Bechara Mein: I want to be a mental care provider but……….? IMA represent the collective consciousness of over three lakh medical practitioners in the country. During our MBBS, we were not taught any subject like mental health or mental well-being. Psychiatry was taught in a few lectures. During internship, psychiatry was less than a week posting with no psychiatrist in the faculty. During my MD medicine, psychiatry was just a touch-and-go subject. But we were still taught that health is not mere absence of disease but a state of physical and mental well- being. As per the WHO, 1 in 4 persons will suffer from mental disorder in their life time and 10% of us at any given time suffer from mental disease. About 800,000 people commit suicide worldwide every year, of these 135,000 (17%) are in India. Every 40 seconds a life is lost through suicide worldwide. The suicide rate in India is 11.5 % per lakh and every 3 seconds a person attempts to die. Suicide is one of the top three causes of death among the young in the age group of 15-35 years. A large percentage of them try to seek help from friends or doctors just before they commit suicide. But I am helpless as a doctor • We are now being informed that depression is no more a stigma or a social issue. That depression is treatable and a manageable disease and it needs to be diagnosed early. Then why does it not have insurance cover? • Our patients do not want to disclose ‘depression’ when getting admitted so that their claim does not get rejected. Often we are socially bound not to divulge the history of depression when we fill Mediclaim form even though we know it is unethical and we can be prosecuted under Indian Penal Code 191 and 193 or our license to practice can get cancelled under MCI Ethics regulation 7.7 • Once we admit such patients we cannot prescribe them anti depressant drugs on the file for the same reason. We cannot call psychiatrists or counselors as their billing would surely reflect that the patient had a mental problem. • Suicidal ideation is a medical emergency as we all are aware and such patient needs emergent admission. But we often do not admit them for fear of insurance rejection. • Government runs social campaigns and special free clinics for substance abuse disorders, smoking cessation clinics, then why can’t they allow treatment of depression under insurance reimbursement. Government can charge extra premium to those who smoke, drink or take drugs. • Smoking cessation, obesity reduction, alcohol cessation, and drug de-addiction should all be covered under insurance. • The proposed new mental care health bill may have some answers in clause (4) - every insurer shall make provision for medical insurance for treatment of mental illness on the same basis as is available for treatment of physical illness. Also under the new bill, suicide has been treated as a form of severe stress, which will not be punishable under section 309 of the Indian Penal Code (IPC). But till the bill is passed in Lok Sabha we all are worried about handling suicidal attempt cases. Under Section 309 of the IPC, whoever attempts to commit suicide and does any act towards the commission of such offence, shall be punished with simple imprisonment for a term which may extend to one year [or with fine, or with both]. Though one can be let off with a simple fine but once the case has been made as a medicolegal case and the police is called, the patient and the family is always in a difficulty. Such patients are at risk for future suicidal attempts and hence needs tender and immediate care and counseling. • We face a similar problem while dealing with substance abusers. Under Narcotic Drugs and Psychotropic Substances Act, 1985, Section 27 there is a punishment for illegal possession of any narcotic drug or psychotropic substance or consumption of such drug or substance. All substance abusers invariably will be in possession of such drugs. Do we call the police when a substance abuser comes for counseling? • But it is also true that under section 39 of the act the courts have the power to release certain offenders on probation for detoxification or de-addiction from a pre-defined institution and to report back within a year that they have been de-addicted. However, ‘Court’ means that we need to inform the police first. • There are less than 6500 psychiatrists in the country with over 150 million mental health patients. Billing by Psychiatrist is not reimbursable under any claim. The answer is to mandate mental health as a subject in family practice. MCI has already mandated 10% credit hours in mental health and IMA has mandated mental health aspects in every medical education class. • Amongst professionals number one suicides are amongst doctors. Over one lakh doctors as per the statistics also need mental counseling. The numbers of psychiatrists are not enough even to manage them. • We are supposed to take mental history in every patient. As per a finance ministry document, average time available with a patient is 4 minutes. In these 4 minutes, we are required to wash our hands twice, greet and acknowledge our patient, brief about our credentials, take detailed history incorporating mental health maintaining privacy and confidentiality, read all the documents, make up our mind and explain investigations and line of management and counsel about rehab, side effects, warning signals and future plan. This is impossible in today’s era. • In Bhagavad Gita, in the first chapter, Krishna only listened to Arjuna when he was in acute depression? Do we have so much time to listen? Will our patents be able to pay us for the extra time spent? May be we need to have mental health counselors, dieticians and pharmacist as our employees in our practice. • Due to paucity of time and in search of giving instant relief, we end up prescribing short-acting benzodiazepines like lorazepam to patients making it the number one addiction drug in the country. • Should we call depression a depression? We have changed the nomenclature of all stigma-related terms then why not depression. We can call it as a mood disorder. We now call impotence as erectile dysfunction, prostitutes as female Sex workers, homosexuals as males havin • g sex with male, penis as male sex organ, vagina as female sex organ, child sexual abuse as sexual violence against children, drug abuse as substance abuse and IV drug addicts as IV substance user.

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