Psychiatry faces numerous challenges stemming from socioeconomic development, changes of medicine & unresolved issues among psychiatrists-Prof.Norman Sartorius


Asia Pacific Conference on Psychosocial Rehabilitation
attract 44 foreign delegates from 17 countries

Psychiatry faces numerous challenges
stemming from socioeconomic development,
changes of medicine & unresolved issues
among psychiatrists-Prof.Norman Sartorius

We should present best of our work impressively, reach consensus
on education of psychiatrists, minimum treatment requirements,
emphasize human interaction and psychosocial aspects of medicine

LAHORE: Mental disorders are becoming more prevalent and psychiatry faces numerous challenges stemming from socioeconomic developments from changes of medicine and form internal unresolved issues among the psychiatrists. To meet these challenges, Psychiatrists must present best of their works impressively, reach consensus on education of psychiatrists, minimal treatment requirements, criteria for the acceptance of treatment methods besides emphasizing on human interaction and psychosocial aspects of medicine. These views were expressed by Prof.Norman Sartorius, a world authority on mental health who has been heading the dept.of mental health in WHO for almost thirty years. He was delivering his inaugural lecture on “Psychiatry 2013 and its future” at the just concluded Asia Pacific Conference on Psychosocial Rehabilitation held at Lahore from November 1-4th 2013. The conference attracted forty four foreign delegates from seventeen countries besides mental healthcare professionals from all over Pakistan.

Prof. Norman Sartorius

Dr. Afzal Javed a Pakistani Psychiatrist settled in UK who is currently President of World Association of Psychosocial Rehabilitation was the moving spirit behind this academic activity and had organized it in Pakistan in collaboration with many national and international institutions, organizations while Dr. Nasar Sayeed Khan Head of the Dept. of Psychiatry at SIMS Lahore was the Chairman of the organizing committee. This inaugural session was chaired by Prof. l.A.K. Tareen an eminent psychiatrist and former Head of the Dept. of Psychiatry at KEMC/Mayo Hospital along with Prof. Khlaid Mufti from Peshawar, Brig. Mowadat Rana Dean Faculty of Psychiatry in CPSP, Prof. Iqbal Afridi from Karachi and Prof. Sultan Ahmad President-elect of Pakistan Psychiatric Society.
Prof. Norman Sartorius in his presentation also laid emphasize on the fact that to meet the challenges psychiatry face, psychiatrists needs to find ways to deal with co- morbidity of mental and physical illnesses. It should also include work against stigma into the routine tasks of mental health services, stand firmly on agreements about services needs besides reaching agreement and collaborate with other stakeholders of psychiatry. Speaking about the social context of psychiatry in 2013, he referred to Globalization which has become a one way street, commoditification , mass migration which is a bad thing for the donors. There has been a change in the middle class which is of course good for the South, rediscovery of religion with contradictory outcomes, major social upheavals, changing role of women and increasing urbanization wherein we have no strategies for urban care. The medical context which has affected psychiatry in 2013 include changes in medical ethics, increasing reliance on apparatus, bureaucratic control of practice, fragmentation and super specialization, increasing reluctance to deal with elementary care and disregard of experience without a true understanding of the evidence. Developing countries, Prof. Sartorius opined have more middle class which is better but there has been no decrease in the number of poor. We need to empower this middle class. At present what is happening is that the best go to the best country institutions, others go abroad and then those who are left cannot adjust themselves in the above two categories will go to the government set up. Middle class is decreasing in the developed world. Communities in urban settings do not exist. Here people live together, over crowded with no link with each other. Referring to the fragmentation and super specialization, Prof. Sartorius said that he recently met someone who was a right thumb specialist who does surgery on right thumb only and does not know anything about the left thumb. Burn Out has become an epidemic in peripheral and higher level institutions for different reasons. There is abundant corruption and we need to take effective measures to stop this corruption. We also need to check the misguided ethical control of research, he added.
Referring to the challenges the discipline of psychiatry faced in the new century Prof. Sartorius mentioned the continuing devaluation of psychiatry, depersonalization of relationships, the epidemic of co-morbidity of mental and physical illnesses, the enhanced stigmatization of mental illness, transinstitutionalization besides the growth and strength and of disagreements among the psychiatry’s stakeholders. Developments of highly efficient equipments and instruments used by various disciplines of medicine leaves the discipline of psychiatry in a disadvantageous position in all comparisons. Fight among the Pharma Giants has also contributed to the low opinion about medications used in the treatment of mental illness. The low reputation of psychiatry also continues to make it a default discipline, preferred by those who fail elsewhere, Prof.Norman Sartorius remarked. Elaborating the above, Prof. Sartorius said that the length of postgraduate education in psychiatry varies in different countries from three months to seven years which seems rather ridiculous. What one can teach about psychiatry in three months, he asked? Similarly the length of hospital treatment from first episode of schizophrenia is five days in Canada and five hundred days in Japan. Again for treatment of various mental disorders, single drugs and polipharmacy both are highly recommended.
The continuing devaluation of psychiatry, depersonalization of relationships, epidemic of co-morbidity of mental and physical illnesses, the enhanced stigmatization of mental illnesses and transinstitutionalization all had their effects. Not only that even disagreements among the psychiatrists on different issues have been growing and strengthening further. There is 62% Burn Out Syndrome among psychiatrists in Europe and 44% residents in psychotherapists in New York. Speaking about medical co-morbidity with schizophrenia he mentioned TB, HIV positive, Hepatitis B and C, osteoporosis, decreased bone mineral density, poor dental status, impaired lung function, sexual dysfunction, breast cancer, increased obstetrics complications, hyperprolactinemia related side effects of antipsychotics, hyper pigmentation side effect o chlorpromazine, obesity, diabetes and thyroid dysfunction besides cardiovascular problems. Studies have shown that mortality can be avoided more in males than females who are suffering from various mental disorders like schizophrenia, severe mood disorders, mild mood disorders, substance abuse, neurotic/somatoform and personality disorders. There is increased mortality in mentally ill as compared to various other diseases. Depression associated with diabetes doubles the cost of treatment. Similarly cost of medical services for people with depression is four times higher than in people without depression. In modern life there is dependence on individuals, feelings are expressed by face book, dress is becoming uniform and friendship is being computerized. Emergency medicine is becoming most popular postgrad study while emphasis on good doctor patient relationship is becoming outdated and impractical. Recent data form UK and elsewhere show an increase in negative attitudes to the mentally ill. In recent studies patients experience show that stigmatization of the patients begins early, the discrimination because of stigma is stronger but better hidden and various campaigns on improving knowledge did not work. But unfortunately healthcare professionals contribute to stigmatization and do not fight for it. Psychiatry as a discipline is stigmatized and mental healthcare professionals feel about it. According to reports almost 50% of prison population in Los Angeles in USA consists of people mentally ill. Non construction of mental healthcare facilities has its own effects. Many of the messages about stigma backfired like mental illness is like any other disease, mentally ill patients are not dangerous and that mental illness can be effectively treated in general practice and these patients can be easily transferred to community. Forced and rapid deinstitutionalization without appropriate service in the community has led to equally rapid growth of the number of mentally ill people in prisons and other institutions. Psychiatry has not paid much attention to the growth of strength of its stakeholders though they agree that they should have a say in all decisions about care. However, the stakeholders disagree about the best form and content of psychiatric services. The consequences are sometimes stagnation and sometimes progress and sometimes regress. Prof. Norman Sartorius concluded his presentation by stating that there is no ready solution to the problems of disabled and chronically ill.
Earlier in his introductory remarks Dr. Afzal Javed became very emotional recalling the services rendered to the rehabilitation of mentally ill by late Prof. Rashid Chaudhry who stated it thirty years ago and this noble and humanitarian task was later take up by his illustrious son late Prof. Haroon Rashid Chaudhry. Had late Prof. Rashid Chaudhry been alive, he would have been chairing this session. Psychiatry, Dr. Afzal Javed said owes a lot to many people but the dedication and devotion, professionalism by both Prof. Rashid Chaudhry and Haroon Rashid Chaudhry was exemplary. We have heard many bad things about our profession but they were determined to make their contribution in this field, hence this session was being dedicated to the memory of late Prof. Rashid Chaudhry and late Prof. Haroon Rashid Chaudhry, he remarked.