History of psychiatry in India.SR Parkar, VS Dawani, JS Apte
Department of Psychiatry, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, India., India
Keywords: Community Mental Health Services, history,History of Medicine, 15th Cent., History of Medicine, 18th Cent., History of Medicine, 20th Cent., History of Medicine, Ancient, History of Medicine, Medieval, Hospitals, Psychiatric, history,Human, India, Mental Disorders, history,therapy,Mental Health, Psychiatry, history,organization &administration,Psychology, history,organization &administration,
Till about 17th century all abnormal behavior was believed to be act of the ‘devil’ i. e. ‘Against God’, ‘ Mentally ill’ were considered evil & described as witches. Gradually over the passing time, mental illness was considered as ‘deviant behavior & mentally ill were considered socially unacceptable & put in jails along with other criminals. In the modern era, there was a shift from ‘evil’ to ‘ill. Mentally ill were called as ‘mad’ or ‘insane’ and were placed in special places called as ‘asylums’. However, gradually these asylums became the place for human exploitation. Phillipe Pinel was the first Psychiatrist to free these mentally ill from asylum. Clifford Beers work ‘ The mind that found itself’ brought in light the treatment meted out to these people in asylums, resulting in a strong reaction to the plights of mentally ill. This uproar resulted in starting of ‘mental-hygiene’ movement.
In the 20th century, the work of Freud and ‘B. F. Skinner & J. B. Watson’ gave a scientific combination of biological & social theories to explain the etiology of mental illness.
Mental disorders are represented in Ancient India in various types of literature. The aetio-genesis of these disorders was thought to be endogenous because of provoked humours like vatonmad, Pittonmad & Kaphonmand. Exogenously the causes were attributed to sudden fear or association with ill influence of certain mythological gods or demon, Charak Samhita designated Psychiatry as ‘Bhuta Vidya’.
The description of personality is to be in terms of sathvik, Rajasik & Tamasik representing intellectual & moral, emotional & passionatic & impulsive respectively & Tamsik is more or less near mental subnormality or angry. Treatment of mental disorders mainly included psychotherapy, physiotherapy, shock, drug treatment, hypnotism & religious discourses by Sages. Psychotherapy used to be in the form of talismans, charms, prayers & sleeping in temples with rituals. The indigenous manner of giving shock to the patient was terrorizing them by snakes, lions, elephant or men dressed as bandits. Then use of 10 to 100 years old medicated ghee, Drugs Cordfolia, horse radish (shigru) with asafetida & rock salt, centella Asiatic (brami) with catechu & honey & powder of roots of serpentine were widely used.
Najabuddin Unhammad (1222 A. D), an indian physician, described seven types of mental disorders viz. :-Sauda-a- Tabee(Schizophrenia); Muree Sauda (depression); Ishk ( delusion of love); Nisyan (Organic mental disorder); Haziyan (paranoid state); Malikholia-a-maraki (delirium). Psychotherapy was known as Ilaj-I-Nafsani in Unani Medicine.
‘Siddhi’ means achievement and Siddhas are men who have achieved results in medicine, as well as yoga and tapas. The great saga ‘Agastya’, one of the 18 Siddhas has contributed greatly to the Siddha system of medicine of the South. He formulated a treatise on mental diseases called as ‘Agastiyar kirigai Nool ‘, in which 18 psychiatric disorders with appropriate treatment methods is described.
Revolution In Psychiatry
The history of psychiatry had witnessed 3 major revolutions that have given its present status. First Revolution occurred when it was believed that sin & Witchcraft are responsible for mental illness and mentally ill were chained in jails & asylums. They were considered as outcaste from society. Second revolution was the advent of psychoanalysis; that explained the etiology of psychiatric disorders. Third revolution was the development of community Psychiatry that resulted in the integration of mental health care in the community.
Mental Illness To Mental Health: Indian Perspective
Indian culture has always given a great importance to spiritual life . Wig (1990 :73) stated that religious texts in India have stressed the search for the spiritual meaning of life and detachment from material thing.
One of the earliest Indian Psychiatrists to explain the importance of health was Govindaswamy in 1948. He gave 3 objectives of mental health - regaining of the health of mentally ill person; prevention of mental illness in a vulnerable individual; and protection & development at all levels, of human society, of secure, affectionate & satisfying human relationships & in the reduction of hostile tensions in persons & groups (Govindaswamy, 1970).
According to one aspect, put forward by Govindaswamy (1970) selfishness on the psychological side & starvation on the Physical side are responsible for the disorganization of individual & society. The second aspect stressed the importance of culture to understand the personality functioning. Carstairs & Kapur (1976) & Chakraborty (1990) found the relation between social stress, modernization & occurrence of mental disorder. The third aspect is the use of traditional concepts of therapy eg. Yoga by Patanjali’ & fourth aspect is importance of family in therapy .
During the reigns of King Ashoka, many hospitals were established for mentally ill. A temple of Lord Venkateswara at Tirumukkudal, Chingleput District, Tamil Nadu, contains inscription on the walls belonging to Chola period. The inscription mentioned a hospital and a school. The hospital was named as Sri Veera Cholaeswara hospital and contained 15 beds.
Maulana Fazulur-Lah Hakim, an indian physician was in charge of the first Indian mental asylum, i. e. Mandu Hospital opened by Mahmood Khilji (1436-1469) at Dhar, M. P. First lunatic Asylum, Bombay Asylum, was built in modern India in approximately 1750 A. D. at the cost of 125/-, no traces of it is present today. In 1794, a private lunatic asylum was opened at Kilpauk, Madras. The central mental hospital, Yerwada, Pune was opened in 1889. First asylum for insane soldiers was started at Monghyr, Bihar and was known as Monghyr Asylum(1795).
Maxell Jones in 1953 introduced the concept of Therapeutic community resulting in the improvement in the Mental Hospital conditions. Subsequently other facilities such as Occupational Therapy, Recreational facilities, Outdoor games and Picnics were started in Mental Hospitals . Lt. Col. Berkley Hill Was the pioneer in starting Occupational Therapy at the European Mental Hospital, Kanke, Ranchi, in 1935. However inspite of all these facilities, the adjustment of the mentally ill patients was poor in these hospitals (Bhattacharya And Chatterjee 1978).
On the recommendation of Bhore committee (in 1946), All India Institute Mental Health was set up in 1954, which became the National Institute of Mental Health And NeuroSciences in 1974 at Bangalore.
An expert committee of WHO in 1974, made several important recommendations, urging its members to consider mental disorder as a high priority problem. The recommendations included : to undertake pilot projects to assess existing mental health care program in a defined populations and training program for health workers and to devise a manual for the same (Isac 1986).
Hence, first community Mental Health unit (CMHU) was started with the Dept. of Psychiatry at NIMHANS in 1975. For short term training of primary care personal, a Rural Mental Health Center was inaugurated in Dec’1976 at Sakalwara, 15 km from Bangalore. Mental Health clinic was opened in a General Hospital in Bangalore to involve General Practitioners in Mental Health, Seminars and orientation programs for General Practitioners & school teachers were conducted. The first training program for Primary Health Care was started in 1978-79. During 1978-1984 Indian Council of Medical Research funded & conducted a multicentre collaborative project on ‘severe Mental Morbidity’ in Bangalore, Baroda, Calcutta & Patiala. Various training programs for psychiatrists, Clinical Psychologists, Psychiatric Social Workers, Psychiatric nurses and Primary Care doctors were conducted at Sakalwara unit between 1981-82 (Ministry of health & family welfare, 1989).
Due to results obtained by all these research efforts, NMHP was launched in 1982. Certain studies were undertaken under NMHP to integrate mental health with PHC. These included : Raipur Rani Project (1975-1981), Sakalwara project (1975), ICMR project, Jaipur Project (1982-84) and Bellary Project .
The specific vulnerable population, children, disaster population, tribal population, the elderly population, and homeless mentally ill, is included for mental health care planning.
Till early sixties Mental Hospitals were the only place available for the treatment of mentally ill. However, as compared to the number of mental ill patients, the services available were very less. Hence General Hospital Psychiatric Units were started to deal with the Increasing number of patients.
The first GHPU was started in R. G. Kar Medical College & hospital, Calcutta in 1933 & GMC R. J. J. group of Hospital Bombay in 1938. (khanna et al 1974). The number has gradually increased since then. Gradually GHPU started the PG training centres at Delhi, Chandigarh, Lucknow, Bombay, Madurai etc resulting in development of District Psychiatrist unit.
Mental Health Camps In India
The first psychiatric mental health camp in India was organised in 1972, at Bagalkot, a taluka town of Mysore. Earlier some service centers were organized by members of team of Kripamayee Nursing Home, Miraj. Following this, Indian Psychiatric Society also started taking active interest in Mental Health camp organization and various health camps were arranged in different parts of India (such as Nandi, Ghosh, Sarkar, Banerjee in 1978, Luktuke in 1976).
Voluntary Health Sector (VHS) in Mental Health
There have been strong mass media movement all over India in last decade where various issues related to Mental Health are brought in public domain. The social movements in relation to Darubandi are doing commendable work and are very well known. Other organization like SCARF (Chennai), Richmond fellowship foundation (Banglore), Cadbum are also helping people in rehabilitation and integrating them in the society
In these various organizations, active efforts have been taken to improve quality of care of patients & rehabilitate them in society. Various self help groups such as Alcohol Anonymous, Narcotic Anonymous, have been organized by people. The major effort of VHS is evident in the area of suicide & Deaddiction where various kind of activities are being carried out to help people in crisis eg : Sanjeevani in Delhi, Sneha in Madras, Prerna in Mumbai.
Psychiatric Social Work
The establishment of Mental Health organization under the directorate of Health services was first recommended in 1946 by the health survey & development committee of the government of India. The first Psychiatric Social worker was appointed in the Child Guidance Clinic started in 1937 by Sir Dorabji Tata Graduate School of social work (now Known as Tata Institute Of Social Sciences) in Mumbai. Banerjee was the pioneer of Psychiatric Social Work training in India; Institute of training in America appointed her the leader of Department of Medical & Psychiatric Social Work established in 1948. The other Social Workers & psychiatrists who gave a major boost to Psychiatric Social Work in India were Vidyasagar, Sarada Menon, U. B. Kashyap, B. D. Bhatia, P. B. Buckshey.
Gradually training for social work started in various centers such as National Institute of Neuropsychiatry in Bangalore (now known as NIMHANS) Indian Council of Mental Hygiene (Institute of Psychiatry & Mental hygiene).
Lunatic Asylum act, Act 36 of 1856 was modified to form Indian Lunacy Act, Act 4 of 1912. The enactment of act resulted in opening of new asylums and improvement in the condition of asylums. The name lunatic asylum was changed to mental hospital in 1920. In 1946, the Bhore committee recommended changes in Indian Lunacy Act 1912, as it had become outdated. Indian Psychiatric Society formed in January 1947 quickly acted on the recommendation and a committee consisted of Dr. J. Roy, major R. B Davis, Dr. Hasib was formed. It was finally enacted on 22nd May 1987.
Drug Dependence : Alcohol
In Rig Veda, 2 types of beverages are described :-Soma Juice : According to vedic hymns, soma was a mushroom & a cannabis like substance (Sethi 1979) and ‘Sura’ – a drink that was obtained from fermented barley after distillation. In Atharva veda ‘Sura’ was mentioned as a reward for performance of sacrifices. In the sutra period (800-300 BC) besides sura, many other drinks were widely prevalent, eg:- Kilala – a drink prepared from Brown Sugar, wines imported from Afghanistan were commonly known as “Kapisayani’.
Consumption of alcholic drink was looked down upon by Buddha & Lord Mahavira, use of alcohol was prohibited among ‘Muslims & owing to this, ban on use of alcohol was first excised during Moghul period. However, use of alcohol on religious grounds was allowed to the ‘Tantrik’ section of saktas among Hindus.
According to Charak, moderate drinking was pleasing, digestive, nourishing & providing intelligence, but excessive drinking causes ‘various elements’.
Ala-u-din khilji tried to control the manufacture & sale of alcohol. His successors Mubarak Shah & Akbar followed him.
The use of cannabis in Indian culture is reported more than 2000 years ago. Cannabis was known to increase concentration during meditation, hence was used by Hindu saints, its use was widespread in religious places like Hardwar, Varanasi, Puri etc. use of cannabis is also mentioned in ‘Atharva Veda’. Opium use became popular during Moghul period.
Gradually in the modern era there was a gradual increase in the drug abuse and the associated complications and antisocial activities. Due to this various laws, Opium act 1857, Opium act 1878, Dangerous Drugs act, 1930, Certain provisions of Cr. P. C. 1973, were enacted to deal with drug abuse
Alternative patterns of care of mental health in community have developed which include GHPU at district level, Home Care Programme, Foster care, Partial Hospitalization etc.
Psychotherapy in Ancient India dates back to the times of Pandavas. In ‘Bhagvad Geeta ‘ there is an incidence of counseling in the battle-field given by Lord Krishna to Arjuna. Guru- Chela relationship is another example of psychotherapy in Ancient India. Neki (1973, 1974) examined the Guru-Chela relationship as therapeutic paradigm.
Dr. Girinder Shekhar Bose founded the Indian Psychoanalytical Association in 1922 in Calcutta. A training institute of psychoanalysis to train young psychoanalysts was started. Satyananda was another analyst who was greatly influenced by Melanie Klein and had received his personal analysis from Berkley Hill. A. V. Vasavada was the only Jungian analyst in India. Dr. N. S. Vahia contributed in the research on the role of Yoga in promotion of mental health.
Various aspect of research work was carried out in India during the period 1947-1972. Wig and Akhtar in 1974 reviewed the research work and found that focus was on mental health and illness in India. Lots of work was done on the phenomenology and natural history eg General Paresis of Insane, relationship between leprosy and mental illness, Indian adaptation of Psychological tests and construction of Intelligence tests to suit Indian needs. Remarkable work was done in the fields of epidemiology, phenomenology and treatment of mental illnesses. However, there was no up to date laboratory research and hardly any attention was paid to psychotherapy education.
ICMR contributed greatly in the research work in the form of “strategies for research on mental health”(ICMR 1981).
On the 35th anniversary of the Indian Psychiatric Society, in 1983, Dr. L. P. Shah in Mumbai started the first of the series of Continuing Medical Education. The first mid-term CME was held in1990. Since then Indian Psychiatric Society and West Zone conduct annual and mid-term CME every year on various novel issues .
Psychiatric Associations In India
Indian Psychiatric Society (IPS)
Berkeley hill in 1929, founded the Indian Association for mental hygiene. In 1935, the Indian division of the royal Medico- Psychological Association was formed due to the efforts of Dr. Banarasi Das. In 1946, Dr. Nagendra Nath De consulted Major R. B. Davis of the Hospital for Mental disease, Kanke, Ranchi & Brigadier T. A. Munro, Advisor in Psychiatry to the Indian Army and decided to revive the association. Due to their efforts the Indian Psychiatric Society was inaugurated at Delhi on 7th January 1947. The rules & regulations were framed by the eminent Psychiatrist such as Dhunjibhoy, Rosie, Kenton, Llyodo, Dr. Masani, Shah, Johnson, Govindaswamy & Kak. Dr. N. N. De presided over the first annual meeting of association on 2nd january 1948 at Patna. Since then annual meetings are held at different places.
Indian Journal of Psychiatry
It was started in 1949 as Indian Journal Of Neurology and Psychiatry, was edited by Dr. Nagendra nath De. After 6 issues publication was stopped in 1954. It was renamed as Indian Journal of Psychiatry in 1958 and Lt. Col. Bardhan, a pathologist was appointed as it’s editor
The other specific associations which were formed by psychiatrist in India are also very active such as Indian Association of Social Psychiatry and Indian Association of suicide in 1996
National Mental Health Programme was implemented to provide services to rural as well as urban population. However even today 80% of the rural population do not get these services. Multidisciplinary approach for the treatment of mentally ill is confined to only few institutions. Importance is attached to treat the mentally ill patients & not much thought is given to prevent mental illness & promote mental health. More importance is given to biological psychiatry and psychopharmacology, and psychology and social psychiatry are not given due importance.