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Contents Inside:
Editorial - Page 1 Message from BIPA Chair Dr. Subodh Dave - Page 2&3 BIPA to collaborate with Indian Association for Geriatric Mental Health - Page 3 My Vision for BIPA - Dr. Sab Bhaumik - Page 4 IGPI & ANCIPS - Page 5 Tribute to Prof. Nitin Purandare Page 5 The CASC New Perspective Page 6 Medication to meditation - A personal Experience - Page 7&8 Obituary - Dr. Harish Gadhvi Page 9 BIPA events pictures - Page 10 Interview: Prof. Thirunavukkarasu - Page 11&12
Editorial
It is that time of the year when we shrug off the lethargy of the winter, adjust our body clocks to the new rhythm of the spring and in preparation of the oncoming summer, raise our expectations and spirits. What could be more exciting than the social milieu that goes with the BIPA AGM, not to speak of the excellent clinical content of the scientic programme that is inherent in the AGM? For this edition of the newsletter, we include contributions which reect the international networks with which BIPA is increasingly being associated. We have also not forgotten some of the issues which continue to be of concern to BIPA, like the low pass rates in the CASC examination amongst trainees from overseas, a substantial proportion of whom are from the Indian subcontinent. We publish an article by Dr. Cherukuri which tries to offer some solutions to this problem. There is also a general perception that psychiatry is too biologically driven and the sole role of the psychiatrist in the multidisciplinary team is to prescribe medication. Dr. Pradeep Chadha's article is very timely to remind ourselves that psychiatrists have a far wider role than that, with the greater breadth of their training. It thus ts in very well with the current debate within the Royal College of Psychiatrists on the role of the psychiatrist within the multidisciplinary team, as well as offering some specic insights which can arise from the cultural heritage of an Indian psychiatrist. This is also reected in the feature which has now become a standard in BIPA newsletters, the e-interview, featuring Prof. Thirunavukarasu, immediate past President of the Indian Psychiatric Society, where he reects on the same problem aficting psychiatrists in India as well. Another innovation is the inclusion of photographs of contributors from this edition of the newsletter, but we apologize that this was not possible for all contributors this time, an oversight for which we take full responsibility as editors. We will endeavour to overcome this shortcoming in future editions. This is also the time to appreciate the efforts of the outgoing members of the Executive committee and prepare to welcome new members and the ofcers. It has already been announced that Subodh Dave nishes his term of ofce and Sab Bhaumik is taking over the Chairmanship. Subodh, in his enthusiasm, introduced several new initiatives that will bring in benets for BIPA members in the short and long term. Our relationship with Indian Psychiatric Society now stands on a rmer footing and BIPA now is an integral part of several international psychiatric societies. A modern constitution for our activities jointly with our sister organizations (BPPA, BAPA, SLPA etc) is under consideration. Our links with BAPIO are rmer than ever before. There will be elections for the rest of the ofce bearers-Vice-Chair, General Secretary, Treasurer, Public Liaison Ofcer as well as other vacancies in the Executive Committee. By the time you read this, the results will be known, be it with or without elections, and the results will be announced at the AGM. The EC will be effective but only in the presence of constructive efforts of the total membership. This has never been in doubt before. No doubt it will continue.
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Newsletter Editors:
Dr Subodh Dave
Parity between UK-trained and IMGs assumes particular relevance with the advent of revalidation and persistence of poor pass rates of non-UK trained trainees in the MRCPsych examinations. BIPA has contributed to consultations by GMC on issues concerning IMGs. BIPA has appointed Dr. J S Bamrah, the RCPsych Director of CPD as the Director of Revalidation to ensure that BIPA members specically and non-UK trained doctors generally are not disadvantaged by the revalidation process. BIPA worked closely with its sister organisations BPPA, BAPA and SLPA to overturn the Colleges misguided decision to implement a rule retrospectively that would have disadvantaged scores of non-UK trainees (as also exi trainees). BIPAs approach has been to work with the College and we have raised these issues in various College Committees including the College Council. BIPA-led symposia on Diaspora issues at the heart of the College at its International Congress in 2011 and 2012 have introduced these issues to a wider audience and have so far received very good feedback. In September 2011, BIPA organized a national Trainees Conference to discuss and debate issues affecting IMGs. As an action point following this, BIPA in partnership with its sister organisations has commissioned a qualitative study to tease out the issues affecting international trainees.
Improving access and mental health care outcomes for BME communities in the UK is a key target not only for BIPA but also for the NHS. CQUIN targets in most Trusts are being linked to this particular outcome. Last year BIPA organized a half-day conference to discuss ways in which this issue could be taken forward. A couple of action points emerged closer working with voluntary sector and application for charitable status. BIPA will be conducting a survey across mental health trusts examining the status of commissioning in relation to health care outcomes for BME communities. BIPA is supporting the development of BME Volunteer Patient groups to train clinical and non-clinical staff in primary care. Engaging service users directly will be essential if we are to improve patient outcomes for BME groups.
The Future
BIPA faces many challenges. In times of austerity with study budgets squeezed and a general lack of sponsorship, achieving nancial sustainability remains a challenge. Tougher immigration laws, the recruitment crisis in the UK and a booming economy in India mean that the demographic trends of the future members of BIPA is likely to be very different. BIPA has taken a few steps to provide some future proong. Charitable status: BIPAs aims, objectives and activities are charitable. BIPA volunteers do not get any expenses and yet the lack of charitable status has hampered our ability to garner resources that would enable us to deliver our aims more effectively. BIPA is likely to achieve this hopefully later this year. Leadership: BIPA member Prof Dinesh Bhugra, CBE and President-elect of the WPA will take on the mantle of Director of Learning and Leadership in BIPA to ensure that BIPA members are able to provide leadership necessary to tackle the above challenges. Great Partnership Council: The coalition of BPPA, BAPA, SLPA with BIPA will represent over 5000 psychiatrists and with its pooled strength will exercise greater inuence over these challenges. Governance and Engagement: Engagement with memberships is improving with regular updates and the Newsletter. New members of BIPA have made the Indo-UK link project possible. BIPAs transparent governance procedures such as Executive Committee meetings open to members and audited accounts should help Executive Committee members become efcient Trustees of the Charity. It has been a privilege to have served as the Chair of BIPA and it has been even more rewarding to have taken a few baby steps towards realizing BIPAs vision. This would not have been possible without the BIPA team to whom I owe a huge debt of gratitude.
The wise counsel of Dr. Bhaumik and Giri, the ever available mentoring from Dr. Mistry and Dr. Singh, Bhavana annd Krishs infectious enthusiasm, the sheer energy of Sridevi, the hard graft of a range of people -JP, our Webmaster; Ranjit and Piyal, the Newsletter Editors, the Education link team members Mary, Ram, Vijender and Kavita; the trainee prize judges Lena, Ananta and Ajay, Venkat, Nora and Vincent have made it a genuine team effort and it is they who are the real architects of BIPAs successes. Finally, I would be remiss in not thanking the families (including my own) of all the hard-working BIPA members for putting up with long meetings, skype chats and hours of BIPA work at their expense. I am aware that a lot more needs to be done - I leave many unnished tasks but I am sure that the wise and experienced Dr. Bhaumik, our next Chair will take BIPA to new heights. I wish him all the very best.
As an initial step, it was agreed to produce a brief Dementia manual by January 2013, to be formally launched at ANCIPS in Bangalore. Dr. Anand Ramakrishnan
ANCIPS 2012
A joint session was held with members from IPS (Indian Psychiatric Society Psychogeriatric section) and BIPA members at ANCIPS 2012 at Cochin, Kerala, India on 21/01/2012 with the theme as Pharmacological Management of Moderate to Severe Alzheimers Dementia chaired by Prof. CHARLES PINTO and Prof. K.S. SHAJI. Following speakers contributed to the session 1. Principles of pharmacological management of Alzheimers Dementia- Prof: S.C. Tiwari (IPS) 2. Pharmacological Management of Moderate to Severe Alzheimers Dementia - Dr. A. Ramakrishnan (BIPA) 3. Management of Behavioural and Psychological Symptoms of Alzheimers Dementia - Dr. Pradeep Arya (BIPA). This session was well attended and an active and meaningful discussion followed. Dr. Anand Ramakrishnan,
The advantage of classifying stations in this format helps in transferring skills that is used can be used for all similar stations, for example: History taking in a Psychotic patient will use the same principles of obtaining Past history, Family history, Personal As Psychiatrists, we know that stress is counter productive and history and a quick MSE with risk assessment and is the same for diminishes performance of candidates in the Examinations. all such history taking station Many candidates are known to have had panic attacks during Similarly, in information giving stations for medication/ the examination. Hence, work on reducing anxiety levels to psychotherapy, it would be helpful if the candidate reads the increase performance appeared reasonable and necessary. Royal College leaets and does not preach to the patient but 2) Language and Communication Skills: Many Asian /Indian candidates who receive feedback from the Royal College have been asked to improve their Communication skills. This is a generic term and leaves many candidates frustrated I think that, though our education is in English, it is not our rst language and it would be helpful to observe and imbibe certain nuances (but not a fake accent!). This helps not only in improving your communication but also in day to day practice. The following has been useful: has a dialogue. Identify your strengths and weaknesses and work on the stations that are difcult for you. Many trainees ounder in the physical examination station and it would be better to practice them well in advance. 4) Practice makes prefect: It is advisable to start preparation well in advance (at least 2 months) and build up to the exam and it is good to remember that it is like preparing for a marathon. So, practice, practice and more practice. This also strengthens the mental framework that we have for the stations and helps in seamless execution.
a. Peer group feedback of my interviewing skills ( to speak slowly When it does not work, remember that setbacks pave the way for and clearly) us to look at things in a new perspective and as always, keep calm b. Practicing in front of a mirror (really helps to avoid unhelpful and carry on! mannerisms such as frequently saying OK, looking at your notes Good luck to all the trainees! whilst the patient is talking) c. Practicing with your Consultant (if he/she can allocate some Dr.Sathya D Cherukuri MD MRCPsych MRCP (Glasg). time for you) Assistant Professor, Department of Psychiatry, SRM Medical College University, d. Using the Leaets (The Royal College as well as the Mind Treatment Team , Bedford, UK. leaets are quite useful to read)
Email: sathyadc@gmail.com Chennai, India 603203.Currently, working in the Crisis Resolution and Home
Dr.McCaffrey and I went to see the patient. You are angry. Arent you, said Dr. McCaffrey to the patient as soon as he entered the room. I saw the patient becoming calm in next few seconds. This made me change my thinking on psychiatry once again. I learnt that what we call psychiatric illnesses in the West could also be called emotional expression in India. As soon as the anger of the patient subsided, he became calm. What Dr. McCaffrey could deal with words in seconds, could also have been treated or subdued with psychiatric drugs. In Ireland at that time (it happens even now), psychotherapy was frowned upon by the psychiatric establishment as a treatment modality. I had realized that my curiosity could not be satised by known psychiatric formulations and that I had to continue to learn on my own, without help from anyone.
help people change themselves using the sympatheticparasympathetic interplay and imagery. If it enabled them to reduce medications and if it went against all the known norms of psychiatry, it was still worth doing it.
Meditation came to my attention at the time I was experimenting with sympathetic-parasympathetic feedback mechanism. I realized that meditation and hypnosis had many similar effects at therapeutic and physiological levels. Incidentally, hypnosis is one of the most researched alternative therapy modalities. Both of them directly and indirectly worked with autonomic nervous system. If we let go of the complexities of the receptor system, the whole theory of mental illnesses revolves around the imbalance between the stimulatory (sympathetic) and inhibitory (parasympathetic) systems. If the imbalance between In 1996, I set up my private practice in Dublin calling myself a the two can occur as a result of genetic inuence and the medical psychotherapist, a profession that I had created. I environment in nature, is it not possible to create a balance was aware that I had to chose between continuing to prescribe between them naturally? medications or to nd another drugless way to help my clients. I chose the latter. Very soon I started to get clients asking The challenge was to develop a system or protocol that could help me to help them come off psychiatric medications with psychiatric sufferers come off medications successfully and safely psychotherapy. In 1997, my rst book -The Stress Barrier-was after the medications have served their purpose. It became obvious published in Dublin. It was based on my experiences dealing with that almost all psychotherapeutic processes were aggressively emotions and how we suffer with bottled up emotions. A Professor marketed by individuals and institutions as if they could solve in psychiatry, in Ireland, challenged me in a radio interview based every psychiatric problem. Each of the psychotherapy techniques on my statement that depressed people can successfully be helped has their own usage and limitations. All of them affect the to come off medication with psychotherapy. The day after the autonomic nervous system in some form or the other. If the interview, my practice picked up. I was busier than ever in my psychotherapy process is like an elephant then each system is followed by blind men (and women) who describe the elephant work. by touching on only one part of the elephants body. There is It became apparent to me that the sympathetic and obviously a need to bring together all the major schools of parasympathetic systems were somehow involved in a feedback psychotherapy. mechanism like we commonly see in the endocrine system. Primal screaming by Arthur Janov was an acknowledged method in Sixteen years and many thousands of hours later, my clients, my which sympathetic tension was allowed to increase before a person peers and the web have been my teachers. I have had the relaxed. The theory of paradoxical effect of drugs also opportunity to develop a protocol of psychotherapy using caught my attention. This effect was propounded by Zuckerman breathing meditation, medication and imagery that has given me and Zuckerman. This effect meant that when sympathetic system an insight into mind-body-spirit connection. Till date I have kept was stimulated or aroused, it caused relaxation, as happens when a the methodology close to my heart. BIPA has given me a chance stimulant is given in hyperactivity syndrome. When the to discuss and teach the methods to those who would like to learn. parasympathetic system was stimulated, a person became In 2011, I had presented a workshop on brief Grief Therapy that was received very well by the members of BIPA. If any physically more active, as happens in autism. members of BIPA are interested in doing research on this In the year 2000, a psychiatric conference in London was methodology, they are welcome to get in touch with me. organized by World Forum on Mental Health. I presented a paper in it. Its title was Drugless Psychiatry- Physiological Explanations The last story is about my time when I was working in the of Clinical Experiences. After the presentation, only three doctors addiction clinic in Dublin. I remarked to a female nursing approached me (out of an odd 70 100 who were in attendance) colleague that in all the years that I have spent in psychiatry, I had to ask me questions. One was Dr. Rohtagi from Glasgow. The learnt that each one of the patients who come in through the door other person was Dr. Bannerjee from Australia and the third feels unloved. Her response was- Oh Dr. Chadha! Only if person was a doctor from Sri Lanka. It makes perfect things could be that simple. Years later, I can say with condence scientic sense was the remark made by Dr Rohtagi at that now that things ARE that simple. time. But for me the message was clear- western psychiatry was (References available on request) closed to change (even if you were in the Royal College of Psychiatrists). Working scientically without medication was still Dr. Pradeep K. Chadha. unthinkable. Address: 5,Grove Garden, Verdemont, Blanchardstown, Dublin 15. Phone: Since I worked in private practice and not afliated to any 0035318242666. University or any research group. I had to stop looking for approval from the western psychiatric system. The alternative for Email: drpkchadha@gmail.com me was either to give up or to continue developing a protocol to URL: www.drpkchadha.com
In spite of his health issues, Dr. Gadhvi was always dedicated to his work. He had maintained keen interest in teaching and training locally, regionally, nationally and internationally. He was a visiting Professor at University of Jaipur until his untimely death. He was an excellent trainer, clinical and educational supervisor. He served his Trust in a variety of capacity. To name a few positions, he was Clinical Lead for Adult services, Appraiser, Chair of Division etc. He was always willing, keen and ready to help others. In 1995 Drs Gadhvi and Chaparala returned from USA having attended the APA conference. They had the occasion of attending the Indo-American Psychiatric Association (in existence since 1984) session and meeting Dr. Manoj Shah, a founder member and then President of IAPA. Both felt enthused to set up something similar in UK. Dr. Gadhvi had his contacts in the London area and Dr. Chaparala in the Birmingham area. In July 1995, the Birmingham 4 (Drs Baburao Chaparala, Thakor Mistry, Vinod Singh and Mohan George) had the rst working lunch meeting at JJs Restaurant in liaison with Dr Gadhvi. Preliminary thoughts on forming an Association were explored and some of the rst ideas were recorded. Further 3 months of discussions and invitations led to the rst Steering Committee of the Association 20th October 1995, at Johnathan Restaurant in Birmingham. 18 Consultant Psychiatrists out of the 30 invited attended and gave further shape to the idea/constitution of the Association with further regular 3 monthly meetings thereafter over the next 18 months before the nal ofcial launch of BIPA as a national organization on 1st March 1997, in London. His Excellency, Dr. L M Singhvi, then The High Commissioner of India, was the Guest of Honour. Dr. Gadhvi served BIPA as the rst Vice-Chair, then became the Chair between 1999-2001. Later, he served on as an active Executive Committee member and for many years took on the mantle of the International Liaison Ofcer. Dr. Gadhvi, with his contacts in Indian Psychiatric Society(IPS) and IAPA (Indo-American Psychiatric Association), from the beginning, established an active relationship with respective ofcials and helped set up Memorandum of Understanding(MOU) between the three organizations and foster an ongoing exchange in educational and research meetings. The start of the BIPA led International Meetings, with rst in Goa(2001), goes to his credit too. After nishing his International Liaison post, Dr. Gadhvi continued to be active with yearly Regional meetings of BIPA held in London. BIPA owes a great deal to Dr. Gadhvi for his vision, commitment and dedication, and active involvement in BIPAs birth, development and growth as an organization. He will be missed sorely. May his family and friends have the solace of his fond memories. He is survived by wife(a GP), two daughters and a son. Two of his children are lawyers and one is a doctor in UK.
I joined as a resident in the Government Mental Hospital, Kilpauk in Madras (now called Chennai) after the completion of my
MBBS course. In 1977, I joined the Diploma in Psychological Medicine course in the same institution and completed the course successfully in 1979. In the same year, I was selected for the MD Psychiatry which I completed successfully in March 1981. The Kilpauk Mental Hospital was attached to Madras Medical College, which was afliated to the University of Madras. So my training in psychiatry was continuously for 5 years in the bicentenary institution. I was trained under famous doyens of psychiatry like Dr. Saradha Menon, Dr. O. Somasundharam, Dr. M. Vaidhyalingam, Dr. V. Ramachandran, Dr. Peter Fernandez, etc. For a very short spell of 6 months I worked as senior resident in psychiatry in the department of JIPMER, Pondicherry under Professor Subha Thiruvedhi where I obtained good exposure of Liaison psychiatry. With a blend of experience in institutional psychiatry and General hospital Psychiatry, I took up the teaching post in Madras Medical College since 1981. Then, in 1988, I had Post Doctoral Fellowship training as a Fulbright scholar in Washington University, St. Louis, Missouri, of United States of America. During that time, I had an opportunity to watch and interact with faculties like Samuel B. Guze, Collinger, and Collin Louis etc. I got an opportunity to visit Butler Hospital, Providence, attached to Brown University, Research Institute on Alcoholism in Buffalo and Toronto of Canada. During this period, I had an opportunity to visit the Master and Johnsons Institute on Human Sexuality Institute for a few days. This period of training and exposure to alcoholism and chemical dependency, as well as sexual medicine, kindled my interest in substance abuse and sexual dysfunction. With the above said formal training in psychiatry, I was continuously working as a teaching faculty in various capacities and levels for more than 30 years. Indian Psychiatry is undergoing tremendous changes and the Indian Psychiatric Society has been instrumental in bringing about these changes. What are the changes to the IPS during your term as president from 2011 to 2012? During my tenure, I was able to materialize a long cherished dream of acquiring our head quarters in NCR, New Delhi. Another thing which was dear to my heart is to bring meaningful role for psychiatry in the under graduate curriculum.But it is till not materialized as expected, but the current president Dr. Roy is at it .I hope he will succeed in this mission. I suggested and requested the BIPA to nominate the president of IPS as an Honorary Fellow of BIPA, which has materialized and I am happy to say that I am the rst president of Indian Psychiatric Society to be nominated as Honorary Fellow of BIPA and I am thankful to the executive members of BIPA. It was a momentous occasion when you were elected as the Zonal Representative for Southern Asia at the World Psychiatric Association Congress held in Buenos Aires in September, 2011. Tell us about your current role as WPA representative in Southern Asia. The WPA is representing the world, but 2/3rd of the population of the world is from Asia. In Southern Asia zone there is a mixture of developed and under-developed countries. So WPA is more obligated to do many things in Southern Asia. Now, we have the President elect Dr.Bhugra in the EC who is born and brought up from Asia. Treatment gap is also more pronounced in Southern Asia. Some countries do not even have mental health policies. To solve this, the agenda will be bringing mental health care to primary care level through general health care. To achieve this, the only answer is to bring bonade and formal training of psychiatry for the under-graduate medical students. Most of the developed countries have practice guidelines which they can afford. But most countries in Southern Asia, the majority do not have practice guidelines (some have in principle but not in practice) because of the reason that is known to everybody. I am requesting the WPA to bring in a guideline which can be followed in all these underprivileged countries or at least lean on those guidelines. In that direction, I might work to get it materialized.
There has been a lot of interest in your concept of the mind called Manas. What is the relevance of Manas to the changing face of psychiatry world wide? Mind has been philosophized for couple of millenniums which cannot be questioned and argued reasonably. The utility value of mind is not of much use in the current teaching and educating in psychiatry. All erstwhile faculties always teach normal anatomy, physiology and then go to pathology. But in psychiatry, we go the other way round; we fear to talk about mind and mental health. We have to dene or at least describe what we are dealing with and what we are about it. To a common man, we have to tell, what we are treating and what we are aiming at. Mental health is not only the absence of mental illness. Time has come, the people are asking, aiming and working for promoting mental health and staying mentally healthy even in the absence of mental illness. Only one or two diseases have stigma, like in any other specialty. So, utilitarian concept of Manas as well as mental health has been proposed without being at loggerheads with the existing mind. I am sure that most of the people may not be able to accept Manas so easily, but the concept of mental health is very well appreciated. I am sure that a day will be there where we can measure the mental health and make people to stay in mental health even in the absence of mental illness. Mental health promotion is still at a nascent stage. What can BIPA and IPS do to improve mental health in India? India is a rich country in culture and heritage. We have more Indian Psychiatrists in UK than in India. All our brothers and sisters who are in the UK are well qualied and well trained. They can contribute by extending their valuable time to sensitize, bring awareness and if possible teach and collaborate their expertise to our Indian colleagues. Indian Diaspora regularly visit their homeland and during that time they can spend a couple of days disseminating their knowledge and expertise in that area. If this effort is routed through Indian Psychiatric Society it will be very much feasible and possible in a larger extent. Mental health in India faces many challenges. What are the current challenges facing psychiatrists in India? Non-pharmacological treatment and rehabilitations are not properly taught to the young psychiatrists of India. They are not exposed properly also. So, the psychiatrists in India are more attuned towards biological modes of treatment. Quite a few are successful in nonpharmacological methods also. But they are self-styled without any policy or practice guidelines. So, if the psychiatrists of India get an opportunity to get training and exposure in UK in the earliest part of their career, they will be very much qualied technically to deliver the results in the goal of promoting mental health globally. The world is shrinking at a fast pace with the advent of technology and the same technology can be used to help improve the quality of life of the people aficted with mental illnesses. Thank you for speaking to us, Prof. Thiru. It has been an extremely informative session and I am sure many Psychiatrists from BIPA will be inspired by your comments and nd ways to collaborate with their counterparts in India and thus promote mental health in the Asian region. Dr.Sathya D Cherukuri,