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March 2008, Volume 58, Issue 3

Letter to the Editor

Independence of Psychiatry

Yasir Abbasi  ( Fitzwilliam Centre, Sheffield Care NHS Trust, Sheffield S1 4JP )

Madam, I read with the interest A.A Gadit's article "Psychiatry in Pakistan: 1947-2006: A new balance sheet," published in your journal (Sept, 2007). It was not surprising to see that in a country were so little is spent on health there have only been few studies in the prevalence of mental health problems.
The author has mentioned that the figures quoted in his paper have been extrapolated from various sources and most studies have been clinic based.1 Therefore I agree with him that it would be difficult to truly represent the state of the mental health in Pakistan. Even though there are some large mental health set ups in Pakistan but there is no collaboration amongst them and no major studies have been conducted whose results can be published in international peer reviewed journals.
What we need is a multi-site national survey to screen and identify the incidence of mental health morbidity in our country. The National institute of mental health conducted a multi-site epidemiological catchment area (ECA) programme in the 80's gathering data from five different US geographical regions. They had about 3500 clients per site and approximately 20,000 clients in total.2 It was a longitudinal study and the patients were diagnosed by Diagnostic Interview Schedule--defined DSM-III mental disorders. This then became the backbone of any future studies into the prevalence or incidence of mental illnesses. We need studies of similar caliber and magnitude.
It was also really astonishing to notice that there have been only 107 FCPS postgraduates in Psychiatry since 1963. It would be naïve of me to ignore the fact that Psychiatry is an upcoming speciality in Pakistan and progress is being made. Nevertheless it was further disappointing to see the number of FCPS reduce to 2 and 6 during the years 2005 and 2006 respectively. It would have been helpful to know how many candidates actually took the exam and what the pass rate is for FCPS in Psychiatry. Correspondingly in the UK the final Part II examination of MRCPsych is conducted twice a year, spring and autumn. The Royal College of Psychiatrists shows that 371 candidates were successful in the MRCPsych Part II Examination held in spring 2007 from a total of 797 candidates who sat the examination (Pass Rate of 46.55%).3 Even with this number of doctors post-graduating in Psychiatry, the UK is still short of them and encourages young medical students to take this as a career.
I was one of the lucky ones who had the opportunity to complete 6 weeks ward based training in Psychiatry and go through a rigorous end of ward exam during the 4th year of MBBS in Karachi, Pakistan. This not only introduced me to a new clinical field but also encouraged to foster a mindset needed to pursue this field at a very early stage. I think it is high time that we put in real efforts to upgrade Psychiatry as an independent subject and speciality at undergraduate level. We also need to develop sub-specialities (e.g. Old Age, Child and Adolescent, Forensic etc.) at post-graduate level within Psychiatry, to bring it at par with other countries around the world.

Reference

1. Gadit AA, Psychiatry in Pakistan: 1947-2006: a new balance sheet. J Pak Med Assoc. 2007; 57: 453-63.
2. Regier DA, Myers JK, Kramer M, Robins LN, Blazer DG, Hough RL, et al. The NIMH Epidemiologic Catchment Area program. Historical context, major objectives, and study population characteristics. Arch Gen Psychiatry. 1984; 41:934-41.
3. http://www.rcpsych.ac.uk/exams/results/partii-spring2007.aspx Date accessed: 06/11/2007.

Response from the Author

Dear Editor, The observations and suggestions made by Dr. Abbasi are quite relevant and appropriate. I agree that there is an acute dearth of scientific data on mental health in our country. Any work quoted and extrapolated are a result of individual efforts and cannot be representative of the population as such. The few tables that I quoted are referred from the book "State of mental health in Pakistan: service, education and research" co-authored by Dr. N. Khalid. This book gave a glimpse of the situation in the aforementioned context. I with my team members collected local information from all the four provinces of Pakistan from sources like individual psychiatric clinics, hospitals and government set-ups and prepared a report with approximate figures under the context of various agreed diagnostic categories. This was reviewed by a team of psychiatrists and researchers and tables were produced and published in the book, of course with no tall claims of its national representation. The book was launched by the then minister and current chief of Higher Education Commission of Pakistan. The book was then sent to all psychiatrists, journalists, institutions both local and abroad and many other relevant places. Reviews were written by a number of newspapers about the usefulness of the book and even W.H.O.'s review was published in the Bulletin of World Health Organization. Table 5 was quoted from annual report published by the concerned department at Jinnah Postgraduate Medical Centre. The community based clinical study conducted in Karachi was quoted to represent Sindh on the advice of the reviewers. A full scientific report will be published in the second edition of the book with full protocol. However, no claims are made for its national representation. Regarding the suggestion for a national survey following the model of ECA program, I believe that it is a good suggestion which should be taken up by the government in collaboration with international funding agencies. We definitely need studies of such caliber and magnitude. Dr. Abbasi's comments on the shortage of specialists in psychiatry in the background of success rates in FCPS, which can be explained on the basis of limited training slots and trainees. Very few candidates appear in final FCPS psychiatry exams in a year. For example, if five out of ten candidates pass the exam, the rate will be 50% which is higher rate than MRCPsych but this comparison is not valid as 797 candidates appeared in part II of MRCPsych in 2007 and out of these 371 were declared successful. Moreover, this exam is an entry exam in a way for higher specialist training in contrast to FCPS which is an exit specialist exam and qualification. UK has roughly ten times more psychiatrists in number than that in Pakistan. Unfortunately, we do not have the option for sub-specialty training and fellowships in Pakistan as yet. It was great to note that Dr. Abbasi was among those lucky ones who had the opportunity to complete a rotation and rigorous exam in his IV year MBBS which had inspired him to such an extent that he opted for pursuing a career in psychiatry. I believe with collective efforts, broad-mindedness and mutual cooperation, psychiatry will progress in Pakistan.

  Dr. Amin A. Muhammad Gadit
  Professor of Psychiatry, Memorial University of Newfoundland,
  St. John's, NL A1B 3V6, Canada

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