“History is a screen through which the past lightens the present and the present brightens the future.”
“The history of psychiatry had witnessed 3 major revolutions that have given its present status. The first revolution occurred when it was believed that sin and witchcraft are responsible for mental illness, and mentally ill were chained in jails and asylums. They were considered as outcaste from society. The second revolution was the advent of psychoanalysis; that explained the etiology of psychiatric disorders. The third revolution was the development of Community Psychiatry that resulted in the integration of mental health (MH) care in the community.
COLONIAL ERA OF PSYCHIATRY
The political instability prevailing in the 1700s saw development of lunatic asylums in Calcutta, Chennai, and Mumbai more at first to treat and manage Englishmen and Indian, sepoyees’ employed by the British East India Company. The First Lunacy Act (Act no. 36) was enacted in 1858. The second phase in the development of mental hospitals extended from the mid 19th century to the late 19th century. This period as significant for the enactment of the first Lunacy Act (also called act no.36) in the year 1858.
Gujarat, (earlier known differently under the British rule and part of Mumbai presidency) saw the first Mental Asylum at the Manchester of India, Ahmedabad, on January 6, 1863, after the first revolution for Independence of 1857. It was looked after by Major General Dr. P. Pirai, the first superintendent. In 1898, Baroda state came up with another one. Both were managed by the then Mumbai presidency, coming under the power of Army Generals.
During this period, these 2 mental asylums were looked after by the jail superintendents, as customary under the Indian Lunacy Act, 1917. Civil surgeons of Civil Hospitals were given the charge afterward, after independence. The first psychiatrist appointed in 1950–1954 at the Mental Hospital, Ahmedabad, was Dr. Major C. B. Miller. The third mental Asylum was built at Jamnagar after independence in 1960.
How the mentally ill were treated during that time is well known. One of the authors has seen the remnants of hot and cold bathtubs in the closed ward inner grounds of the Mental Hospital at Ahmedabad even during 1980s, though such practices stopped long back in 1950s after the advent of antipsychotics. Till 1990s, the old jail-like wings opening in a central sanctum through the narrow corridors remained, though the humanitarian approach was there.
POSTINDEPENDENCE ERA OF MENTAL HEALTH
After the independence of 1947, India had to handle all its institutions, and progress was the color in the air all around. In India, all medical institutions saw a gradual sea change. In MH, the discovery of Chlorpromazine around 1952 was the most important milestone, which changed the practice of psychiatry world over; and India was quite quick to follow.
In Gujarat, B. J. Medical College was established in 1950, although Gujarat was still part of a bigger state. Gujarat was separated from Brihan Mumbai on May 1, 1960 after the Mahagujarat Andolan. Dr. Jivraj Mehta was the first chief minister of state, and under his leadership, the health sector developed. Sector developed. In the first annual conference of west zone of 1970 held at Maroli, inaugural address by then deputy health Minister Urmilaben Bhatt emphasized the young age suicides and the need for trained manpower in MH sector of the state. She talked about expanding services with 4 Mental hospitals and 538 beds.
The Mental Hospital and Civil Hospital of Ahmedabad were visited by Dr. R. A. Hakim. Dr. Shanti Sheth, DPM, from the College of Physicians, Mumbai was transferred from Mental Hospital, Thane to MH, Ahmedabad as superintendent.
A teaching Department of Psychiatry was established at BJMC, Ahmedabad on February 2, 1962. Dr. Anil Shah, the first PG student to be registered for DPM Mumbai University at Seth GS Medical College, Mumbai, trained under Psychiatry stalwarts like Dr. N. S. Vahia, Dr. V. N. Bagadia, Dr. Masani, and Dr. J. C. Marfatia. He joined B. J. Medical College, Ahmedabad in the newly formed Gujarat State in 1962. For this first young enthusiastic Professor of Psychiatry at this premier institute of Gujarat state, at an early age of 28 years, with the support of Chief Minister, Health Minister, Director, and Dean, there was no looking back.
Under the able leadership of Dr. Anil V. Shah, the psychiatry department developed very fast in a general hospital set up. By 1966, a full-fledged department was established, with a 10 bed unit, registrars, resident doctors, a clinical psychologist, psychiatric social worker, one occupational therapist, and psychiatric nurses. (But today, this multidisciplinary team is missing in all departments). Within just 1 year, a Child Guidance Clinic was also established, with a part-time psychiatrist and 2 playroom workers. Along with Dr. Anil Shah, Dr. Madhuben Patel and Clinical psychologist Mr. B. K. Sinha; Dr. Usha Goswami, Dr. Hitendra Gandhi, Dr. Ratna Bilwani were the first generation teachers who trained the psychiatrists for the state.
At Vadilal Sarabhai Hospital run by the Ahmedabad Municipal Corporation, another Department of Psychiatry was started in 1972, which in turn started the MD psychiatry course in 1977. It developed under the guidance of Dr. V. D. Shah, Dr. Pratap Mehta, and Clinical psychologist Mr. Verma and then Dr. Mahesh Chudgar, Dr. Rajesh Maniar, Dr. Laxman Dutt, and Dr. Hitendra Gandhi. Today, it can boast of having done maximum number of drug trials in psychiatry.
A NOVEL FAMILY AND COMMUNITY PSYCHIATRY IN 1950S
Kasturba Sevashram [Figure 1] was established at Maroli, Navsari district in 1931 with a Gandhian philosophy and multipurpose social, educational, cultural, vocational, and medical activities. Baroness Mithuben Petit, [Figure 2] known lovingly as “Maiji,” was the founder and a fountain of inspiration behind this Ashram, supporting Adivasis and the poor of the 4 districts of South Gujarat. As the story goes, two-three freedom fighters had gone insane and nobody was prepared to harbor them, nor even their families. Mithuben took them in her affectionate wings, and without any scientific treatment, they improved in 2–3 months. In the meantime, a very valued congress worker and GPCC leader developed mental illness after the tortures and rigors of jail. He was hospitalized in Mumbai, had to be chained and tied to cot, because he bit off a nurse's finger. At the behest of Sardar Patel, he was brought in chains to Maroli. Mithuben ordered his chains to be removed and took him in her loving embrace. He recovered in just 2 months, totally sane. With these experiences, Mithuben decided to create a center for scientific treatment of mental ailments (from speech by Shri Kalyanji Mehta, Trustee of Kasturba Sevashram, 1970). In 1942, the services started and it became an established “Mental Hospital” in 1951, with a very different approach and motivation.
It was the first of its kind family care in the community for psychotic patients. Hosting the first West Zone conference there, Dr. Ishwarlal Desai, Superintendent of the hospital, reported of treating 19,000 psychotic patients by admitting them along with their family members, in 27 years, becoming a model institution and known throughout India. Patients came not only from the Indian states of Maharashtra, Rajasthan, Madhya Pradesh, Karnataka, Kerala, Punjab, and Uttar Pradesh; there were also Indian patients from Africa, Aden, and England who also came here. Imagine being given one, two, or three room cottages in a serene green village background for each family of a patient! And for free… Today, it may appear an impossible dream, which may cost lakhs… The hospital had an 80 patient cottage capacity. Moreover, the treatments offered other than pharmacotherapy were individual, group, and family therapy as well as insulin subcoma, ECT, and transorbital leukotomy. After 1982, even the resident doctors from the Psychiatry department of the Medical College, Surat were posted at the hospital.
From 1988 to 2001, Dr. Mahesh Desai worked there as a superintendent and developed more scientific approaches of modified ECTs, stopping insulin subcoma therapy, and leukotomy. A daily outpatient department (OPD) of 50–60 patients became a regular feature. However, only visiting psychiatrists go there presently, and the hospital requires a major overhaul of infrastructure and recruitment of workforce.
A MENTAL HEALTH INSTITUTE FROM CORPORATE CHARITY
B M. Institute was established in 1966. Smt. Kamalini Sarabhai, one of the leading names in the field of MH services was the key person to develop the pillars of B M Institute and transformed it into one of the pioneering institutions of Asia. She studied psychoanalytic training at the British Psychoanalytical Society (BPAS) and the Tavistock Clinic, London. She was also a member of the BPAS with a special interest in child development.
Erik H. Erikson, held a seminar at the BM Institute in 1962, on preadolescents in India (reported in Childhood and Society). His host was Ambalal Sarabhai, the mill owner who had been Gandhi's chief opponent in a 1918 strike for higher wages by Ahmedabad mill workers. Erikson met many men and women who remembered Gandhi and had been participants in the events of 1918. Erikson studied in depth the Ahmedabad strike, which was Gandhi's first major reform activity in India and also the occasion of his first public fast. Erikson interviewed many who had worked closely with Gandhi including Gandhi's biographer, who had been Gandhi's secretary for three decades. Erikson also studied Gandhi's letters, books, essays, and autobiography. This resulted in a book, “Gandhi's truth,” a psychobiography.
The early activities of B. M. Institute, as an agency interested in conducting research, service, and training in preventive social medicine, were based on the kinds of services which members of our society need. Research and training components were built around these service functions. It sought the services of highly qualified and trained personnel with a psychodynamic approach in the medical and social sciences, namely, medicine, psychiatry, clinical psychology, sociology, anthropology, education, and psychiatric social work. The Child Guidance Clinic of the Institute was inaugurated by the then Vice President of India, Dr. S. Radhakrishnan on October 9, 1955.
In 1962, B. M. Institute set up an OPD at V S General Hospital, Ahmedabad.
Institutions of MH till Statehood
- Mental Hospital, Ahmedabad
- Mental Hospital, Baroda
- BJMC, Ahmedabad
- B M Institute, Ahmedabad
- Mental Hospital, Maroli.
POSTSTATEHOOD ERA OF MENTAL HEALTH
Young institutions and various young leaders of all these five MH setups were working in tandem for the cause, during which many milestones were achieved. Gujarat hosted the first ANCIPS – 21st annual conference [Figure 3] in Ahmedabad in 1969. Dr. Marfatia as president of Indian Psychiatric Society, and other stalwarts of Indian Psychiatry were present for the occasion, when Shri Umashanker Joshi, the vice-chancellor of Gujarat University as chief guest announced the first course of DPM at BJMC, Ahmedabad. This was the first successful conference, followed by many more. The first west zonal conference was held at Maroli-Navsari, again by the efforts of these leaders of psychiatry in 1970. The 33rd ANCIPS [Figure 4] was also held at BJMC, Ahmedabad in 1980. The MH Education and Research Trust was created from the savings of the 33rd ANCIPS, which worked significantly after the Ahmedabad earthquake.
As the Head of Department of psychiatry at a key institute BJMC, Ahmedabad, [Figure 5] Prof. Anil V. Shah ably improved the MH Sector. He established the Gujarat Psychiatric Society as its founder secretary in 1970. He was made MH Advisor by Government of Gujarat (GoG) in 1974, in recognition of his dedication and academic achievements to develop the MH sector in Gujarat state. Gujarat State was the first state in India to create the post of Advisor in MH, GoG in 1974 after the Bhore committee recommendation, to advise various departments such as health, medical education, social defense, jail, home, legal services, judiciary, training and employment, education, etc.
In his presidential address at the 5th IPS-WZB Gujarat, in 1974, at Ahmedabad, he emphasized on Rural Psychiatry and Community Psychiatry. Statistics shown at that time as 3 MH, 4 GHPU, and 2 trust hospital with 650 beds, 3% of all medical beds for MH and 2.8% of total Health budget spent on MH. His memberships and official positions of IPS, WASP, and ICMR task force of Biological Psychiatry (1982), WHO Expert Consultation Group on MH at Chandigarh (1977) put Gujarat in the International MH scenario. He was the only psychiatrist from Gujarat who has the credit of becoming President IPS (1982) and President IASP (1992).
COMMUNITY MENTAL HEALTH CARE AND NATIONAL MENTAL HEALTH PROGRAM IN THE STATE
There were earlier efforts at developing MH care as part of the general health care, starting with the Bhore committee report. Under the leadership of Dr. Sushila Nayar, in the 1960”s, as part of the Mudaliar committee report, a detailed plan of district MH units, school MH program, training of health personnel, and most importantly, public MH education were planned. The WHO expert committee meeting on “organization of MH services in developing countries” held in 1974 at Addis Ababa marked an important expression of the WHO about its priority for MH care in developing countries, followed by a project “Strategies for Extending MH Care (1975–1981)” in seven countries, one being India, the first major country to adopt it at the national level.
To promote MH sector from time to time, the Gujarat state government administration took various steps. As a MH Advisor, Prof. Anil Shah was instrumental in starting parapsychiatric courses for clinical psychology, psychiatric social worker, teachers for mentally retarded, etc., Initially, class II doctors with DPM were posted in mental hospitals and they were exempted from postmortem duties as incentive. He persuaded the Government to start District MH clinics.
Many years before DMHP-NMHP were envisaged and implemented, 8 District MH Centers were started in Gujarat at District Civil Hospitals to offer Psychiatric services to rural population. A new category of MH Worker was introduced to work at District MH centers who were trained in-service and posted at Districts. Superintendents and DPM medical officers were posted to run OPDs in these district centers. During Prof. Anil Shah's tenure as President-IPS, with the help of the Health Minister and the Chairperson of the task force Shri Manoharsinhji, the Parliament approved the National MH Program in 1982.
1980-2016 – CONSOLIDATION AND PROLIFERATION PHASE
From 1980 to 2000, there was a phase of consolidation and proliferation in the MH sector, with many more GHPUs and degree courses starting in various medical colleges, and the number of Psychiatrists increasing. Eight educational departments trained many MD and DPM psychiatrists, gradually spreading across the state. The number of psychiatrists increased from a meager 17 in 1974 to 300 in 2010.
Moreover, following the launch of NMHP, as per the guidelines of Government of India (GoI), a State level MH Council was constituted in 1986 to plan and develop MH activities in various departments under the chairmanship of the Health Minister. The first District MH Program was started in Navsari with GoI funding. Today 16 districts are under DMHP, and all 33 districts have a sanctioned post of psychiatrist from GoG.
Although there was no national-level conference held in the state, the Gujarat Psychiatric Society became more active, with all departments conducting some research and taking up community level awareness programs. As Editor of Archives of Psychiatry for more than 15 years, Prof. Ganpat Vankar contributed immensely to Research and Publications.
There was an attempt to amalgamate Mental Hospitals with Medical Education departments of Psychiatry and a GR was also issued by GoG in 1988, but due to lack of consensus, it did not materialize. This was an attempt to improve the Mental Hospital services with the existing workforce of medical college psychiatry departments along with increase in the MH training programs. This would have been a step toward a MH Institute in the state, but it failed. Later on, through NMHP manpower scheme A, HMH, Ahmedabad received the Center of Excellence grant in 2010 and has established now as Gujarat Institute of MH.
During 1976-1983 the Indian Council of Medical Research funded and conducted a multicenter collaborative project for the first time in India on “Severe Mental Morbidity” in Bengaluru, Baroda, Calcutta, and Patiala. Between 2000 and 2016, Gujarat participated in three other major National surveys, two Alcohol Household surveys, and the third NMHS (National MH survey– 2015–2016) in collaboration with NIMHANS, funded by Department of Health and Family welfare-GoI, under the leadership of Prof. Ritambhara Mehta.
MENTAL HOSPITALS’ TRANSFORMATION
The new Mental Hospital campus at Ahmedabad was ready at the time of partition (May 1, 1960) and was to be built under the supervision and on the lines of NIMHANS, Bengaluru, but could not see its day. If the area of 34 acres, designated for the New Mental Hospital was not encroached on by government offices, this would have been a dream come true for the infrastructure and services in MH in Gujarat.
During the tandem working with the Department of Psychiatry, BJMC, Ahmedabad; under the guidance of MH Advisor Dr. Anil Shah, as part of the District MH clinics, Mental Hospital Superintendents and MOs Dr. Ravindra Bakre, Dr. Buch, Dr. Nanawala, and others started visiting district hospitals since 1985. Community outreach services were started at 8 districts of Himatnagar, Bhavnagar, Junagadh, Rajkot, Godhara, Bharuch, Navsari, and Ahwa by posting Hon. Psychiatrist by 1986.
To reduce the stigma, Mental hospitals were named as Hospital for MH in 1983. The staff pattern of Mental Hospital was changed as per modern developments and appointment of Psychiatric Social Worker, Clinical Psychologist, Occupational therapist, Psychiatrists, and Nurses were made to take up new role of services such as OPD, day care, psychotherapy, etc., Occupational therapy and vocational training center were separately identified as departments since 1990.
The State MH Council was established in 1986 to plan and develop MH activities in various departments for liaison, advice, planning, monitoring, and supervision of MH facilities in the state under the chairmanship of the Health Minister. The MH Act 1987 was implemented from May 1, 1993, which also reformed the services. The State MH Authority was established in 1993.
The old British Jail-like hospital building [Figures 6-9] was demolished and a new building for the Hospital for MH-Ahmedabad came up in 2002. This was patient-friendly and right-oriented. Family ward (Open ward) [Figures 6-9] was started in 2002 by the current Superintendent Dr. Ajay Chauhan. Inpatients were not wearing the same prisoner-like clothes now. Voluntary admissions were started in 2003, bringing down the stigma associated with Mental hospitals. Rehabilitation of the wandering mentally ill project started in 2004 with the police commissioner of Ahmedabad. This initiative took care of the lost mentally ill, and rehabilitated them.
21ST CENTURY DEVELOPMENT OF MH SECTOR
Gujarat has the oldest plateau of land and the big desert of Kutch, and is also prone to natural disasters such as earthquakes and floods. The Cyclone of Kutch was the first disaster to receive psychosocial rehabilitation service. A major earthquake on 26 January, 2000 led to the development of services through an ICMR project with a consequence of fewer cases of PTSD. Today, Gujarat has a well-organized Disaster Management cell.
The MH Mission 2003 was a unique state-level mission involving all stakeholders commissioned by GoG with the grant from Royal Netherlands Embassy, led by IIM professor Ramesh Bhat. Two years of rigorous research and survey of MH health systems brought together a MH report, which ultimately led to the first ever State MH policy in 2004, much before any other state or even the nation.
As the MH Program officer, from 2002 to April 2009, Dr. Ravindra Bakre was instrumental in receiving Central grants for GHPUs, as well as HMHs through NMHP one time and Manpower scheme, which improved the infrastructure and workforce of all units in the state.
Despite the National MH Programme since 1982 and National Rural Health Mission, there has been a very little effort so far to provide MH services in rural areas. In this regard, Gujarat has sown some seeds in the community MH area. The Gujarat Foundation for MH and Allied Sciences – a not-for-profit Company under section 25 of Company Act was established for MH Sector Development and to support community MH services and research in the state.
“The GoG has a vision to provide comprehensive health care for all its citizens by the year 2010. If this goal is to turn into reality, MH, which forms an integral component of public health, needs to be addressed. The Department of Health and Family Welfare (DoHFW) therefore constituted a Mission Team, whose task was to assess the existing status of the MH sector and suggest strategies to strengthen it. The findings of the Mission Team were published in the Mission Report 2003, which drew a roadmap to respond to the complex and challenging needs of the MH sector development in an integrated manner with the involvement of the community. The MH Support Programme was conceptualized to pave the way for the operationalization of the mission strategies and prioritize them. The prime objectives were to develop and implement capacity strengthening, pilot-test certain key interventions in community-based settings, and document learning from these pilots undertaken to identify critical conditions for future programs.” (Excerpts from Preface of MH Care Pilots in Gujarat – Processes, Outcomes and Learning, published by IIM, Ahmedabad, 2007).
Fourteen MH Support Programmes were started from the research funding from the Royal Netherlands Embassy, New Delhi, implemented through the CBOs and NGOs [Table 1]. Even today, many projects are ongoing after 10 years. These projects are varied covering adult, elderly, women to Child, and adolescent population addressing specific needs, initial work compiled very well for any other CBOs to adopt and adapt. (Ramesh Bhat et al. 2007 in MH Care Pilots in Gujarat– Processes, Outcomes and Learning).
MENTAL HEALTH-CARE PILOT PROJECTS
Other large-scale projects which were taken up by Psychiatry departments through the Gujarat MH Foundation are as follows [Table 2].
Another unique project was developed over time in North Gujarat, at Mira Datar Dargah, with traditional healers of the dargah [Figure 10], called “Dava and Dua” project since 2008, run by the Altruist Trust and its founder Milesh Hamlai, a caregiver himself. The model takes care of preserving traditional systems but incorporating detection and treatment of mentally ill and preventing torture and cruelty toward mentally ill by advocacy and training of traditional healers [Figure 11]. A psychiatric service is established just beside the shrine to facilitate the treatment, providing free psychiatric consultation, psychological assessment, and therapies along with medicine. Referrals and follow-up system are established. Furthermore, there is a monitoring committee chaired by the District Magistrate/District Judge, with the District Health Officer, a local police officer, a local medical officer, two representatives from the local community, a representative from the religious place, and a MH professional as other members.
With a full thrust to the NMHP Manpower schemes, an M. Phil Clinical Psychology course was started with GFS University and Diploma in Psychiatry Nursing was started with the nursing college Ahmedabad in 2010 under the Center of Excellence in MH.
A Community MH Development Project for rural and tribal population of Panchmahal district started in 2011 under NMHP in collaboration with the Melbourne University, Australia.
A unique “AADHAAR” helpline for wandering mentally ill has been started at the HMH, Ahmedabad from 2011 and at HMH, Vadodara from 2015. It helps people who are lost and wandering get into the hospital, treat, rehabilitate, and reunite with their own family members. It has helped thousands of patients with mental illness so far.
Today, the Hospital for MH Ahmedabad and Vadodara are accredited by National Accreditation Boards of Hospitals and Healthcare providers from 2012 (the first Mental hospitals in the country to get Accredited). All Gujarat health units are NABH accredited and pursue high standards.
”Quality Rights Gujarat” project was implemented in 2013 for 3 years at 9 institutes of MH in Gujarat in collaboration with the WHO, ILS Pune, CAMH Toronto, and SCARF India, with financial grant support from Grand Challenges Canada (GCC). This is a unique project aiming to improve quality of MH services through training and attitudinal changes of staff in the areas of rights of mentally ill and communication skills, and involving Peer support volunteers to bridge the gap between service user and MH service provider. Recently, after the positive impact of the project, GoG has approved 50 posts of Peer Support Volunteers in the state, first state to take such a forward step for the cause.
Today, the MH sector in Gujarat is developing very fast and Gujarat psychiatrists have spread across the globe. Golden roots have nurtured a tree with Golden fruits.
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Conflicts of interest
There are no conflicts of interest.
This article was prepared after many personal interviews with significant MH professionals in Gujarat. We are especially thankful of Dr. Anil Shah sharing old souvenirs, presidential addresses, and photographs through which we could peep through the past. Dr. Mahesh Desai, Dr. Jitendra Nanawala, Dr. Hitendra Gandhi, Dr. Mukesh Jagiwala, and many others gave insights into the developments in Gujarat. They also provided data, photographs, and articles.