Non-psychiatrists practising psychiatry in India: ethical concerns

The deficit of psychiatrists in India is about 77%, which is a huge gap especially in the context of the enormous burden of psychiatric morbidity (1). Unfortunately, this gap is being filled by an under-skilled or unskilled workforce. Self-proclaimed/unqualified psychologists, psychotherapists, life coaches, social workers and counsellors are not authorised in their professional capacity to deliver mental healthcare. Similarly, practitioners of alternative medicine and traditional/religious/faith healers are not competent to provide mental health care. Finally, non-psychiatric non-specialist/specialist/super-specialist doctors who are not sufficiently trained to diagnose and treat psychiatric disorders treat mentally ill patients. To attract patients, these practitioners inadvertently or intentionally take advantage of the stigma associated with being treated by psychiatrists (2). In the process, inadequate and inapt care is meted out to a lot of mentally ill patients.

There is no provision for licensing/regulation of clinical psychology and its practice. No accreditation or proof of adequate supervision is deemed necessary for offering psychological services (3). Bonafide clinical psychologists merely form the tip of the iceberg, with MA-level psychologists, counsellors, special educators, teachers, anganwadi workers and others offering similar services (3). As against this, psychiatrists are required to register their postgraduate qualification with the Medical Council of India, as well as obtain a license before offering inpatient services. Given the poor state of mental health literacy in India, most people do not appreciate the difference between a “psychiatrist” and a “psychologist”. It is not uncommon to find mental health departments of multispecialty hospitals in metropolitan centres being headed and run by psychologists (with or without the required expertise) as convenient and cheaper substitutes for psychiatrists. A recent newspaper report also indicated the illegitimate and rampant practice of the mental health profession by ill-qualified persons posing as counsellors and life-coaches (4).

About 25% of patients that consult general physicians have active, diagnosable psychiatric illnesses; and neurologists in adult ambulatory settings can expect this proportion to be 40% (5). Though increasingly the border between neurology and psychiatry is getting blurred (6), the fact is that the two remain distinct specialties, as is clear from the 10th revision of the International Classification of Diseases, where Chapter V deals with psychiatric disorders, and Chapter VI with diseases of the nervous system. Although assessment of mental status is an integral part of a neurological examination, neurologists are not sufficiently trained to analyse behavioural elements (6). Neurologists are not entitled in their capability to diagnose and treat primary mental illnesses. Treatment in psychiatry involves much more than just prescribing psychotropic agents and reducing overt symptoms. However, it is widely known that several neurologists in India treat psychiatric patients; this is subtly accepted by the society as well as the medical fraternity. Is this practice not a breach of professional ethics by neurologists?

Ideally, optimal mental health services are best delivered by a team led by a psychiatrist. Based on the setting, the team may have a clinical psychologist, a psychiatric nurse, an occupational therapist and a psychiatric social worker. After a thorough diagnostic assessment that incorporates physical, mental and social factors, the psychiatrist may recommend initiation of psychological or social intervention delivered by a member of the team with the most appropriate skills (7). Clinical psychologists practising independently should collaborate and liaise with psychiatrists for diagnostic and pharmacological considerations, and in a best-case scenario should only consider diagnosed cases referred to them by psychiatrists, rather than assessing and diagnosing patients first-hand. Mandatory regulation and licensing for clinical psychologists could be a way to check the quack practice of psychology by unqualified individuals.