Where There is No Psychiatrist (Second Edition)

Where There is No Psychiatrist (Second Edition). Vikram Patel, Charlotte Hanlon (eds). RCPsych Publications, Glasgow, UK, 2017. 282pp, £10.00. ISBN 978-190-972-6833.

The book, Where There is No Psychiatrist, in its second edition, represents a well-timed and much- needed attempt at devising strategies to bridge the gaps in mental health services in low-resource countries. The authors, Dr Vikram Patel and Dr Charlotte Hanlon, are both veterans in the field of psychiatry with extensive clinical and research experience of working at various low-resource settings in Zimbabwe, Ethiopia and India. The lucidly written, aptly titled book has the potential to be the ‘go to guide’ for devising mental health interventions in settings where trained mental health professionals are scarce.

Mental and substance use disorders have become a major contributor to the global burden of disease, with WHO estimating it to be responsible for about 7.4% of the total disease burden in 2010.^[1] The National Mental Health Survey of India (2015-16) reports the lifetime prevalence of mental disorders at 13.7%, with roughly one out of every sixth Indian getting affected.^[2] Unfortunately, the same survey estimated a huge treatment gap of >70% for both common and severe mental disorders in all the 12 states included in the survey. In India, the average national deficit of psychiatrists currently stands at around 77%, with more than one-third of the population having a deficit of psychiatrists even >90%.^[3] The situation is similar in most low- and middle-income countries (LMICs), where a gross deficiency of mental healthcare workers is the norm rather than an exception.^[4]

In this background, the authors’ effort to provide a framework for identification and management of common mental health conditions, targeting health providers without structured training in psychiatry is commendable. The authors have extensively revised and re-organized the first edition of this manual published in 2003, bringing it up to date with advances in our understanding of mental health problems and their pharmacological and psychosocial management. The assessment and treatment recommendations made in the book have been revised to reflect the latest evidence-based guidelines of the WHO mental health Gap Action Programme (mhGAP). Further, sections in the book have been expanded and added to cover a broader range of mental health problems such as eating disorders, internet addiction and autism spectrum disorders.

The book has 18 chapters divided into 5 functional sections, each building on the concepts explained in the preceding parts. Part one gives an introduction about the general approach and basic skills needed for assessment and management of various mental health problems. The authors attempt to make the readers understand the causation and presentation of various mental health problems in a culturally sensitive manner. The use of simple English terms such as ‘physical’, ‘feeling’, ‘thinking’, ‘doing’ and ‘imagining’ to describe the somatic, emotional, cognitive, behavioural and perceptual domains of psychological symptoms, epitomizes the approach followed throughout this book to communicate complex psychiatric concepts using simple words, avoiding jargons and technical terms.

Part two covers the general principles of pharmacological and non-pharmacological interventions to be used for the treatment of various mental health problems. Practical and effective counselling techniques for giving hope, providing psychological first-aid, teaching problem-solving, relaxation exercises, behavioural activation, anger management and improving motivation are well discussed.

Part three describes specific management strategies of mental health problems using decisional algorithms and flowcharts. The authors describe management of more than 30 specific clinical syndromes covering common and severe mental disorders such as depression, anxiety and psychosis; as well as habits that cause problems such as alcohol or drug dependence. The revised edition additionally highlights mental health problems of the young and elderly age groups and discuss emerging health problems resulting from trauma such as domestic violence, rape, torture or death of a loved one.

Part four deals with the integration of mental healthcare across various healthcare (e.g. primary healthcare centres and reproductive health clinics) and community settings (e.g. schools and workplace). The fifth and the final part provides information regarding psychotropic medications, including details on the WHO essential drugs list and recommendations to be followed by general health workers under WHO mhGAP guidelines. This section also discusses strategies for adapting the manual to meet the local need of the reader, for example, by entering information related to the local resources and voluntary agencies providing support to people with various mental health issues and brand names and prices of commonly prescribed medications.

The book has an attractive cover, handy size, is relatively inexpensive and easy to read. The extensive use of tables, illustrations and case descriptions increases the readability of text and helps emphasize important principles of mental health to the readers. There is extensive cross-referencing in the book, a glossary of technical terms used, a bibliography and an index provided at the end for enhancing the ease of use. The authors state in their preface that the book has been written to meet the needs of general health workers, with no special training to work with persons having mental health problems. The intended readership includes community health workers, social workers, primary care nurses, midwives and general physicians. The authors have been largely successful in achieving their stated goal of creating a practical and clinically oriented practice manual for general healthcare workers. The book describes evidence-based pharmacological and non-pharmacological interventions for the management of mental health problems without including too much details and the research behind them, making it palatable for the readers with no previous background in mental health. However, the book is available only in the English language currently, and a substantial number of general health workers in LMICs might not be able to use this manual efficiently by reading on their own. In our opinion, short-duration training courses for general health workers are required to complement this manual, for them to be able to efficiently handle mental health problems.