Undergraduate Psychiatric Education in SAARC Countries

The South Asian Association for Regional Cooperation (SAARC) countries account for 3% of the world’s land area and host about one-fourth to one-fifth (21-25%) of the world population.[1] Almost all the SAARC countries have less than one psychiatrist per 1,00,000 population, which is much below than that recommended by the World Health Organization.[2] The majority of these countries also see a lot of brain drain when it comes to psychiatrists. According to one of the estimates, about 5000 psychiatrists in the United States of America (USA) and Canada are of Indian Origin,[3] which is equal to about half of the psychiatrists working in India.[4] According to the available information, the British Indian Psychiatric Association is the second most prominent organization of Psychiatrists in the United Kingdom after the Royal College of Psychiatrists (BIPA).[5] An article published in 2010 estimated that among the psychiatrists registered in the USA, UK, Australia, and New Zealand, 4687 were of Indian origin, 1158 were of Pakistani origin, 149 were from Bangladesh, and 142 were from Sri Lanka.[6] These numbers have increased in the last one and a half decades or so. Considering the low number of psychiatrists per 1,00,000 people in SAARC countries and the ongoing “brain drain,” it is difficult to reach the WHO-recommended number of psychiatrists soon, despite an increase in psychiatry postgraduate positions. Hence, some change is required at the undergraduate training level to improve access to mental health care. Given the high mental morbidity, it is essential to give due importance to psychiatry in the undergraduate curriculum so that every medical graduate has reasonable knowledge about the subject to provide some level of psychiatry care to needy patients. The Current Level of Exposure to Psychiatry During Undergraduate Training As per available data, current undergraduate medical training in SAARC countries ranges from 4.5 to 6 years with an additional 1 year of internship. During the undergraduate training, the number of hours dedicated to psychiatry teaching ranges from 20 to 150. The duration of clinical posting in the psychiatry subject during undergraduate training in these countries ranges from 2-12 weeks, with only two countries having clinical posting for eight or more weeks. The duration of clinical posting during the one year of mandatory internship ranges from 5 days of optional posting to 2 weeks of posting, except for Sri Lanka. In none of the SAARC countries, except for Sri Lanka, psychiatry is an independent subject in the undergraduate curriculum [Table 1].[7-12]Table 1: Comparison of Undergraduate psychiatry education in SAARC Countries[ 7-12 ]However, an important thing to note is that, in general, there is no difference in the time dedicated to psychiatry during undergraduate training between high-income and low-middle-income countries. A survey conducted by the World Psychiatric Association reported that only 4% of the time during undergraduate training is given to psychiatric education, with no significant difference between high-income countries and low-income countries. In this survey, when asked about the optimal duration of exposure to psychiatry in undergraduate training, the participants reported that about 9% of the time should be devoted to psychiatry during undergraduate training.[13] If there is no difference in the time devoted to psychiatry between high-income countries and low, middle-income countries, does this mean that exposure to psychiatry is the same across the globe? The answer is complicated. When one attempts to evaluate the difference in the exposure to psychiatry during undergraduate training, it is apparent that, in contrast to the time-based exposure to psychiatry in SAARC countries, psychiatry training is competency-based, and psychiatry is included in the foundation/pre-clerkship years in high-income countries. There is an emphasis on skill development and flexible and learning-based training.[14] Further, in most high-income countries, primary health care is based on the general practitioners, who are the first point of contact, who manage various ailments, including mental disorders, and who decide about further referrals. As a result of this, possibly a higher proportion of trainees take psychiatry rotations more seriously, considering the high prevalence of mental disorders in primary care settings. Further, these countries have general practitioner specialist training pathways that specialize in providing care at the rural and community levels and incorporate significant mental health training components.[15] In contrast, for example, in India, primary care is usually provided by physicians who have completed their basic undergraduate training and have no general practitioner training pathways. Hence, it becomes much more critical that psychiatry training at the undergraduate level should be strengthened. Over the years, many authors have made specific recommendations to improve psychiatry training to overcome this poor exposure to psychiatry during undergraduate training [Table 2].[7,16,17] Some of these recommendations have been implemented to a certain extent. However, acceptance of psychiatry as a full examination subject in the undergraduate curriculum has not been achieved. Until this is achieved, psychiatry training is unlikely to improve significantly in the SAARC countries. Hence, various psychiatric professional organizations in the SAARC countries should try to give psychiatry the status of an examination subject in undergraduate education.Table 2: How to improve exposure to psychiatry during undergraduate training[ 7 , 13 , 14 ]The limited exposure to psychiatry during the undergraduate curriculum is further complicated by the lack of seriousness among graduate students about the same (because it is not an examination subject) and the prevailing stigma attached to mental illnesses. Due to this, most undergraduate students are ill-equipped with knowledge and practical skills to manage common mental disorders. They are also not aware of how and when to refer a patient with mental illness to a psychiatrist. Additionally, the trainers (faculty in psychiatry) may not do much about training undergraduates in psychiatry basics due to the overwhelming patient load, limited resources (few faculty members in the department), and other administrative responsibilities. Further, many of them are not accustomed to teaching methods. In recent years, there have been specific improvements in psychiatry training in SAARC countries. For example, in line with the high-income countries, the National Medical Council of India 2019 introduced a competency-based medical education (CBME) curriculum emphasizing competency-based learning rather than traditional knowledge-based learning.[9] However, there is a long way to go! As mental health professionals, we need to improve awareness about mental health conditions and additionally focus on mental well-being. We also need to address stigma by having more public awareness campaigns. Another essential aspect that needs to be considered seriously is doing psychiatry training for undergraduates in a consultation-liaison psychiatry setting (with emphasis on common mental disorders) rather than in a mental health setting, which lays more emphasis on severe mental disorders. A shift in the training setting will also help the trainees understand the role of psychological factors in developing various physical illnesses and how psychological factors affect the outcome of other medical diseases. Further, this will also provide an opportunity to emphasize the role of untreated mental morbidity on the outcome of other medical illnesses. Further, as psychiatrists, we have to take our role of a trainer seriously and ensure that undergraduate students are exposed to and develop skills to handle persons with various mental disorders. Similarly, the psychiatry clinical posting during the internship should also be utilized to buttress the skills developed during the undergraduate years. Acknowledgement None. Ethical policy and institutional review board statement Not required. Statement on the generative artificial intelligence technology “The authors attest that there was no use of the generative AI technology in the generation of text, figures, or other informational content of this manuscript.” Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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