August 25th: CMC Psychiatric Department and Nambikkai Nilayam

Playground area for the children at the psychiatric department

Today was our last day at the psychiatric department/hospital. We leave for New Delhi tomorrow and are actually working out details to change our travel plans because of a hunger strike and political protests occurring in New Delhi. The hotel we planned to stay at is in the area of the protests. While right now the protests are nonviolent, the government has closed several metro stations in the area and there is a big debate tomorrow in the government. Since the nature of the protests could change at any moment, we thought it best to avoid the area entirely.

In the morning we went to the Occupational Therapy department. This department was different than the OT rehabilitative services we went to yesterday because this service is for the inpatients at the hospital. OT is very comprehensive here and seems to be the backbone of the hospital especially in regards to the schedule.

At 8am the patients (divided by gender) meet and perform simple exercises for 15-20 minutes. The exercises are especially helpful for patients taking anti-psychotic medications who experience EPS (extra-pyramidal symptoms) as a side effect and exhibit Parkinson's-like movements followed by breakfast from 8:30-10am. From 10-11am, all of the patients (including outpatients who live locally and participate in day care) meet for discussion time which includes reading a newspaper article and discussing the topic. One patient reads the article aloud, another summarizes it, and then they all discuss. There are three language groups: English, Hindi/Bengali (combined), and Tamil (the local language). Then there is general discussion about hobbies and sports. The OT said that this helps with cognitive ability as well as overcoming social phobias and practicing speaking in groups. All topics are encouraged, but, murders and suicides are not topics that are encouraged.

From 11-12pm, there is activity time and people participate in individual hobbies that are tailored to their abilities. For example, one woman was working on sewing and a man, previously a physician, is working on computers. From 12-2, patients eat lunch and rest (during the hottest time of the day). From 2-3:30, there are individual and group sessions in which stress management is addressed as well as other topics. Games are included, and there are also goal-oriented activities. From 3:30-4 is tea time followed by 4-5pm with outdoor extracurricular activity time (such as playing volleyball or badminton).

Caregivers (i.e. the patient's relatives) are encouraged to participate, especially in the beginning. The OT said that it is helpful for the relatives to observe how the physicians are interacting with the patient and the behavior can be modeled. Also, the caregivers can participate in their own stress management group. In terms of rehabilitation and re-integration into the community, the patients are encouraged to simulate activities they will participate in upon discharge. For example, one teacher with paranoid schizophrenia was unable to teach for a year, but was able to re-integrate into the community and wanted to return to teaching. She was very nervous about speaking in a group, so students were brought in to simulate a classroom setting and she felt much more confident.

Then we went to observe ECT ("shock therapy") in a seizure is therapeutically induced and helps with many types of mental disorders, including depression. One woman we observed felt a lot of guilt from
her past and could not function. Today was her last round and she received 12 rounds total in 6 weeks. She has been improving and her guilt has dissipated. The patients walk into the treatment room and lay down, then a sedative is administered followed by a muscle relaxer. One of the young men we observed today was chanting something to himself to help keep calm before the sedative took effect. The beeping was loud but he kept his chanting up and even though we were listening to the chant, it slowly faded away and his chant became the monitor beeping. One woman had to receive two shocks because the first was sub-therapeutic. The anesthesiologist was great and showed us around and grilled us with questions. Andrea was the best at answering his questions because of her background in cardiac nursing. He knew that we wanted to see, so he allowed us to get up close for observation.

ECT is not like it was many years ago - the patient is sedated and also given a muscle relaxant so the body does not convulse widely. A blood pressure cuff is used on one arm to block the muscle relaxant from going into the patient's lower right arm but the shock goes through and the M.D. can observe how long the seizure lasts (at least 20 seconds is therapeutic). This is like how it is done in the US. We also observed the recovery room. It seems like the nurse's role here is concerned mostly with the biological needs of the patient (medications, sleeping, eating) unlike in the states where nurses would lead group activities like in the OT department.

In the afternoon, we observed the child and adolescent ward. Children with autism, mental retardation, developmental delay, and cerebral palsy come here for support. The family is invited to stay for at least 3 months, and after discharge, the family checks in with CMC every few months (if they lie locally) or annually (if from the north). Parents are taught how to engage with the children as they are the main caregivers and will have to care for the child everyday. At CMC, the parents learn about positive reinforcement and how to administer the rewards (like keeping charts and then giving candy, stickers, or an activity as a reward). Psychologists are the head teachers in each room and take part in the interdisciplinary rounds each week. The patient's progress. Siblings are also brought here to help encourage sibling relationships and sibling rivalry is addressed. The families can leave on outings and are free to explore the city.

There was a separate child and adolescent OT department that we didn't see. Patients with OCD, ADHD, oppositional-defiant disorder and conduct disorder (the disorder that is correlated with antisocial personality disorder) are treated here.There are games, learning how to interact in a social environment and group activities.