Introduction to the special issue on psychiatry in Asia

Asia is a huge region with a myriad of cultures, languages and religions each bringing with it its own special characteristic. Whether it is in South Asia, Far East Asia or the Australasian regions, the practice of psychiatry in Asia does occur but is not as yet well known in other regions of the world. This is not to say, however, that psychiatry in Asia is less important or relevant than psychiatry in the rest of the world or in the western hemisphere; on the contrary, Asia is constantly facing major natural disasters that have major implication in the mental health well being of the Asian population and resources get diverted. Asian cultures have made major contributions over the centuries to the world as a whole. Thus focusing on psychiatry in Asia in the beginning of the twenty-first century was not only appropriate, but a necessity as well; hence this issue of the International Review of Psychiatry is fully dedicated to key and relevant aspects of psychiatry in Asia. It is our hope that the topics covered in this special issue of the International Review of Psychiatry will serve as a window of opportunity for the education of the state-of-the-art of psychiatry in Asia not only for readers everywhere but also bringing together the information from neighbouring countries. We invited a group of scholars who have dedicated their entire professional careers to improving the mental health system that currently prevails in different regions of Asia, to the well being of the Asian population who suffer all types of psychiatric disorders and conditions, to the advancement of the mental health and psychiatric educational system in Asia, and to create and develop new knowledge via research efforts related to the psychiatric conditions prevailing in the Asian population to contribute to this unique issue of the International Review of Psychiatry. Inherent in these objectives and goals is the opportunity to secure these advancements within the unique cultural characteristics and milieu prevailing in Asia.

Historical perspectives

Psychiatry in Asia in general, although there are honourable exceptions, has not been well understood or systematically studied in most parts of the ‘Far East’ (Veith, [1975]). Perhaps, this situation is due to the fact that psychiatry has not been systematically practised in many regions of Asia (Veith, [1975]). As westerners began to be exposed to the different regions of the Far East, they always did it based on their own particular view of the world; that is, their Judeo-Christian beliefs and colonial perspectives which focused on the religious and spiritual differences. This ideological point of view was unfortunate because whether it is the Judeo-Christian traditions or the Far Eastern traditions, each of them has their unique richness, values, and positive aspects. It would have been more productive if these religious and spiritual differences had been integrated for the benefit of humanity as a whole. A good example of this situation was the perception of westerners that the Chinese population never suffered from mental illness due to the commonly observed expression of calmness among the Chinese population (Veith, [1975]). In this respect, it was not until the conclusion of the Pacific War of the 1930s and 1940s that psychiatry became a medical specialization in China (Veith, [1975]). Based on the oldest Chinese medical writings, diseases, including mental diseases, were the outcome of imbalances between the ‘yin’ and the ‘yang’; that is, these positive and negative forces needed to be in good balance within the body in order for diseases not to develop (Veith, [1975]). From a cultural viewpoint, the unique syndromes that are commonly observed in Asia and, nowadays, known as culture-bound syndromes such as ‘dhat’ or ‘jiryan’ in India, ‘sukra paameha’ in Sri Lanka, and ‘shen-k’uei’ in Taiwan; also, ‘hwa-byung’ in Korea; ‘koro’ in East Asia and South Asia (‘shuk yang’, ‘shoo yong’ and ‘suo yang’ in China) (‘rok-joo’ in Thailand); ‘latah’ in Malaysia and Indonesia; ‘qi-gong’ in China; ‘shenjing shuairuo’ in China; ‘taijin kyofusho’ in Japan; as well as others (APA, [1994]). Other authors have also reported on the relevance and clinical implications of culture-bound syndromes not only in Asian countries and cultures, but on Asian populations living outside of Asia as well (Gonzalez et al., [2001]; Lu, [2004]; Ruiz, [2004]), although recently these notions of culture bound syndromes have been challenged (Sumathipala et al, [2004]).

With respect to culture, we must also be fully aware that as a result of migration trends and, more recently, due to the globalization process that is affecting all regions of the world, a large number of Asian populations leave Asia looking for an improvement in their socioeconomic conditions, but in so doing, they also bring with them their languages, their religious beliefs, their heritage, and their values and customs; in other words, their ‘culture’. Similar patterns emerge from industrialization and urbanization when people move from villages to urban conurbations, and changes in family structures but also support systems produce changes in explanatory models and expectations of healthcare. When this happens, cultural interactions, misunderstandings, and lack of Asian cultural knowledge on the part of non-Asian healthcare professionals, including psychiatrists, lead to misdiagnosis, mistreatments, and lack of culturally competent health and mental healthcare services (Lim, [2006]; Munoz et al, [2007]; Ruiz, [1995]).

Besides the Far East, other Asian regions and/or countries have been the focus of attention from a historic point of view. For instance, psychiatry in India goes back to the prehistoric period and the period preceding the Indus valley civilization (Rao, [1975]). Contributions from folklore, Vedas, Upanishads, and the great epics Ramayana and Mahabharata, as well as the ancient medical schools such as Ayurveda are clear symbols of the history of psychiatry in India. While the words of psychology and psychiatry did not exist in ancient India, ‘manas’ and ‘unmad’ were used to respectively represent ‘mind’ and ‘insanity’ (Rao, [1975]). Historically, the phases or periods of ‘medicine’, as well as ‘psychiatry’ can be described as ‘Pre-Vedic’, ‘Vedic’, ‘Post-Vedic’, and ‘Modern’ (Rao, [1975]). In each of these periods, the cultural trends that prevailed in each of them had a major impact on how psychiatry was used in India. The impact of British colonialism on the spread of asylums at the cost of traditional Ayurvedic systems cannot be under estimated (Bhugra et al., [2001]).

Thailand has also been a country of major relevance in so far as psychiatry in Asia is concerned. Superstition symbolizes the early history of psychiatry in Thailand (Sangsingkoo, [1975]). Gods, angels, ghosts and spirits represented the practices that prevailed in Thailand during the antiquity period. Even, today, ‘holy wells’ still exist in Thailand. Chaining of mental patients was quite common in the early history of psychiatric care in Thailand (Ruiz, [2007a]). It was not until 1889 that the first mental hospital was built at Klong Sarn, Dhonburi, again as a result of the European influence. England, in particular, was very influential in the growth of psychiatry in Thailand. In the 1920s Thai psychiatrists began to exercise the control of the mental health system of Thailand.

Current trends

Psychiatry in Asia, today, has advanced a great deal in so far as newest approaches to psychiatric care, while at the same time in certain countries and regions or in areas of some countries, particularly rural areas, there are still remnants from the historical periods. In areas where there are not enough advances as yet, traditional care tends to prevail. Similarly, in those countries where socioeconomic conditions have improved, major scientific advances are already in place. In general, modern trends are commonly observed in big urban areas while in rural areas and in poverty-stricken slums progress and advances are minimal (WHO, [2001a]).

Advances in neurosciences, biological psychiatry and in particular pharmacology nowadays go hand in hand with poverty, lack of access to psychiatric care, poor quality of care, and inhumane care, and this situation is currently prevailing not only in Asia but in western countries such as the USA as well (Ruiz, [2007]). A good example of this unfortunate situation can be easily observed in the distribution of psychiatric beds worldwide. In Europe in year 2001 there were 9.3 psychiatric beds per 10,000 people, and in the Americas there were 3.6 psychiatric beds per 10,000 people; on the other hand however, in south-east Asia there were only 0.3 psychiatric beds per 10,000 people (WHO, [2007b]). Another trend that clearly shows the psychiatric state of affairs in some poor countries in Asia can be seen in the number of psychiatrists in these countries; for instance, in India there is only 1 psychiatrist for every 250,000 people, in Bangladesh there is 1 psychiatrist for 1 million people, in Sri Lanka there is also 1 psychiatrist for 1 million people, and in Nepal there are only 25 psychiatrists in the whole country (Patel et al., [2007]). In certain countries of Asia, such as Pakistan for instance, 70% of the population, or 140 million, live in rural areas; needless-to-say, in these rural areas, access to health and mental healthcare is almost non-existent (Ruiz, [2007]). Additionally, in some regions of Asia such as the South Asian region, 11% of disability adjusted life years (DALYs) and 27% of years lived with disability (YLDS) are due to neuropsychiatric conditions (WHO, [2001b]; Patel, [2007]).

Future perspectives

The globalization process that is currently in full speed worldwide will permit further easier exchanges of information, including scientific information to reach every corner of the globe. This process will enhance the communication exchanges at all levels; that is, the government level and the private sector, but at all levels of the educational systems as well. This will lead to a more educated society not based on the traditional methods of education, but based on media expansion at all levels. In turn, societies across the world will demand from their government better access to what works not only for industry and government, but medicine and healthcare as well.

From a different perspective, full integration of mental healthcare into the primary care system will by necessity become a reality. Additionally, evidence-based medicine is expanding widely across countries in the western hemisphere, and soon will reach all parts of the world. Moreover, continuing education requirements, particularly in medicine including psychiatry, is nowadays expanding in all parts of the globe. In addition, new discoveries in the field of psychopharmacology are producing excellent results; these discoveries are nowadays quite advanced insofar as ethnicity and race are concerned, and in particular among Asian populations (Lin & Smith, [2000]; Pi & Gray, [1998]; Ruiz, [2000], 2007).

The recent decade of the brain has produced more attention and priority on the investigation of psychiatric disorders than at any other previous time in the history of psychiatric research. Although the research focus during this decade has been on the neurosciences and biological psychiatry, all aspects of the biopsychosocial and sociocultural models of understanding and implementation in the care of psychiatric disorders have benefited. For it is the pre-eminence of research and investigation, coupled with evidence-based approaches to care, that have revolutionized the conceptualization of psychiatric disorders, from its diagnosis to its treatment.

It is within this context that the content of this issue of the International Review of Psychiatry was conceptualized and made a reality. It is our clear objective to focus on the most populous region of the world and also the one that is currently facing the worst socioeconomic challenges. It is our hope and intention to bring focus onto Asia from a psychiatric and mental health point of view. We are fully committed to improving the current mental health system that prevails nowadays in Asia, and to call attention worldwide to the unique needs of this region. It is also our sincere hope that wars, poverty and natural disasters, as well as human-made disasters will be substituted by full and comprehensive access to psychiatric care, as well as humane care for a population that has lacked high quality and appropriate care for centuries.

We also feel very hopeful because joining us in these efforts is a cadre of clinicians, educators and researchers from Asia who are currently practising in Asia; a cadre of mental health professionals who are experienced in all mental health and psychiatric aspects of Asia, and are fully committed to resolving the challenges faced by the current mental health system that prevails in most countries of Asia, as well as within the Asian population, particularly the most improvised population from Asia. To them we extend our deepest appreciation for joining us in this journey of hope on behalf of those who suffer from mental illness in Asia.