The psychiatric trainers in our country have undergone training, which is not in keeping with the aims and objectives of undergraduate curriculum. Due to the shortage of mental health professionals in the country, the psychiatric trainer in most of the medical colleges today is a young postgraduate, who has undergone training based on Western models. He or she has had practically no exposure to psychiatry at undergraduate level. During postgraduate training, the trainee has extensively dealt with the diagnostic and therapeutic controversies of major psychiatric syndromes. He or she has had extensive clinical exposure in the hospital, but has rarely gone to the community to know whether the mental health needs there. In other words, the psychiatric teacher of today has been trained as a specialist clinician and researcher, rather than a health care provider at community level, which is the aim of undergraduate medical training. On the other hand, a teacher for psychiatry for undergraduates needs to be sensitive about the needs of the students and the expectations of the community. Due to inappropriate training at postgraduate level, undergraduate teaching gets reduced to a stereotypic ritual of telling them about how to fit a patient in the category of schizophrenia or bipolar disorders, instead of focusing upon the common mental disorders seen in the medical outpatient clinics. MBBS students who are new to psychiatry find the postgraduate trainers talk full of ambiguities, technicalities and dry jargon. This kind of exposure strengthens the culturally prevalent stereotyped image about the psychiatry and psychiatrist. Undergraduate students never seem to get taught about what the community needs from a mental health care provider. However, postgraduate students can be an asset for undergraduate psychiatric training for two major reasons; firstly, they are mostly engaged in clinical work; therefore, they can give the “actual feel” of patient with psychiatric problems; secondly, they make up for the shortage of trainers in psychiatry, which is likely to persist for many years to come (Polan and Riba 2010). Therefore, the postgraduate trainer too needs to train well according to the needs of the community. Due to the gross discrepancy between our community mental health needs and the Westernised training at postgraduate level, psychiatrists prefer to go abroad whenever there is an opportunity and prefer never to come back, despite the adverse mental health situations and attitude of the country (Patel 2003; Mellor 2003; Thirunavukarasu 2007). Those who get trained in psychiatry abroad would naturally feel less interested in coming back to India (Patel 2003).

As teachers in psychiatry, we have observed over years that many of aspirants choose psychiatry for postgraduate training not as a choice but as compulsion. The moment they see a chance, the choice of discipline is quickly changed. All these facts, though not very well researched, are common knowledge. During the postgraduate career in psychiatry, due to many constraints including manpower, the doctor is primarily trained as a “psychiatric drug prescriber” and a “psychiatric philosopher”, rather than an undergraduate teacher. To impart a community-need-oriented training at undergraduate level, we need to reorient our postgraduate training curriculum too. We need to make it more Indian with a focus on community mental health needs.

There is so much of cultural influence on understanding and practice of psychiatry that it cannot be refuted by any argument (Avasthi 2011). The students both at the postgraduate and undergraduate level read either Western or Westernised textbooks on psychiatry, which are devoid of any description of Indian culture. We have a strong need of mental health literacy in India, and this need is qualitatively different from the Western needs due to the sociocultural influences. We need to follow a different Indian approach to the treatment of psychiatric, especially neurotic disorders. The Western psychotherapeutic approach to such disorders may not be equally suitable to our patients due to cultural inappropriateness and inadequate mental health resources. Indian patients are not aware of their rights as in the West. Consequently, doctors in India have more accountability towards the health of their patients. Most of the patients instead of being an equal partner in the treatment process prefer to leave the decision on the doctor and follow his or her advice. Under such circumstances, the doctor–patient relationship is much more important than anywhere else in the world. The undergraduate curriculum of psychiatry, adopted by the MCI, the discipline that should emphasise this aspect of treatment the most, does not lay any emphasis on it. Going further, most of our patients enjoy good family support. Dr. Vidya Sagar recognised this fact and involved the family members along with the patient in mental hospitals. Unfortunately, none of these aspects are adequately addressed in the present-day academic curriculum for undergraduates (Undergraduate taskforce-IPS-2010). Even when we know what we need to train about, how we need to train our undergraduates has been a matter of concern to all of us for a long time (Sharma 1984).

Before joining medical school, the undergraduate student carries the cultural stereotype image of psychiatric patients with him or her. When suddenly exposed to the patient with psychiatric problems with inadequate preparation, this often evokes a feeling of fear and hate in the student. During the two-week posting in the psychiatric ward, each student is exposed to two or three patients. The history and mental status examination recorded by them clearly reflect their anxiety and disinterest in the patient. Many students find it very easy to skip the posting as they need only 50 % attendance in psychiatric theory and clinics. When they leave the posting, they carry the same negative attitude with them, which they had brought (Chawla et al. 2012; Lingeswaran 2010). Even at the end of two-week posting in psychiatry, students are still not able to empathise with the patient. They are not aware of aetiological factors for mental illness and believe supernatural factors responsible for the mental disorder. Modified ECT remains an undesirable treatment option to them. Majority of the students even after their posting are not very keen on choosing psychiatry as career (Chawla et al. 2012). The earlier studies too highlighted that fact that only a few final year students wish to take up psychiatry as their career, as they too find it less rewarding (Alexander and Kumaraswamy 1993; Tharayan et al. 2001). Perhaps the current medical curriculum is not designed to dispel the myths and stereotypes a medical student carries as a part of societal beliefs. Even today, people with minor emotional and psychological problems approach the general physician at first level. With such negative attitudes even if the student prefers to become a general physician, the impact on the community about patients with psychiatric problems would still be the adverse. The studies quoted above all reflect a need to modify the psychiatry training curriculum at MBBS level.

The MCI has neglected psychiatric training at the undergraduate level (MCI 1997; Sethi 1978). The council recommends 20 h of didactic lectures and two-week posting in the psychiatry ward during MBBS course. The duration is much less in comparison with our national needs (Jacob 1998; Kattimani 2010; Yerramilli and Murty 2012; Chawla et al. 2012; Rajagopalan and Kuruvilla 1994). The time allotted for teaching is just about 1.4 % of the total training time during the four-and-a-half-year MBBS course (Thirunavukarasu and Thirunavukarasu 2010). In the United Kingdom, which has a population comparable to any single state of India, the General Medical Council recommends training for 80 h in behavioural sciences and a 36-week clinical posting. In Denmark, the psychiatry curriculum has much superior status compared to paediatrics and gynaecology. The current training is not sufficient as the medical graduates are unable to diagnose common psychiatric problems in the emergency room (Balhara et al. 2010).

For decades, the IPS is fighting for psychiatry to be accorded the status of a full subject. However, such efforts have not yielded the desired results. The biggest problem at present seems to be creating some space for psychiatry in the already overburdened undergraduate curriculum. It must be realised that a positive attitude towards a particular discipline and its growth is not feasible till it is allowed to be an essential part of the curriculum. Certain specialities such as paediatrics and orthopaedics are good examples of this approach. The clinical posting and number of theory lectures prescribed in these subjects far exceed what has been prescribed for psychiatry. Not just that attending classes in these subjects is compulsory, but the students at undergraduate level are also examined in these subjects in their final examination by the concerned specialists. Both these compulsions make the undergraduate student “serious” towards the speciality. Certainly, creating space for any speciality in the undergraduate curriculum is an uphill task, when the demands of already existing subjects are also increasing due to the rapid advancements in the field. In the UK, it was felt that the undergraduate curriculum is loaded with unnecessary factual details, which a student simply needed to reproduce as such without any advantage in the training. Omitting these details reduced the academic burden by about 35 % of the training time (GMC 1993). Similarly, there is an urgent need to revise our training programme so as to make it suitable for the needs of the community, to make it less burdensome for the students and get sufficient time slots for the subjects such as psychiatry. The MCI seems to have overlooked the state of the country’s mental health problems, while responding to the call from the IPS for making psychiatry a complete subject at the MBBS level. The MCI, in its letter dated 20 August 2011, as stated by Kallivaylil (2012) gave psychiatry a respectable status in the MBBS curriculum, but denied the status of full examination subject due to the overburdened curriculum. This step is, thus, less likely to bear the desired results as we know that students take a subject seriously only if they have to take up an examination in the subject. The current MBBS curriculum is considered as one of the most overloaded of all academic curricula. Mental health needs special attention in the undergraduate curriculum (Das et al. 2002) and should be given the need-based priority it deserves. It needs to be revised according to the recommendations of the Taskforce on Undergraduate Training of the IPS and the World Psychiatric Association to meet the national needs and international standards (Murthy and Khandelwal 2007).

India is a large developing country. It has multiple demands and needs for adequate community and economic development. For that reason, priorities for development keep on changing from time to time. It has been realised that only those issues for which our leaders are sensitised get a place in policies and become a priority for development. The IPS has made seminal efforts to make the administrators and policymakers aware of the mental health needs of the country. However, political still seems to be lacking. Policymakers either have a negative attitude towards mental health needs or seem to be unaware of mental health problems. It is possible that this is the reason why whenever mental health issues of the country are a matter of concern, policymakers find it very easy to circumvent this priority (Mellor 2003).

As per a national report, 856,065 MBBS doctors who are registered were with the Indian medical register till 31 July 2011 (PTI 2011). India ranks 67th among the developing countries, with the doctor–population ratio in the country estimated to be around 1:2,000 (PBI 2013). But, this number is quite significant keeping in view that many graduates opt for training or working abroad despite facing hardships. On the other hand, we have only 23 % of the required number of psychiatrists in the country (TNN 2011). We must bear in mind that the health care system in India is still based on the quality of primary care. It is, therefore, the quality of training at the undergraduate level, which influences the health care outcome. Thus, we need to strengthen mental health training at the undergraduate level in order to meet the current mental health needs of our country. In 1946, the Bhore Committee recommended setting up of separate departments of psychiatry in the existing general hospital for specialist training within the teaching institution itself, instead of sending the students elsewhere for training (Bhore 1946). This suggestion led to opening up of many general hospital psychiatry units and psychiatry departments within the medical colleges. Consequently, we now have 149 medical colleges offering postgraduate training in psychiatry in comparison with almost none in the 1950s. Since then, the efforts to improve undergraduate training in psychiatry have been continuing. The Committee also stressed that the aim of undergraduate training in psychiatry should be to enable the medical student think, observe and take decisions by themselves. Training the medical graduates in social aspects was also recommended so that the undergraduate student became aware of mental health needs of not just patients with mentally illness, but also of the emotional problems of patients with medical problems. The social aspect of training could never be properly imparted due to the lack of sufficient trainers. Consequently, undergraduate students continue to have negative attitudes towards the mentally ill patients and psychiatry. The first seminar on teaching psychiatry to undergraduates was held at the Central Institute of Psychiatry (CIP), Ranchi, in 1965. A task force for training in psychiatry at undergraduate level was also constituted. In the first meeting of the IPS Subcommittee on Undergraduate Psychiatric Education (1965), it was pointed out the “if all five year plans are geared to make up for the deficiency of psychiatrists in the country, it would take 100 years to fill the gap”. Undergraduate students were also found apathetic to psychiatry. The reasons for such apathy that could be identified are as follows:

Due to all these factors, medical graduates considered psychiatry as the odd man out in the whole academic curriculum. To overcome these deficiencies, the following reforms were proposed by the task force (Neki et al. 1965):

In the mid-1970s, the Srivastava Committee, a group of educators commissioned by the Indian government, advocated reorientation of medical education in accordance with national needs and priorities. They recommended the formation of a medical education committee to implement reforms. A National Workshop on Undergraduate Training in Mental Health was held at Jawaharlal Institute of Postgraduate Medical Education and Research, Pondicherry (JIPMER), in 1983. A National Workshop on Social and Behavioural Sciences in Mental Health was held at the All India Institute of Medical Sciences, New Delhi (AIIMS), in 1994. It was observed that the one of the main reasons for the undergraduate not being keen on studying psychiatry was lack of orientation towards behavioural sciences. A workshop and teachers’ training programme on undergraduate training in psychiatry was held in the National Institute of Mental Health and Neurosciences, Bengaluru (NIMHANS), in 1989, for teachers from 10 medical colleges, which identified the necessary steps to improve undergraduate training and teaching. One of the important recommendations of this workshop to the MCI was giving psychiatry the status of a full-fledged subject at the MBBS level. We still need to persist in our efforts for this status for psychiatry.

In 1986, the Bajaj Committee and, in 1993, Katker and Adkoli advocated to updating the course content, introducing revisions in student assessment and innovative teaching methodology. To implement these changes, they suggested faculty development, establishing medical education units and making educational funding more transparent. These recommendations were reiterated in 2004 by the Majumdar Committee in a government-commissioned report, in which the need for political commitment and leadership to achieve relevant, evidence-based medical education was emphasised. Efforts were continuously put in. But these could not bring any noteworthy change in the medical curriculum, especially in psychiatry (Reddy 2007; Thirunavukarasu 2007). This undergraduate psychiatry task force is continuing to review undergraduate training and submitted its latest recommendations under the leadership of Prof. Jiloha and Prof. Parkar in 2010 to the MCI (Jiloha and Parkar 2010; Manohari 2013). They stated that a medical student on graduation should be able to deliver mental health services at primary care level as was proposed by Trivedi (1998). The following were listed as the main objectives for undergraduate teaching: