MENTAL HEALTH POLICY GROUP
June 2010.
Mental Health Care in India –Past, Present and Future
R. Srinivasa Murthy
Professor of Psychiatry (retd)
Bangalore.
Background to FOUR Essays
Professionally, starting from 1972, I have been both an activist in the area of mental health care in India and other developing countries. In the last one month, there has been focus on mental health care in the OUTLOOK (mental hospitals: abandoned women, May 17,2010); Tehelka(MIND SNARE, 15 May 2010)and The Hindu( HUMANISING MENTAL HOSPITALS, June 6,2010). It is with these experiences of the last four decades that I have put together the following four essays reflecting my understanding of mental health care in India.
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The FIRST essay outlines the need for mental health services and the way services can be organises at the level of primary, secondary and tertiary levels. It calls for a shift from institutions to community care, from sole emphasis on professionals to people as the focus of mental health care.
The SECOND essay reviews the development of National Mental Health Programme(NMHP) in India , since 1982, and the successes and limitations of the same, along with lessons learnt for planning for the future.
The THIRD essay covers the District Mental Health Programme (DMHP) in detail, outlining the way the idea of integration of mental health care with general health care came up, how it spread to the district level model and the progress in the last two decades. The sources for the current problems of DMHP are identified and the way forward to strengthen the DMHP is outlined.
The FOURTH essay, takes the PEOPLE oriented mental health care to a different level- from the constraints of professionals and institutions to making the FAMILIES the centre of care process and ways to make this shift in the Indian context.
In summary, the progress of the last four decades gives hope that it would be possible to address the vast needs of the persons with mental disorders and their families, if newer approaches are adopted with greater technical support to the mental health care programmes, along with monitoring of the programme on a continuous basis.
ESSAY 1
Mental Health services in India: Primary, Secondary and Tertiary level including Rehabilitation
The organisation of mental health services demands a wide variety of interventions, ranging from public awareness, early identification, treatment of acute illness, family education, long-term care, rehabilitation, reintegration and ensuring of human rights of the ill persons. In addition, mental disorders consists of a wide variety of clinical conditions , some self-limiting( eg. acute stress reaction) and others lifelong(eg. mental retardation). The other aspect of importance is the unwillingness/unawareness of the ill person, in some clinical conditions/situations to seek help on his own. All of these factors have to kept in mind in planning of mental health services at the primary, secondary and tertiary levels.
This essay covers the vast topic under three broad sections, namely (i) the mental health needs of the community and (ii) international developments in mental health care;(iii) optimal mix of services; and (iv) mental health activities that can be undertaken at different levels of health care. The appendix outlines the distribution of tasks of different professionals and non-professionals for mental health care.
Mental health needs of the community:
The mental health in the community encompasses a wide variety of needs. These include (i) serious mental disorders in the community; (ii) persons with Acute conditions; (iii) persons with long-standing(chronic) mental disorders;(iv) mental disorders in primary health care; (v) mental health of women; (vi) children and adolescents- school going and out of school; (vii) special groups like refugees, survivors of disasters, (viii) persons attempting suicide; (ix) public mental health education; (x) persons in institutional settings;(xi) prevention of mental disorders and (xii) promotion of mental health( SrinivasaMurthy et al,1978, Chandrasekar et al,1981, Parthasarathy et al,1981,Chatterji et al,2003, Srinivasa Murthy et al 2004, Thara et al,2008, Thirthahalli et al,2009)
Serious mental disorders in the community
General population epidemiology studies indicate that severe mental disorders like major depression, schizophrenia, bipolar affective disorder, dementia would be seen in all the populations. In view of the limited services available in the community, especially in the rural areas, it can be expected that there will be a large number of persons with these disorders without any or incomplete treatment and rehabilitation who will be brought for care when services are made available.
Persons with Acute conditions.
The fresh episodes of acute psychoses would be 3 per 10 000 population. Treatment of these conditions is important as they cause significant distress to the ill individual, burden of care to the family and sometimes social disruption. More importantly, they are all treatable and recovery is possible to a great extent. Equally important is the observation that early interventions give better outcome with less of possibility for long-standing illness (chronicity). Most of this treatment can be undertaken as ambulatory care by general medical practitioners with only short-term hospitalization in some patients.
Persons with long-standing(Chronic) mental disorders:
This group of disorders include schizophrenia, bipolar affective disorders, dementia. It is estimated that the point prevalence of this group would be about 5-8 per thousand population. The “chronicity” is mostly contributed by the lack of early treatment and absence of rehabilitative services, besides a small group due the non-response to treatment(eg. schizophrenia) or the progressive nature of the illness(dementia). The “chronic” patients of schizophrenic illness have demonstrated to be responsive to treatment even in late stages of illness. The treatments are simple to administer .The requirements in these group of patients are regular medication; support of the family; training to the family in caring skills; support in crises and respite care; rehabilitation; acceptance and integration into the community. The primary health care personnel, health workers and medical officers can provide this care. In bipolar affective disorder, prophylactic treatment can prevent relapses and recovery. In dementia, support to the family, symptomatic treatment and guidance to accommodate the failing mental functions can reduce the distress, disability and burden to the family.
Substance abuse (Ranganathan,1996, Ray,2004):
Substance abuse and substance dependence are growing public health problems in India. The abuse includes use of alcohol, drugs of intoxication, prescription drugs. There is evidence that the prescription drugs are occupying a greater role in substance abuse in the country(GOI,2004). The public health costs are enormous, Interventions need to be addressed both at prevention, early identification, care and rehabilitation.
Mental Handicap ( Girimaji, 2008)
MR belongs to the class of developmental disabilities (DD). These are conditions in which one or more of human capabilities fail to develop adequately from childhood. Apart from MR, other DD’s are specific delays in speech and language, in motor skills, in scholastic skills, and autistic spectrum disorders. Most of them are static encephalopathies, meaning that though they have some significant delay, they continue to improve with the passage of time, albeit as a slower rate. Widely accepted definitions that are currently available stress on 3 dimensions: the intellectual (IQ less than 70), developmental (onset before 18 years of age) and thirdly the social (diminished ability to adapt to the daily demands of the normal social environment) criteria. Prevalence of mental retardation in India is around 2% for mild mental retardation and 0.5% for severe mental retardation (defined as IQ less than 50). The major correlates are excess in males and rural areas. At least one-third of children attending Child Psychiatry OPD’s or Child Guidance Clinics have MR. Important interventions are the prevention, early identification, early stimulation, special education, parental training, vocational training, rehabilitation and long term care when carers are no more. National Trust specifically addresses the needs of this group of persons.
Rehabilitation
Rehabilitation is an important part of mental health services. Rehabilitation is an important part of mental health services for a number of reasons. Firstly, in a number of severe mental disorders like schizophrenia, bipolar disorder and substance abuse, there is a proportion of persons who do not fully recover and have limitations in their functioning resulting in disability that needs to be addressed through rehabilitation. Secondly, chiefly due to the paucity of services, in India, large proportion of the severely ill persons are not under treatment till late in the illness, when there is associated disability along with the symptoms of illness, the disability alleviation requires rehabilitation. Thirdly, at different stages of the treatment rehabilitation in the form of intervention like activities of daily living, living in a therapeutic community to learn social skills, day care centres, vocational training, sheltered workshops where ill individuals can do productive work under support and supervision and community care facilities for long term stay when there are no family members to support the ill person. At present in India, the rehabilitation facilities are very limited and largely the result of efforts of individual persons and voluntary organisations(Patel and Thara,2003).
Mental disorders in primary health care :
This group forms the biggest group of persons with mental disorders. In normal circumstances about 20% of those seeking primary care are known to suffer from different mental disorders .This group represents an important group for four reasons. Firstly, when not correctly diagnosed, often they are subjected to inappropriate treatments which are non-specific(vitamins, tonics etc) and form a group where investigations are wasteful; Secondly, these persons can be effectively cared for by the physicians at the level of primary health care ;Thirdly, by providing care at this level the stigma of mental disorders are reduced or absent; Fourthly, this approach is cost-effective. Specific measures known to be effective to care for this group are: correct diagnosis with explanation; avoiding unnecessary investigations; listening to the patients; relaxation techniques; guidance about daily routines and activities; mobilising the family resources; use of medicines for short periods and formation of groups of patients for self-help.(Channabasavanna et al, 1995, Ustun and Sartorius,1995,Patel et al, 2007WHO, 2008)
Mental health of women (Thara,2004):
Women represent a special group for mental health care. The needs of women from mental health point is well recognized in all populations. Though the overall prevalence of mental and behavioral disorders are not different between men and women, anxiety and depressive disorders are more common among women. Almost all studies show that depressive disorders are 1.5 to 2 times that in men, during the adult life. The reasons for these differences are partly biological, partly social and psychological. In addition women are more often the victims of domestic violence. Studies in developed countries have shown that women experiencing domestic violence have higher symptoms of psychological distress and greater frequency of contemplation of suicide. From all these perspectives, mental health needs of women are greater, of special nature and need interventions that are sensitive to their needs. Specific measures to care of this group would include the following strategies: greater number of women health personnel; specific training to health personnel on gender issues; mental health education about self-care for mental health; support to women to form self-help groups; emotional support at individual and family levels and income generating activities.
Children and adolescents- school going and out of school (Kapur, 1997, Malhotra,2004):
Children and adolescents (CAA) form a very important group for mental health care. Besides the needs of children in peace conditions, CAA have been exposed and experience intense trauma in form of wars, displacement, disability and disruption of childhood. In this way they are specially vulnerable. There are three broad mental health needs requiring urgent attention. Firstly, the emotional problems relating to developmental processes. This number is likely to be about 10% of the children. Secondly, mental retardation. Estimates place this to be about 5 per thousand with severe mental retardation and a total of 3% with all degrees of mental retardation. This group requires early identification, home based stimulation, special education, behavioural training for self-care and daily activities and at a later age vocational training. Third need is for promotion of mental health, for example the life skills education(LSE).LSE not only improves immediate functioning of children, but also have the potential to prevent problems of drug abuse, suicide, delinquency and risk taking behaviour (eg.HIV/AIDS).These needs to be addressed in school going children as well as in the non-school going children The latter group requires a lot of innovative approaches, similar to the ones developed for street children in countries like India, Brazil etc. The most important goal would to be to restore childhood to all children; create conditions for optimal development at home and society; provide healthy adult contacts; facilitate life skills education; crisis support; friendly non institutional mental health services and create an atmosphere of security and hopeful future.
Mental health needs of elderly (Varghese and Patel, 2004)
As a result of demographic transition, India’s elderly population has increased from 12 million in 1901 to 57 million in 1990 and is expected to cross the 100 million number by 2013. From mere 5.1% in 1901 the elderly will become 20% of the population by 2050.Elderly people suffer from the dual medical problems of both communicable as well as degenerative diseases. The two commonest mental disorders are depression and dementia. There is need for prevention( control of diabetes, hypertension etc), early identification, treatment and rehabilitation. As t over 70% of elderly in urban areas and 34% in rural areas are economically dependent on their families, and almost all the elderly live with their families, support programmes for the families is an important area for intervention.
Special groups-refugees, disaster affected populations (Srinivasa Murthy, 2010)
It is well recognized that refugees, disaster affected populations represent a group of persons with special emotional needs. This is because of the extreme disruption that they have experienced and the lost opportunity for normal life. All of these groups need opportunity to rebuild their lives and reorganize their life goals. Some of the well recognized strategies are: recognition of the special needs by community and health personnel; community based and ambulant mental health care; opportunities to share the trauma; formation of self-help groups with common needs; crisis support and rehabilitative efforts for vocational and social life.
Suicide and attempted suicide(Venkoba Rao,2004):
Suicide and attempted suicide represent a “cry for help” in a situation perceived as hopeless. Suicide and attempted suicide rates vary across countries. Organising services for suicide prevention has the double advantage of preventing premature loss of lives as well as the sensitization of the community to mental health issues as being relevant to all of the population.(normalcy of emotional distress).Experience in other countries have shown that following measures would be effective in addressing the problems of attempted suicide and suicide: recognition of the “normalcy” of suicidal ideation inn specific adverse life situation; increasing intra-Family communication to share feelings, experiences and mutual support ;life skills education to children and adolescents; early recognition and treatment of mental disorders by general physicians; support for acute crisis support through volunteers in crisis centers; support to persons who have attempted suicide to prevent repetition; support to families where suicide has occurred and use of religious centers for mental health education. Voluntary organizations working with small communities can address these needs effectively.
Public mental health education (Wig,1997, Srinivasa Murthy, 2005):
This need, though not usually seen as part of the services, becomes importance due to the very limited public awareness in the community. Mental disorders are traditionally very much stigmatized and persons with mental disorders experience many forms of discrimination. This largely arises from lack of information about the importance and nature of the mental health and mental disorders, how individuals can maintain their mental health and the treatability of mental disorders, the reversibility and the biological basis for many of the mental disorders. Specifically, there is need to share with the general population: principles of child growth and development; emotional needs of individuals in different stages of life; response to stress and its presentation in individuals; importance of family in child development; importance of family in crisis situations; the value of social supports in maintaining mental health; adolescent experience and manifestations of adolescent behaviour; early symptoms of mental disorders; treatment methods ; importance of work in rehabilitation of mentally ill persons; avoidance of mistreatment of persons with mental disorders; understandability of mental disorders ;what individuals, families and communities can do to promote mental health, prevent mental disorders and care for mentally ill persons.
Persons in institutional settings (prisons, orphanages etc):
Persons in institutional settings have special needs for mental health care. Generally these institutions have greater proportion of individuals with mental health needs. These can be in the form of acute and chronic psychoses, mental retardation, dementia and drug dependence. In addition living in an institution, without daily routines, social contacts and opportunities for fulfillment of ones needs and capacities can result in emotional problems like depression, adjustment problems and suicidal thoughts. Solutions to these problems have to found by recognising the emotional needs of the persons; sensitising the staff of institutions to emotional aspects of the residents; training the medical staff in mental health care; providing coping skills to the residents; creating opportunities for emotional fulfillment through education, hobbies, entertainment, forming relationships etc.
Prevention of mental disorders (WHO, 2005)
There are a number of mental disorders that can be prevented. An example is prevention of mental retardation by a wide variety of public health measures. These measures include antenatal care, nutrition support to pregnant mothers, supervised delivery, postnatal care, immunization, adequate nutrition for infants, iodinisation of salt, early stimulation for low birth babies, prevention of accidents and treatment of epilepsy.
Promotion of mental health(WHO,2005)
The promotion of mental health should on a priority begin in schools through the life skills education programme. The religious precepts and practices that are promotive of mental health(eg. meditation, yoga, prayer, social supports in crisis situations) should be identified and encouraged.
International developments in mental health care
The development of mental health care all over the world is best described as a developing process. The World Health Report, 2001(WH0, 2001), described the changes over the last two centuries, where the shift of care has moved from Institutions to the community as follows(BOX):
"Over the past half century, the model for mental health care has changed from the institutionalization of individuals suffering from mental disorders to a community care approach backed by the availability of beds in general hospitals for acute cases. This change is based both on respect for the human rights of individuals with mental disorders, and on the use of updated interventions and techniques.
The care of people with mental and behavioural disorders has always reflected prevailing social values related to the social perception of mental illness. Through the ages, people with mental and behavioural disorders have been treated in different ways . They have been given a high status in societies which believe them to intermediate with gods and the dead. In medieval Europe and elsewhere they were beaten and burnt at the stake. They have been locked up in large institutions. They have been explored as scientific objects. And they have been cared for and integrated into the communities to which they belong. In Europe, the 19th century witnessed diverging trends. On one hand, mental illness was seen as a legitimate topic for scientific enquiry; psychiatry burgeoned as a medical discipline, and people with mental disorders were considered medical patients. On the other hand, people with mental disorders, like those with many other diseases and undesirable social behaviour, were isolated from society in large custodial institutions, the state mental hospitals, formerly known as lunatic asylums. These trends were later exported to Africa, the Americas and Asia. During the second half of the 20th century, a shift in the mental health care paradigm took place, largely owing to three independent factors, namely (i) psychopharmacology made significant progress, with the discovery of new classes of drugs, particularly neuroleptics and antidepressants, as well as the development of new forms of psychosocial interventions; (ii) the human rights movement became a truly international phenomenon under the sponsorship of the newly created United Nations, and democracy advanced on a global basis, albeit at different speeds in different places and (iii) social and mental components were firmly incorporated in the definition of health of the newly established WHO in 1948.These technical and sociopolitical events contributed to a change in emphasis: from care in large custodial institutions to more open and flexible care in the community. Community care is about the empowerment of people with mental and behavioural disorders. In practice, community care implies the development of a wide range of services within local settings. This process, which has not yet begun in many regions and countries, aims to ensure that some of the protective functions of the asylum are fully provided in the community, and the negative aspects of the institutions are not perpetuated. The accumulating evidence of the inadequacies of the psychiatric hospital, coupled with the appearance of “institutionalism” – the development of disabilities as a consequence of social isolation and institutional care in remote asylums – led to the de-institutionalization movement. De-institutionalization is a complex process leading to the implementation of a solid network of community alternatives. Closing mental hospitals without community alternatives is as dangerous as creating community alternatives without closing mental hospitals.
De-institutionalization has not been an unqualified success, and community care still faces some operational problems. Among the reasons for the lack of better results are that governments have not allocated resources saved by closing hospitals to community care; professionals have not been adequately prepared to accept their changing roles; and the stigma attached to mental disorders remains strong, resulting in negative public attitudes towards people with mental disorders. In some countries, many people with severe mental disorders are shifted to prisons or become homeless. In most developing countries, there is no psychiatric care for the majority of the population; the only services available are in mental hospitals. These mental hospitals are usually centralized and not easily accessible, so people often seek help there only as a last resort. The hospitals are large in size, built for economy of function rather than treatment. In a way, the asylum becomes a community of its own with very little contact with society at large. The hospitals operate under legislation which is more penal than therapeutic. In many countries, laws that are more than 40 years old place barriers to admission and discharge. Furthermore, most developing countries do not have adequate training programmes at national level to train psychiatrists, psychiatric nurses, clinical psychologists, psychiatric social workers and occupational therapists. Since there are few specialized professionals, the community turns to the available traditional healers”.
Optimal mix of services (WHO,2003):
The key issue for the service planners is to determine the optimal mix of services and the level of provision of particular service delivery channels. The absolute need for various services differs greatly between countries but the relative needs for different services , i.e. the proportions of different services as parts of the total mental health service provision, are broadly the same in many countries. Services should be planned in a holistic fashion so as to create an optimal mix.
Figure shows the relationship between the different service components. It is clear that the most numerous services ought to be self-care management, informal community mental health services and community mental health services provided by the primary health care staff, followed by psychiatric services based in general hospitals and formal community mental health services, and lastly by specialist mental health services. The emphasis placed on delivering mental health treatment and care through services based in general hospitals or community mental health services should be determined by the strengths of the current mental health or general health system, as well as by cultural and socioeconomic variables.
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In a country like India, where majority of the mentally ill persons are living in the community ( srinivasa Murthy et al,2004, Chatterji et al,2004, Thara et al,2008, Thirthahalli et al,2009) and where there are vast amount of unmet mental health service needs, it would be prudent to utilise the approaches of self care and informal care. It is to be recognised, as of date, efforts in this direction has been limited. Most of the past quarter century of mental health planning has been on integration of mental health with general health services (Wig.,et al,1981, Issac et al,1982, 1986). However, there are pockets of self-care, informal care by the families (eg. mental handicap, schizophrenia) and patient groups (eg.drug dependence) to point to the value of this approach to mental health care (Ranganathan, 1996). In order for this to become a reality, there has to be a paradigm shift in the organisation of knowledge, dissemination of information and skills and greater efforts towards empowerment of the community. This is both a challenge and an opportunity for India ( Srinivasa Murthy, 2006). For India, self care and informal care has a special relevance. Some of the issues related to functions and competencies required are outlined in a recent WHO document and summarised in the following Boxes
Informal Community mental health services (WHO,2005).
Local community members who are not professionals in mental health or health care can provide a variety of services. Examples of people working at this level of service provision include: lay volunteers, community workers, staff in advocacy organizations, coordinators of self-help/user groups, humanitarian aid workers, traditional health workers and other professionals such as teachers and police officers. Many of these informal community-care providers have little or no formal mental health care training, but in many developing countries they are the main source of mental health provision. They are usually accessible and generally well accepted in local communities. They can help with the integration of people with mental disorders into the community, and thus play an important supportive role to formal mental health services.
In India, the role of non-specialist personnel in various mental health initiatives have been well accepted for over 25 years (Issac et al,1982, DGHS 1982, Srinivasa Murthy and Wig,1983, Srinivasa Murthy, 2004)) .
Functions of community carers
It is important to point out that informal community mental health service providers are unlikely to form the core of the mental health provision. Indeed, countries would be ill-advised to depend solely on their services. However, they can complement formal mental health services and form useful alliances.
Some of the important functions performed by informal services are:
Supportive care, including counselling and self-help. They can provide basic counselling for brief and acute mental health problems. This includes individual supportive counselling, family support, as well as group-based counselling for people with mental disorders and their families. They can play a useful role in catalyzing the setting up of self-help groups as well as support groups for individuals, carers and their families. They can also provide day-care services for people with mental disorders.
Help with activities of daily living and community reintegration. Many people with mental disorders have difficulty gaining access to the services necessary for living in the community. For example, a number of people with chronic and severe mental illnesses have enormous difficulties with activities such as shopping, travelling on public transport and obtaining benefit payments, to name a few. Informal services can play an important role in helping such individuals with these activities, thereby assisting them to reintegrate into the community.
Advocating the rights of people with mental disorders. Informal services can play an important role in advocacy. For example, they can educate individuals and their families about mental health issues and leadership, help individuals and their families to form their own organizations and contribute to the development, planning, evaluation, and monitoring of mental health services. They can also contribute to the development of mental health policies and legislation. Other advocacy actions include awareness raising, dissemination of information and education and training.
Preventive and Promotive services. Examples of such services include teachers providing mental health services in schools, preventive programmes for alcohol and substance misuse, and interventions aimed at reducing domestic violence. In most countries community members, who are not necessarily mental health professionals provide these services, and in many instances these interventions are part of wider health and /or social interventions.
Practical support. In many communities, lay people provide basic, practical support, such as community –based housing for people with mental disorders, employment opportunities in sheltered workshops as well as in open employment, and shelters for women who are victims of abuse and domestic violence.
Crisis support. Informal services can play a useful role in crisis intervention, such as counselling in humanitarian emergencies, setting up and running telephone helplines, crisis support and help to families in distress, and counselling support to women who are victims of domestic violence.
Identification of mental health problems and referral to health services. When informal service providers are able to identify people with mental health problems but lack the competencies to address those problems, a key function is to refer those individuals to the relevant health services equipped to deal with such problems. .(pages 67-69) (from Human Resources and Training in Mental Health- Mental Health Policy and Service Guidance Package, WHO, 2005)
Competencies required of community carers
By definition, local community members involved in providing informal community care are not expected to have formal mental health training. Moreover, it is a heterogeneous group comprising lay people and family members, who may have no mental health training, traditional healers , who may be trained in indigenous systems of healing, and professionals from other fields, such as human rights activists, lawyers teachers and police personnel, who may be involved in many other functions described above. It is therefore not possible to prescribe minimum competency criteria for individuals involved in providing informal care. Instead, it is useful to think of some discrete competencies that may enable such individuals to become more effective in helping people in the community who suffer from mental disorders.
Useful competencies at the level of informal community mental health services include:
Basic understanding of mental disorders. This includes understanding the symptoms of mental disorders and how they affect the behaviour of individuals with those disorders. It also requires an understanding of the need for treatment, including medical and psychosocial interventions. In addition, it is useful to have an understanding of the needs of the people with mental disorders for ongoing treatment, the role of psychological and environmental factors in precipitating relapse, and the effect of mental disorders on individuals ability to deal with the activities of daily living, and to handle stigma and discrimination.
Basic counselling competencies. This includes listening and communication skills, especially empathic listening. Training should be provided in basic competencies, such as the need to maintain confidentiality, managing conflict of interests when dealing with individuals as well as their families, maintaining a neutral stance and dealing with disturbing emotions. The aim is to enable informal community caregivers to provide basic supportive counselling interventions. It is not expected that they will necessarily be trained in specific psychotherapy techniques, although in certain instances they may be under the supervision of trained professionals.
Advocacy. This is particularly useful because informal community caregivers are the best placed to advocate on behalf of people with mental disorders to professional service providers (including health and mental health care providers) as well as institutions. They may need to be informed about the legal framework and entitlements of people with mental disorders, as well as be trained in effective public communication and negotiating skills to help them in their advocacy work.(pages 67-69) (from Human Resources and Training in Mental Health- Mental Health Policy and Service Guidance Package, WHO, 2005)
Mental health services at different levels of health services (Wig,1993)
India is the first developing country formulate the National Mental health Programme (NMHP) based on the principle of decentralized and deprofessionalised mental health care(DGHS,1982). This is reviewed in detail in Chapter……. The District mental Health Programme (DMHP) which forms the core of the services aspect of NMHP has been covered in detail in Chapter…….
This section considers the mental health activities that can be undertaken at the different levels of health care in India i.e. from the village level health functionaries, the primary health care centres, the taluk hospitals/community health centres and the district hospitals supported by tertiary centres in the form of medical college departments of psychiatry or the mental health institutes. It is to recognized that as the health system structure is varied in various states and union territories the amount and the range of activities that can be undertaken would be dependent on the health infrastructure of the state or union territory.
Village Level
Accredited social health activist (ASHA) Multi-purpose worker(MPW) and health supervisors/Junior health assistants and Senior health assists with the support of the medical officer can provide:
Early identification and referral of psychiatric problems; Management of psychiatric emergencies
Administration and supervision of maintenance treatment for chronic psychiatric conditions in accordance with guidance by the supervisors;
Counseling in problems related to alcohol or drug abuse.
Public education.
Activities by these groups can result in all acute psychosis to brought under care within one month of onset. All of the persons with chronic mental illness, mental retardation identified and brought under continuous treatment. They can also bring about changes in the understanding of mental health and mental disorders in the community. They will provide first aid-Emergency mental health care for acute excitement, suicidal attempt, side-effects of drugs etc. They will extend home care to those unable to come to the health facilities for care, by carrying the drugs on a periodic basis. They would work with the Panchayat Raj institution for mental health care, including prevention, promotion and care. They will facilitate the disabled persons getting the disability benefit.
Primary Heath Center(PHC)/Community Health centre(CHC)
Supervision of the MPW’s performances of specified mental health tasks,
Elementary diagnostic assessment of cases,
Treatment of functional psychosis, anxiety, depressive disorders and alcohol dependence
Treatment of uncomplicated cases of psychiatric disturbance associated with physical diseases;
Management of psycho-social problems using psychosocial interventions
Public mental health Education
Maintenance of care records
The PHC and CHC will not have a psychiatrist or other mental health professionals, as of at this point of time in most of India. It will the general medical officers who will provide the first level of treatment.
The interventions at this level will include the periodic training of the health workers on priority mental disorders and their day to day supervision, along with monthly review of the mental health programme during the regular review of other health programmes. By this process, the mental health programme will not be seen as separate from the other health programmes like malaria, tuberculosis, leprosy, maternal child care etc. It is also clear from the last 30 years of experience, that mental health care by health workers will occur only by providing support and supervision. The PHC/CHC will have beds for inpatient care and this will allow for emergency mental health care, for acute psychosis, hysterical episodes, suicide attempts etc. the doctors will diagnose and treat the common mental disorders and severe mental disorders using both pharmacological and non-pharmacological interventions. They will maintain mental health case records and review periodically(monthly) of the “drop-out’ and “irregular” patients and take corrective measures for follow up. The goal should be to bring all acute psychosis(expected 3/10000 population) under care within one month of onset.80% of the persons with chronic mental illness, mental retardation should be identified and brought under care. As a goal at least 50% of the chronic cases should complete the treatment or be on continuous treatment. The medical team would prepare monthly report of mental health care ( new cases, cases under care, cases cured, emergencies, referrals,) and send it to the district authorities. The team would organize a wide variety of activities to being about changes in the understanding of mental health and mental disorders in the community. The centre would organise disability certification on a monthly basis. Another important activity would be to work with the Panchayat Raj institutions and voluntary organizations for community level rehabilitation of patients, including the setting up of support to self-help groups.
District Hospital (Team consisting of psychiatrist, clinical psychologist, psychiatric social worker, psychiatric nurse, statistician)
Medical consultation to the health center’s medical officer with regard to “difficult” cases of psychiatric disorders,
Admit and provide brief hospital treatment for psychiatric patients including ECT treatment
Training of medical officers and health personnel
Support to NGOs
Linkage with state mental hospital and teaching departments of medical college for further referral facilities.
The district will be, for the coming few years, first specialist referral support system for the health workers and the primary health care physicians. The team has an important role in the provision of specialist mental health care as well as the monitoring of the DMHP. It would be desirable for each district to prepare a mental health plan, reflecting the mental morbidity, resources available in the community and the socio-cultural characteristics of the population, the exact roles and responsibilities would differ depending on the terrain(e.hilly areas), distances to be covered(tribal forest areas) etc. The plan would also help in evaluating the impact of the programme from year to year. The likely indicators for monitoring a district level mental health programme is attached as Appendix II.
Each of the districts will have a separate inpatient care for acute psychiatric disorders(10 beds).There will be regular daily outpatient care for those referred from the periphery as well as those seeking help directly.
The mental health team will carry out a number of training programmes, from time to time to train all the health personnel of the district and all the General practitioners of the district.
The centre would hold monthly Disability certification, along with the District Disability Board. Towards promotion of mental health , life skills education in schools would be taken up , especially by the non-medical members of the mental health team. The team would visit to all institutions that are providing care for persons with mental disorders(jails, destitute relief centres , homes for MR, women in distress, ). Another important activity at this level is the support to family self-help groups. There should be an attempt to set up at least one Day care centre at the district level and if possible a half-way home for the care of long stay patients. Involving the district wide voluntary organization in mental health care and supporting them would be an another of the activities at this level. Monitoring and evaluation of the mental health programme of the district would occur at this level(Appendix II).
Medical College/Psychiatric Institutions
The department of psychiatry at the medical college or the mental health Institute will form the apex institution for support to the total mental health programme. At this level there will be number of mental health specialist and specialized treatment facilities( about 30-50 beds) for the care of children, elderly, substance abuse. Following are the activities at this level:
Medical consultation to the district psychiatrists, health center’s medical officer with regard to “difficult” cases of psychiatric disorders,
Admit and provide brief hospital treatment for psychiatric patients
Specialised treatments, eg. Children, drug dependent persons, old age problems, behavior therapy
Rehabilitation
Training of specialist mental health human resources, namely, psychiatrists, clinical psychologists, psychiatric social workers and psychiatric nurses
Training of undergraduate medical students
Training of medical officers and health personnel
Training of general practitioners
Monthly disability certification
Monthly data of psychiatric care
Support to NGOs-self help groups, CBO,
Operational research studies
Telepsychiatry, through the village resource centres, support to the area mental health care facilities.
Community care facilities for short and long term care:
As noted in an earlier section, rehabilitation is an important need in the community. Decentralised and centres of rehabilitation as close to the places of stay of patients decreases the delay in seeking help as well as help in easier and fuller reintegration of the recovered patients. The community care facilities also decrease the stigma of long stay in distant institutions. Voluntary organizations have a very important role to play in these activities. Some of the types of facilities that should be part of the total mental health care system are outlined below.
Day care centres: These centres will provide for the recovering patients opportunities for social interaction, learning of social skills, therapy(individual and group, and vocational training. These centres will also decrease the burden on the family of continuous care.
Short term stay/ half way homes: In situations where the patients needs supervised care, not amounting to that of the hospital, with an emphasis on psychosocial rehabilitation and the benefits of therapeutic community, these centres are valuable. The usual duration of styay is about 89 months. During this period of stay emphasis is on both therapy and rehabilitation. Depending on the orientation of the centre and the staff various therapeutic modalities would be used for recovery purposes. An important part of the therapy is the work with the family so that family is ready for receiving the recovered patient along with the patient learning the skills to live at home and community.
Long stay homes:
Due to reasons relating to some of the illnesses (chronic schizophrtenia, personality disorders), the changing family situations(elderly parents, siblings being away , single parent) and the stigma of seeking local psychiatric help, these long stay homes are becoming a necessity and a growing phenomenon. These places are also the places for the homeless mentally ill persons. The challenge of care in these centres is to provide humane living conditions,. Respect the rights of the ill persons, and to orient their stay towards independence. There are dangers of these becoming ‘mini mental hospitals’ along with possible human rights abuses.
Vocational training centres /Sheltered workshops: For recovered and rehabilitated patients, income generation is an important goal. Often they can not compete in the open market. These facilities will provide both an opportunity to earn a living as well as the protection of a therapeutic setting in which trained staff will give the support. The possibilities for the clients to develop cooperatives should be encouraged.
Other systems of mental Health Care (Sebastia,2009)
India is home to a large number non-allopathic systems of care. This ranges from the well establishments health systems of Ayurveda, Homeopathy, Unani systems who all have their own approaches to mental health care(Somasundaram,2009, Srinivasa Murthy, R.2010). There are other methods used for mental health care which are well organized and varies depending on the practitioners like the use of religious treatments, temples for mental health care (Sebastia,2009). These are popular among the general public both as a reflection of the long held beliefs and practices, the confidence in the heritage as well as the availability and accessibility of these interventions more easily in the rural areas.
Conclusions
In a country like India, where the mental health resources and services have been limited and a large number of ill persons are living in the community, there is no wisdom in emphasising one or other components of mental health care. There will be need for all of the components of mental health care outlined above. The emphasis on one or more of the components would be decided by the local situation in a district/state and the needs of the population. A very important part of the thinking of mental health services at primary, secondary and tertiary levels is to use the wide variety of human resources in the community for mental health care. (A possible distribution of responsibilities for different groups of non-specialists is outlined in Appendix I). The development of mental health services in India will occur at all levels and involving the plural approaches practiced by the population.
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Appendix I:
The following are the different categories of personnel from the health and related sectors and the mental health activities that they can carry out.
1. Accredited Social Health Activist(ASHA)
• Mental health education to community using different means like lectures schools and village community gatherings.
• Educating and supporting the family and community care of mentally ill patients, helping to remove the stigma of mental illnesses and the importance of regular medication.
• Identification of patients with major mental health problems like psychosis, epilepsy, and mental retardation.
• Referral of patients to health unit/centre, district centre and keeping records of old and new patients.
2. Multi Purpose Health worker
• Advising health team about traditions and beliefs in the community.
• Facilitating the role of the ASHA e.g. by organising village meetings.
• Identification of people in need of mental health care.
First aid in psychiatric emergencies.
Follow up of patients at home and guidance about side effects
Assistance in the re-integration of the mentally ill in the community, and
• Collaboration with health personnel to promote mental health and psychosocial development.
3. Anganwadi worker
• Early recognition of preschool children with problems.
• Provide first aid in emergencies.
• Use mental health promotion activities in the day care facility by plan and stimulation.
• Guidance to parents about parenting skills and referral of problem children.
4. School teacher
• Early identification of childhood problems and referral to health facility.
• First aid in emergencies.
• Provide mental health education to children regarding accident prevention, risk-taking behaviour and drug abuse, along with methods to increase self- esteem(life skills education).
• Parental counseling about adolescence and its management.
• Early detection of sensorial defects and referral for help.
• Contributing by educational activities, to the promotion of positive attitude towards the mentally ill.
5. Police
• Recognition of acute mental disorders and undertaking of necessary action to protect the human rights of the mentally ill, his family and his fellow citizens.
• Provision of first aid in specified problems. (e.g. an epileptic fit, acute excitement, threatened suicide)
6.General practitioner/Medical Officer at Primary health Centre
(Trained for short periods in mental health)
• Recognition, diagnosis and treatment of commonly occurring psychiatric problems in the clinics and community.
• Referral to district hospital difficult cases with information and treatment details.
• Maintenance of records of all treatment and patients of the area.
• Provide in-service training to and health workers(ASHA,MPW)
• Supervision and support of health workers.
• Mental health statistics of care
7. Clinical psychologist
• Activities to promote mental health through health workers, voluntary agencies, teachers, police and village leaders.
Psychosocial treatment
School mental health activities
• Mental health research of public health priority mental disorders.
• Development of teaching and training materials and assessment methods.
8. Psychiatric social workers
• Supportive activities and vocational help to the patients and their families.
• Development of teaching and training materials for different categories of personnel.
• Activities to promote mental health through health workers, voluntary agencies, teachers, police and village leaders.
• Rehabilitative initiatives in the community
• Social assessment of outpatients and inpatients and visits to homes and workplaces.
9. Psychiatric nurse
• Training of health personnel in task-oriented mental health care.
Clinical care for admitted patients
• Strengthening of the family supports and acceptance of the mentally ill by the families.
• Supervision and support to health and personnel of the other sectors in mental health care.
10. Psychiatrist at District hospital
• Correct diagnosis and treatment of mental disorders attending the outpatient department and those referred by the peripheral units.
• Inpatient treatment of patients requiring intensive care and observation for short periods of time.
• Annual maintenance and analysis of the records and feedback to the peripheral units and the Department of Health.
• Initiation of preventive techniques and develop mechanisms for mental health promotion.
• Training to general practitioners, MPW,ASHA, and develop manuals and other teaching aids.
• Initiate research into problems of relevance to programme implementation.
• Evaluation of effectiveness of the different training programmes.
• Support and supervision of the different personnel.
Appendix II;
District Mental Health Programme of (DMHP):
Objectives:
1.To provide sustainable basic mental health services to the community and to integrate these services with other health services;
2.Early detection and treatment of patients within the community itself;
3. To see that patients and their relatives do not have to travel long distances to go to hospitals or nursing homes in the cities;
4. To take pressure off the mental hospitals;
5. To reduce the stigma attached towards mental illness through change of attitude and public education;
6. To treat and rehabilitate mental patients discharged from the mental hospitals within the community.
OUTPUT:
Baseline studies:
Description of the District in terms of the available mental health facilities (general health facilities, psychiatrists, psychiatric beds, mental health NGOs, number of persons in mental hospitals, wandering mentally ill persons, suicide rate etc)
Current knowledge of the health, welfare and education sector personnel about essentials of mental health care;
Attitude of the community to mental health and mental disorders- either through focus groups or through survey of sample population of the population using a questionnaire /case vignettes with key informant interviews. Alternatively the data from the health workers, teachers and anganwadis can be used as the reflection of the community knowledge, attitude and practices).
Training of Personnel:
Immediate impact of the training (pre-post training evaluation) in each of the trained groups;
Record of questions raised by the trainees during the training;
Care activities:
Number of persons with mental disorders seen month by month- by individual health workers,(from the catchment area and outside the catchment area) individual health facility;
Diagnosis of the persons with mental disorders;
New cases
Duration of illness at the time of first contact with psychiatric services
Past treatment record
Severity of symptoms
Degree of disability, at first contact
OUTCOME OF INITIAL CONTACT:
Follow-up cases/ once a month (since medicines are expected to be given once a month)
Admission details, if admitted
Outcome of first contact with psychiatric care- drop out, irregular, completed/continuing treatment, recovered (at 6 months and one year)
Final status regarding symptoms and disability
Support programmes for the family members
Review of the case Records by the DMHP officer/ team:
Completeness of the records;
Correctness of the diagnosis
Appropriateness of the medicine used
Appropriateness of the dosage of the medicine (depending on age, severity of illness)
Follow-up record-completeness,
Follow up -appropriateness of changes in the treatment
Medicine stock-
Checking of the stock as per records;
Linkage with the use from records and the remaining stock
Drugs and their expiry dates
Record of health workers
Meeting with health workers to evaluate their work- public education, follow up care, problems encountered etc)
Identification of problems of care programme.
Other activities undertaken by the DMHP Team:
Training activities
Organization of camps for issuing disability certificates/ ID cards
Community level activities
Support to families of persons with mental disorders
Follow up of individual patients (about 10% of cases to be followed up for detailed evaluation of the different points identified in the case record)
Coordination with the monitoring team
Monitoring Team:
Review of doctors skills in caring for the persons with mental disorders;
Review of the skills of health workers in caring for persons with mental disorders;
Checking of a LIMITED /SPECIFIED number of patients in the clinic/community- adequacy of the records, diagnosis, treatment and follow up
Identification of the areas requiring strengthening of the cases
ESSAY 2
NATIONAL MENTAL HEALTH PROGRAMME (NMHP) of India
“A network of decentralised mental health services for ameliorating the more common
categories of disorders is envisaged. The programme outline for such a disease would involve the diagnosis of common disorders, and the prescription of common therapeutic drugs, by general duty medical staff. In regard to mental health institutions for indoor treatment of patients, the Policy envisages the upgrading of the physical infrastructure of such institutions at Central Government expense so as to secure the human rights of this vulnerable segment of society”. National Health Policy 2002.
Mental Health Care in Independent India
At the time of Independence, the existing mental health infrastructure and specialist manpower was very meagre. The situation can be understood by comparing the 10,000 psychiatric beds in India in 1947 for a population of over 300 million, with that of UK, with one tenth the population of India having over 150,000 psychiatric beds. The first two decades of Independent India, were devoted to doubling the mental hospital beds followed by setting up of general hospital psychiatric beds(Wig,1978). However, the major breakthrough occurred in 1975, when a new initiative to integrate mental health with general health services, also referred to as community psychiatry initiative, was identified as the approach to develop mental health services. Community psychiatry in India is nearly four decades old. Starting as isolated extension psychiatric clinics in primary health clinics,(SrinivasaMurthy,2000) today the integration of mental health care in general services covers over 127 districts( about 20% population of the country). The National Mental Health Programme (NMHP) was formulated in 1982 to develop a national level initiative for mental health care. During the last 25 years, there are a large number of other community initiatives to address a wide variety of mental health needs of the community like homeless mentally ill, day care centres, half-way homes, long stay homes, rehabilitation facilities, suicide prevention, care of the elderly, substance use persons, and disaster mental health care. From a situation of nearly no services for persons with mental disorders in 1947, today there is a broad framework for mental health care in the public, private and voluntary sectors. In these developments, India has been influenced by the local situation as well as the international developments.
This essay describes the background to the development of NMHP, the first 25 years of the implementation with specific focus of the developments of the last five years and concludes with identification of areas for future action.
Background to NMHP
The need for setting up of district psychiatric clinics was recognised in the 1960’s as part of the Mudaliar Committee Report(Mudaliar,1962). A few centres did come up following this Report. However, the important national level professional initiative is the discussions of the Indian Psychiatric Society at Madurai in the early 1970’s where the need to integrate mental health care with general health care was voiced. Simultaneously , in 1975, the Expert Committee on Mental health of the World Health Organisation published the important document’ Organisation of mental health services in developing countries’ (WHO,1975). These professional ideas were put to practical test both at Bangalore and Chandigarh centres, by taking up pilot programmes to integrate mental health with general health services during the 1975-1981 period. (Wig et al, 1981, Kapur et al,1981). A detailed description of these initiatives and that of other centres in the country and the move to a district level model in Bellary, Karnataka(1984-1990) is described in detail in Chapter.....
NMHP
In the 1980’s, the Government of India felt the necessity of evolving a plan of action aimed at the mental health component of the National Health Programme. For this, an expert group was formed in 1980, who met a number of times and discussed the issue with many important people concerned with mental health in India as well as with the Director, Division of Mental Health, WHO, Geneva. Finally, in February 1981, a small drafting committee met in Lucknow and prepared the first draft of the NMHP. This was presented at a workshop of experts (over 60 professionals) on mental health, drawn from all over India at New Delhi on 20–21 July 1981. Following the discussion, the draft was substantially revised and a new one was presented at the second workshop on 2 August 1982 to a group of experts from not only the psychiatry and medical stream but also education, administration, law and social welfare. The final draft was submitted to the Central Council of Health, India’s highest health policy making body at its meeting held on 18–20 August 1982, for its adoption as the NMHP for India(DGHS,1982). The Council discussed this programme at length and adopted a resolution for its implementation in the states and UTs as follows:
“Mental health must form an integral part of the total health programme and as such should be included in all national policies and programmes in the field of Health, Education and Social Welfare. Realising the importance of mental health in the course curricula for various levels of health professionals, suitable action should be taken in consultation with the appropriate authorities to strengthen the Mental Health Education components. While appreciating the efforts of the Central Government in pursuing legislative action on Mental Health Bill, the joint Conference expressed its earnestness to see that the bill takes a legal shape at the earliest”.
Summary of NMHP
The NMHP document reviews the mental health situation in terms of needs, facilities and services. The document noted that a wealth of information is available in India concerning the prevalence of mental disorders. According to most of the surveys, about 10 to 20 per 1,000 of the population are affected by a serious mental disorder at any point in time (point prevalence). The main burden of psychiatric morbidity in the adult population consists of acute mental disorders; chronic or frequently recurring mental illnesses; emotional illnesses such as anxiety, hysteria, neurotic depression; alcohol abuse, and alcohol and drug dependence and psychiatric disturbances among children. No factual data are currently available regarding the loss of productivity, of income and even of life, due to mental illness. However, it should be pointed out that suffering due to mental illness often is not confined to the affected individual, but causes severe social dysfunction of entire families. From the available data, it is safe to conclude that not more than 10% of those who need urgent mental healthcare are receiving the required help with the existing services. The situation is worse in rural areas as the concentration of services and facilities is greater in the cities. Further, a simple extension of the present system of care will not be able to ensure adequate services to the vast majority of the Indian population in the near foreseeable future.
In view of the gross disparities between needs and available services, there are essentially two approaches for immediate action. They are not alternatives, since the difference between them lies mainly in the emphasis and in the level of priority assigned to different levels of service development. The first option would be to direct available resources to the establishment and strengthening of psychiatric units in all district hospitals. It would be hoped that these units would become foci of an expanding mental health service, through setting up out-patient clinics and mobile teams. In general terms, the approach would be directed from the centre to the periphery. In contrast, an alternative approach would be to train an increasing number of different categories of health personnel in basic psychiatric and mental health skills. There would thus be a functional infrastructure before completing, in all instances, a physical independent mental health infrastructure.
Most mental health facilities in India actually function as passive recipients of patients. They
become operational only where coping mechanisms in the community fail. These institutions
have little knowledge and hardly any impact on the coping mechanisms as they exist and operate in the community. It is essential that the role of all mental health institutions in India become more active with the social mechanisms involved, not only in the development of mental illness, but also in the more important issue of maintaining mental health.
The objectives of NMHP were: (a) to ensure the availability and accessibility of minimum mental healthcare for all in the foreseeable future, particularly to the most vulnerable and underprivileged sections of the population; (b) to encourage the application of mental health knowledge in general healthcare and in social development; and (c) to promote community participation in the mental health service development and to stimulate efforts towards self-help in the community.
Approaches to NMHP were: diffusion of mental health skills to the periphery of the health service system; appropriate appointment of tasks in mental healthcare; and integration of basic mental healthcare into general health services and linkage to community development and mental healthcare. The service component will include three sub-programmes—treatment, rehabilitation and prevention.
The plan document outlined a set of actions for achieving the objectives in the form of a set of targets, and of detailed activities, namely, (i)within one year, each state will have adopted the present plan of action in the field of mental health; (ii) within one year, the Government of India will have appointed a focal point within the Ministry of Health, specifically for mental health action; (iii) within one year, a National Coordinating Group will be formed comprising representatives of all states, senior health administrators and professionals from psychiatry, education, social welfare and other related professionals; .
(iv) within one year, a task force will have worked out the outlines of a curriculum of mental health workers identified in the different states as the most suitable to apply basic mental health skills, and for medical officers working at Primary Health Centres (PHCs) level.
(v) within five years, at least 5,000 of the target non-medical professionals will have undergone a two-week training programme on mental healthcare; (vi) within five years, at least 20% of all physicians working in PHC will have undergone a two-week
training programme in mental health; (vii) The creation of the post of a psychiatrist in at least 50% of the districts within five years; and will be fully operational in at least one district in every state and UT, and in at least half of all districts in some states within five years; (viii)
each state will appoint a programme officer responsible for the organisation and supervision of the mental health programme within five years; (ix) each state will provide additional support for incorporating community mental health components in the curricula of teaching institutions (within five years); (x) on the recommendation of a task force, appropriate psychotropic drugs to be used at the PHC level will be included in the list of essential drugs in India; (xi) psychiatric units with in-patient beds will be provided at all medical college hospitals in the country within five years and (xii) the proposed plan needs to be reviewed periodically for the evaluation of goals achieved. In that aspect the present plan should be understood as an initial statement of intent, rather than a rigid blueprint for all future
programmes.
The programme outlined above clearly and deliberately reached beyond the traditional tasks
of a specialised psychiatric service. In the first instance, it was proposed to use the primary healthcare structure to provide basic psychiatric and mental health services. This means that at least at the grass-root level of healthcare, mental health will be totally integrated into the general healthcare delivery system. The close cooperation of mental health professionals with other providers of care was thus imperative. In fact, it is hoped that mental health consciousness will become an integral part of all health and welfare endeavours in India. A strong linkage of the programme should be with social welfare and education sectors. Teachers would therefore have to be given adequate orientation in the early diagnosis of most of the common mental health problems. The necessary links with the mental hospitals and medical colleges have already been mentioned. They will be centres of referral for special cases, as well as centres of various teaching activities. In view of diverse and varying level of development and health infrastructure in India, a certain degree of flexibility will be essential in the implementation of this programme. The National Advisory Group would have the responsibility of regularly monitoring the progress of the programme. Appropriate legislation for better implementation of the NMHP would also have to be looked into.
Looking at the NMHP document of 1982, twenty seven years later, the main strength of the document was the envisaged integration of mental health care with general primary healthcare. However, there were some inherent weaknesses in this otherwise sound conceptual model. The entire emphasis was on the curative, rather than preventive and promotive aspects of mental health care. Community resources like families were not accorded due importance. Ambitious short-term goals took precedence over pragmatic, long-term planning. Most glaringly, no estimate, leave aside provision, of budgetary support, was made. These deficiencies possibly contributed to the limited progress for nearly for a decade, after the formulation of the document.
Progress between 1982 and 2009
Since the adoption of the NMHP, it has been the guiding document for the development of the mental health programme in India. The most important progress has been the development of models for the integration of mental health with primary healthcare, in the form of the district mental health programme. The District Mental Health Programme (DMHP) developed during 1984-1990, was extended initially to four states and then to 25 districts in 20 states between 1995 and 2002. The other areas that have received support in the NMHP are the human resources development and improvement of mental hospitals.
Magnitude of mental disorders in India
Epidemiological studies are important in understanding the magnitude of the problem in the community, the need for services, understand the historical trends, calculate morbid risk and identify aetiological factors in the causation and distribution of the mental disorders. In India, during the period of 1964-1995, there were a large number of general population epidemiological studies(VenkataswamyReddy and Chandrasekar,1998, Ganguli,2000, Gururaj and Issac,2004, Badamath et al, 2008). Interestingly, during the last 15 years there have been no similar studies of the general population, except the one that is part of World Health Survey, which provides new information about prevalence and treatment utilisation with regard to ‘psychosis’ from World Health survey(WHO,2006).
World Health Survey(WHS),2003(WHO,2006).
The information about’ psychosis’ and ‘depression’ at the community level from an all India perspective is available from the WHS is an unique source of data. The coverage of six states and the excellent methodology used represent an important source of information.
The objective of the WHS is to provide an evidence base on health expenditure, insurance, health resources, health state, risk factors, morbidity prevalence, and health system responsiveness for inpatient and outpatient care. In India, the WHS survey covered six states, Assam, Karnataka, Maharashtra, Rajasthan, Uttar Pradesh and West Bengal. The health status was assessed from individual questionnaire administered to 9994 adult population in ages of 18 and above. Twenty seven percent of respondents were from urban areas and seventy three percent from rural areas. The section on morbidity included diagnostic conditions depression, psychosis and mental health symptoms like sleep disturbance, feeling sad, low or depressed, worry or anxiety, and dealing with conflicts and tensions(WHS India,2006).From the total report, the following section relates to psychosis. The report of the study gives data about the prevalence, service coverage across different population groups. The reference period was one year prior to the study. Percentage diagnosed and treated in the six states is given in Table.....
Prevalence of ‘psychosis’ in six states.
|State |Need(percentage diagnosed) |Covered(percentage treated) |
|Assam |1.0 |39.1 |
|Karnataka |0.7 |85.2 |
|Maharashtra |2.2 |48.7 |
|Rajasthan |3.6 |36.2 |
|Uttar Pradesh |2.7 |45.5 |
|West Bengal |1.8 |66.5 |
The treated cases were in the urban areas(61.7% vs 47.5%); higher in the higher income quartiles.(p.62-66). The rates of treatment was lower in the rural population.
Prevalence of ‘depression ’ in six states.
|State |Need(percentage diagnosed) |Covered(percentage treated) |
|Assam |3.2 |32.3 |
|Karnataka |9.2 |13.0 |
|Maharashtra |27.3 |9.6 |
|Rajasthan |7.3 |29.7 |
|Uttar Pradesh |7.4 |8.2 |
|West Bengal |11.7 |17.8 |
Though the prevalence rates of depressive is higher than psychoses, the rates treated are far lower, pointing to the limited awareness in the community. The rates of treatment was lower in the rural population.
Mental Health in 10th Five Year Plan (2002-2007) (Agarwaal and Goel,2004)
Detailed account of the developments during the 1980’s and 1990’s has been covered in earlier articles( Reddy et al, 1986, Srinivasa Murthy and Wig,1993, Srinivasa Murthy,2004).After an in-depth situation analysis and extensive consultations with various stakeholders, the NMHP underwent radical restructuring aimed at striking a judicious balance between various components of the mental healthcare delivery system, with clearly specified budgetary allocations. After approval by the Ministry of Health and Family Welfare, the Planning Commission, the Ministry of Finance and, finally, the Cabinet Committee on Economic Affairs (CCEA) the restrategised NMHP was formally launched by the Secretary (Health) at a National Workshop held at Vigyan Bhawan, New Delhi on 22 October 2003. The programme comprises five closely networked/interdependent strategic components, with a total outlay of Rs 190 crores , which was later reduced to about Rs.130 crores.
5 Strategies of NMHP in Tenth Five Year Plan:
1. Redesigning the DMHP, around a nodal institution, which in most instances will be the
zonal medical college.
2. Strengthening the medical colleges with a view to develop psychiatric manpower, improve psychiatric treatment facilities at the secondary level, and to promote the development of general hospital psychiatry in order to reduce and eventually eliminate to a large extent the need for large mental hospitals with a huge proportion of long-stay patients.
3. Streamlining and modernisation of mental hospitals to transform them from the present
mainly custodial mode to tertiary care centres of excellence with a dynamic social
orientation for providing leadership to research and development in the field of
community mental health.
4. Strengthening of central and state mental health authorities in order that they may
effectively fulfil their role of monitoring ongoing mental health programmes, determining
priorities at the central/state level and promoting intersectoral collaboration and linkages
with other national programmes.
5. Research and training aimed at building up an extensive database of epidemiological
information related to mental disorders and their course/outcome, therapeutic needs of
the community, development of better and more cost-effective intervention models,
promotion of intersectoral research and providing the necessary inputs/conceptual
framework for health and policy planning. Focused Information, Education and
Communication (IEC) activities, formulated with the active collaboration of professional
agencies, such as the Indian Institute of Mass Communication and directed towards
enhancing public awareness and eradicating the stigma/discrimination related to mental
illness, will form an important component of this policy objective.
The budgetary allocations for the programme were, DMHP Rs 633 million; modernisation of mental hospitals Rs 742 million; strengthening of medical college departments of psychiatry Rs 375 million; IEC & Training Rs 100 million; research Rs 50 million.
The grant of Rs 5 million for each medical college department of psychiatry was for
creating/augmenting the infrastructure, including the construction of wards and the procurement of essential equipment, with the aim of providing quality secondary care as well as for developing postgraduate training facilities for various categories of mental health personnel.
The financial package for the 37 government-run mental hospitals, was for improving the clinical and infrastructural element in these institutions which have been found to be grossly inadequate by various surveys, including the National Human Rights Commission (NHRC) report on quality assurance in mental health in 1999.
Special efforts were expected to energise the State Mental Health Authorities (SMHAs) in order to enable them to play their designated role as envisaged in the Mental Health Act 1987 and central/state Mental Health Rules 1990. These statutory bodies form the first tier of the 3-tier monitoring system incorporated in the restrategised NMHP.
Substantial funds were allocated for scientifically formulated IEC initiatives at the central level. A multidisciplinary workshop, involving experts from the field of mass communication, advertising, media and other related fields, developed focused strategies in this area.
Recognising the need for research support and noting that research often receives step-motherly treatment in the matter of funding, the restrategised NMHP dedicated budget for operational research, relevant to planning more effective/cost-effective interventions or models of community-based mental healthcare. Such research was expected to provide significant inputs, relevant to policy reform and improved programme implementation. Simplified, transparent and non-bureaucratic machinery for implementing this research agenda was created.
A 3-tier machinery for monitoring at the state level (by the SMHA and a designated nodal officer), continuing online performance appraisal at the central level by a working group headed by a Joint Secretary level officer in the Directorate General of Health Services and periodic review by a High-Level Steering Committee in the Ministry of Health and Family Welfare, chaired by the Secretary (Health) was put in place. A provision has also been made for the mid-term evaluation of programme implementation by an independent external agency(Covered in detail in Chapter......).
Mental Health in 11th Five Year Plan (2007-2013) ( GOI, 2007, Planning Commission2006, Srinivasa Murthy,2007)
There is acute shortage of manpower in the field of mental health, namely, psychiatrists
clinical psychologists psychiatric social workers and psychiatric nurses. This is a
major constraint in meeting the mental health needs and providing optimal mental
health services to people. The existing training infrastructure in the country produces
approximately 320 Psychiatrists, 50 Clinical Psychologists, 25 PSWs and 185 Psychiatric
Nurses per year. Due to shortage of manpower in mental health, the implementation
of DMHP suffered adversely in previous plan periods. During the 11th Five Year plan, there has been further substantial increase in the funding support for NMHP. The total amount of funding allotted is Rs.472.91 crores ( a three fold increase from the previous Five Year Plan).
The areas identified for support are:
Manpower development, in the form of establishment of Centres of Excellence in the field of mental health (Rs. 338.121 crores). Centres of Excellence in the field of mental health will be established by upgrading and strengthening identified existing mental health hospitals/institutes for addressing the acute manpower gap and provision of the state of art mental health care facilities in the long run. These Institutes will focus on production of quality manpower in mental health with primary aim of manpower needs of NMHP.
Scheme for manpower development in mental health(Rs.69.8890 crores). Support would be provide3d for setting up/strengthening 30 units of psychiatry, 30 departments of clinical psychology, 30 departments of psychiatric social work, and 30 departments of psychiatric nursing with the support of upto Rs.51 lakh to Rs.1 crore per postgraduate department.
Spill over activities of the 10th Plan , which includes upgradation of the psychiatric wings of Government medical colleges/general hospitals and modernisation of Government mental hospitals(Rs.58.030 crores). Upto Rs.50 lakhs per college will be provided.
Modernisation of state run mental hospitals. A grant of upto Rs.3 crores per mental hospital would be provided.
Continuation of the existing DMHPs under implementation on existing norms(Rs.6.900).
There are also plans to integrate with the National Rural Health Mission.
DMHP at the National level :
DMHP implementation is the most important public health initiative in mental health with a direct impact on the needs of persons with mental disorders living in the community. At the National level, DMHP is in operation in 127 districts. The background to the development of DMHP and the progress of its implementation in the different states is covered in detail in Chapter.......(Srinivasa Murthy,2000)
The DMHP had the following objectives:
1.To provide sustainable basic mental health services to the community and to integrate these services with other health services;
2.Early detection and treatment of patients within the community itself;
3. To see that patients and their relatives do not have to travel long distances to go to hospitals or nursing homes in the cities;
4. To take pressure off the mental hospitals;
5. To reduce the stigma attached towards mental illness through change of attitude and public education;
6. To treat and rehabilitate mental patients discharged from the mental hospitals within the community.
The reports of professionals in published papers and the independent evaluation of the DMHP point a large measure of ineffectiveness of the DMHP, as conceived and in practice. This has been covered in detail in Chapter…….
The following are the seven reasons for the current state of the DMHP:
Limited development of the DMHP in its operational aspects by the Central agency: the core idea of integration has not been fully developed to operational level so that the states could follow the guidelines. The components of the programme like the training manuals, treatment guidelines, IEC activities have been developed to a limited extent and poorly disseminated.
Limited state level capacity to implement the DMHP- in most states the mental health programme is under the responsibility of non-psychiatrists and often as one of the many other responsibilities. As a result the technical inputs required for the programme have not been invested in the programme. This is all the more important as there has been inadequate central guidance.
Location of the DMHP with teaching centres: This is a serious barrier to integration of mental health with the general health care. The teaching centres did not have the knowledge of public health as well as did not work with the field level personnel to make the programme effective. Examples of this disconnect can be seen in the training at medical colleges, without involving the DMHP team. The expected technical support did not come medical colleges as they did not accept the core idea of integration of mental health with primary health care.
Inadequate technical support from professionals: At the initial stages of the programme, NIMHANS, Bangalore and few other centres provided the technical inputs and field level experiences of implementing programme on a regular basis. For example a number of centres like Bangalore, Delhi, Ranchi developed training manuals for PHC personnel. The ICMR, New Delhi set up a Centre for Advanced Research in Community Mental Health to develop supports to the NMHP. As noted in the earlier section a number of inputs to the programme like record system, health education material, manuals for the different categories of health personnel were developed. However, all of these developments needed further field level application, modification when the DMHP moved from demonstration project to programmatic stage of expansion to a large number of centres. This should have been a continuous process and it did not occur. This is also one of the reasons for the programme to be psychiatrist centred rather than medical officer/health worker centred.
Lack of emphasis on creating awareness in the community: As noted in the DMHP evaluation,. IEC activities ids the most important need and least emphasised till recent times. However, the last few months, massive national and state level mental health messages are broadcast on radio and TV, which should go a long way to increase the demand and the utilisation of the services.
Lack of mental health indicators: The programme did not develop simple indicators to address the objectives and for want of these there was only emphasis on training and drug supply and not the clinical outcome. A simple list of indicators is attached as Appendix 1.
Lack of monitoring: There was no central/state level technical advisory committees to monitor the programme and carry out the evaluation.
Looking to the future of DMHP:
DMHP will have to be the flagship programme of the NMHP for the following reasons , covered in detail earlier: (i) currently large proportion of the mentally ill are without care , along with poor awareness of the illness dimension of the mental disorders, especially in the rural areas; (ii) significant proportion are already seeking help from the existing primary health care facilities; (iii0 most rural population will not travel long distances to seek help; (iv) those seeking help will not continue the care unless it is available close to their places of residence; (v) the limited specialist manpower limits the reach of specialist services; (vi) it is possible for the health personnel to provide essential mental health care; and (viii) when care is provided patients can recover/function better with better quality of life to the patient and decreased burden to family and society.
It is important that in the coming years these aspects are given importance in the implementation of the DMHP. DMHP, by taking services to the population as closed to their residence has the greatest potential to provide care to the ill population. However, at present the technical inputs to organize the programme, the training of PHC personnel, support and supervision of the health personnel by the mental health professionals and the administrative supports needed to monitor and periodically evaluate the programme are inadequate.
Other mental health Developments
Evaluation of the Community mental health care programmes: In India, during the last few years four important research studies have addressed the situation of persons suffering from schizophrenia living in the community and the effectiveness of community level interventions.( Chatterji et al, 2004, Srinivasa Murthy et al, 2004, Thara et al, 2008, Thirthahalli et al, 2009). These studies show that about half of the patients of schizophrenia are living in the community without treatment. It is further seen that such patients have significant disability, cause a lot of emotional and financial burden on the family and caregivers. It is important to note that all of these studies show the benefits of regular treatment in decreasing the disability, the burden on the family and costs to the families. These studies also emphasise the need for community involvement in the care programmes “community based initiatives in the management of mental disorders however well intentioned will not be sustainable unless the family and the community are involved in the intervention program with support being provided regularly by mental health professionals”. If the mindset that chronicity of schizophrenia can be reduced and every person with schizophrenia can improve is coupled with an enthusiastic, aggressive management comprising of both medical and social interventions, then it is possible that many patients can improve or recover and have meaningful, productive lives.
In addition to the activities under NMHP, the other important activity that has occurred in the last 27 years is the wide variety of community care alternatives essentially coming from the voluntary sector. These initiatives have included day care centres, half-way homes, long-stay homes, suicide prevention, care of the elderly, disaster mental health care and school and college mental health programmes(Covered in Chapters.......). All of these have demonstrated that there is a felt need for alternative community care facilities, as well as the fact that they would be used by the general public when they are provided in user-friendly manner.
The other major development is human resource development. At the time of the formulation
of the NMHP, the number of psychiatrists was less than a 1,000 and in the last 27 years it has
nearly tripled to about 3,000. However, the unsatisfactory aspect is in the fields of clinical psychology, psychiatric social work and psychiatric nurses, who form a vital part of the team, have not been trained in adequate numbers. Eleventh Five Year Plan specifically addresses this need by funding the setting up of centres of excellence.
Stigma of mental disorders
Stigma of mental illness continues to be a major issue in India. Thara et al(1998) reported on the beliefs about mental illness from a rural South-Indian community. Tiwari et al(1999) studied perceptions and expectations of rural population in Uttar Pradesh, in advantaged and disadvantaged villages. 90% and 79% of the respondents were aware of the mental symptoms and drug treatment. Only a quarter of the respondents recognised the mental hospital as the place of treatment. 40% of the subjects perceived the available treatment as adequate. Only about half the respondents were utilising the available facilities and 81% were dissatisfied with the available services. 57% wanted the services in the village and 34% at the primary health centre. Majority of the community expected free consultation and treatment. Kulhara et al(2000) studied the magico-religious beliefs in schizophrenia in 40 cases of schizophrenia and ascertained magico-religious beliefs held by their key relatives. It was observed that the majority of the patients had undergone magico-religious treatment. Nearly 74% of the patients who had symptoms coloured by cultural influences such as delusional explanation in terms of paranormal phenomena had undergone magico-religious treatment. It was also seen that though many relatives denied personal conviction in such magico-religious beliefs, yet they sought some kind of magico-religious treatment for the patients. Belief in supernatural influences is common in patients' relatives from urban background and with adequate education, and treatment based upon such beliefs is sought to a considerable extent in such cases. Local and community belief in such phenomena appeared to be a factor in influencing the decision to seek magico-religious treatment. Thara and Srinivasan (2000) studied the nature of stigma and its relationship to attribution in primary caregivers of 159 urban patients of Madras. Marriage, fear of rejection by neighbour, and the need to hide the fact from others were some of the more stigmatising aspects. Female sex of the patient and a younger age of both patient and caregiver were associated with higher stigma. Attributions to faulty biological functioning , character of lifestyle, substance abuse and intimate interpersonal relationship discriminated between the group with experiences of high and low stigma. Beliefs about causation of schizophrenia influence the attitudes patients’ families adopt towards the patient and the help seeking behaviour. In order to understand these factors, key relatives with 254 chronic schizophrenic patients were asked to name the causes they believed were behind the illness along with factors related to attributions(Srinivasan and Thara, 2001). A supernatural cause was named by only 12% of the families and as the only cause by 5%. Psychosocial stress was most commonly cited cause , followed by personality defect and heredity. A small number of families (14%) could not name any cause and 39% named more than one cause. Patient gender and education, duration of illness and the key relative’s education and the nature of relationship were related to the type of causal attributions . In an another study (Thara,2003) using focus group approach, four dimensions of stigma were identified, namely, interpersonal interaction, structural discrimination, public image of mental illness and social roles. Padmavati et al (2005) studied the socio-cultural explanatory factors for mental health problems determine help seeking behaviors. Persons with mental illness and their families were interviewed at religious sites using a guideline questionnaire. Issues such as significant life events, explanations for perceived abnormal behavior and reasons for choosing a specific religious site for 'treatment' were explored. Seeking religious help for mental disorders is often a first step in the management of mental disorders as a result of cultural explanations for the illness. This behavior also found to have social sanctions. Saravanan et al(2007a) studied 131 patients with schizophrenic illness, for the explanatory models . The majority of patients(70%) considered spiritual and mystical factors as cause of their predicament; 22% held multiple models of illness. Female sex, low education and visits to traditional healers were associated with holding of spiritual/mystical models. These beliefs influence help seeking behaviour. In an another report (Saravanan et al, 2007b) focussed group discussions were conducted with people who have relatives with psychosis, with members of general public, with patients who had recovered from psychosis. Participants recognised psychosis as an illness category, and viewed indigenous healing methods as complementary to allopathic treatments. Multiple and contradictory beliefs on different aspects of psychosis were often simultaneously held by participants. People in the community were more likely to express negative views about mental illness. Relatives of patients wanted more support from mental health professionals and community in combating stigma against mental illness. Charles et al(2007) from Vellore, studied the association between stigma and beliefs about illness in patients and their relatives. The majority of the patients and their relatives simultaneously held multiple and contradictory models of illness and its treatment. Many of the patients had also visited local and traditional centres of healing, with nearly three-quarters of patients having used at least two systems of medicine/healing. The total stigma score of patients was associated with male gender, external non-stigmatising beliefs about illness (karma and evil spirits), the disease model of illness, the total number of causal models, the total number of non-medical causal beliefs, visiting the temple or other place of worship for cure, total family stigma score and the relatives’ perception of stigma on the patient (subscale). Stigma scores in relatives were significantly associated with male gender, literacy, rural residence, belief that illness is due to karma and total patient stigma score. There was a significant correlation between the stigma scores of patients and relatives. The patient stigma scores were also associated with disease models and belief in karma and evil spirits as causes of illness. The stigma scores of relatives were associated with belief in karma. These causal explanations of illness are generally considered non-stigmatising. While patient stigma scores were associated with the belief in visiting places of worship for cure, the other treatment beliefs were not significantly related to stigma scores. It is possible that explanatory models held by the patients and relatives can be the cause of increased stigma or can also be an adaptive mechanism to reduce the impact of stigma. Loganathan and SrinivasaMurthy (2008) focussed on the stigma and discrimination experiences of patients from rural and urban areas suffering from schizophrenia. The experiences of stigma and discrimination were assessed using a semi-structured instrument. Urban respondents felt the need to hide their illness and avoided illness histories in job applications, whereas, rural respondents experienced more ridiculing, shame and discrimination. A strength of this study is the narratives providing direct views of patients supporting the key findings. Authors call for mental health programs and policies need to be sensitive to the consumers’ needs to organize services and to effectively decrease stigma and discrimination. In an another report, they report on the gender related experiences of stigma and discrimination (Loganathan and Srinivasa Murthy,2009). Significant gender differences were observed among the people suffering from schizophrenia. Men felt stigmatized in their occupational area (the need to hide their illness, avoided illness histories in job applications and experienced stigma, ridicule and discrimination). Women experienced symptoms related to their marriage/ domestic area. The narratives of this study offer cultural insights into the issues such as marriage, occupation, pregnancy and childbirth, which may not be easily picked up on quantitative analysis alone. Possible protective factors related to post- partum care of mothers could contributing to better outcomes in women. The narratives provide a cultural matrix to base discussions that can be applied in appropriate socio- cultural backgrounds. There is need for mental health programs and policies to be sensitive to such gender specific needs to organize services and to effectively decrease stigma and discrimination, special needs of women related to marriage, pregnancy and childbirth; and myths related to marriage need to be addressed depending on the socio-cultural background.
Public awareness has increased due to community-based mental health care, initiatives of voluntary organisations, trained mental health professionals working in remote areas in the private sector, effort by professionals to address the general public with modern mental health information. Notable among these are the initiatives of books authored by mental health professionals, as well as the use of the mass media, especially the radio and television, for sharing of mental health information with the general public. The recent initiative of Ministry Of Health, Government of India, beaming the mental health care messages on the radio both in Hindi and the local languages and the TV channels is an excellent initiative.
Legislation
The above changes have been supported by legislation for mental Health care, namely, the Narcotic Drugs and Psychotropic Substances (NDPS) Act 1985, the MHA 1987 and Persons with Disability Act 1995. All of these legislations have changed the dialogue of penal approach to mental healthcare to a promotion, prevention and rights approach. The Persons with Disability Act 1995 is significant as for the first time mental illness is included as one of the disabilities. The recent UN Convention on Rights of Persons with Disabilities(UNCRPD) (2006) adds a new dimension to the rights of the mentally ill persons. It is expected some of the existing laws will be changed to bring into harmony, keeping the Indian situation in mind, into effect.
Traditional Systems of care for mental health (Srinivasa Murthy,2009)
Systematic research into yogic practices and their effect in different mental disorders has been a recent development during the second half of the twentieth century. There is a resurgence of academic interest in the effects of different types of Yogic practices and the mental health effects of Bhagavad Gita. For example during February 2006, there was a World Conference on “expanding paradigms: science, consciousness and spirituality’ at the All India Institute of Medical sciences, New Delhi. In March 2007, a national seminar on “yoga therapy for psychiatric and neurological disorders” was organised at Delhi and Bangalore. In September 2008, a two day conference examined the mental health aspects of Bhagavad Gita at Bangalore. In January, 2009, the Indian Psychiatric Society brought out a volume on “Spirituality and Mental Health” containing over three dozen articles on various aspects of spiritualism and mental health. All of this leads one to conclude that there will be greater examination of spirituality in general and the impact of yoga and meditation in particular, in the coming years, using a wide variety of physiological and psychological tools. (Duraiswamy, 2007, Srinivasa Murthy,2008) Initial research reports of use of yoga and meditation were with a wide range of mental disorders . In addition the special relationship between the patient and the therapist in the Indian context and its advantages were explored. This was followed by comparison of standard treatment with yoga in psychoneuroses ; anxiety, drug addiction, psychogenic headache. There was also a number of studies on the various aspects of Transcendental Meditation(TM) and its physiological effects.
Recent research studies on Yoga:
Sudarshan Kriya Yoga(SKY) is a procedure that involves essentially rhythmic hyperventilation at different rates of breathing. Janakiramaiah and colleagues(2000) treated 48 patients diagnosed as dysthymia with SKY alone. It was a out-patient study. A trained SKY teacher taught the procedure in the first two weeks and patients practiced the same at home. At the end of the study (3 months) 37 patients were available. 25/37 (68%) of patients were remitted at the end of one as well as three months after the start of SKY. 7 of these practice SKY irregularly (< 3 times a week). None of these seven patients were remitted at the end of the study. That close to 70% responding favourably to the sole treatment with SKY in this open study encouraged the authors to test SKY in randomised controlled studies. The next study compared relative antidepressant efficacy of SKY in melancholia with two of the standard treatments, namely electroconvulsive therapy and antidepressant medication. 45 hospitalised patients were randomly assigned to the three groups. Assessment were weekly for four weeks. Remission at the end of the trial period were 93,73, and 63% in the ECT, antidepressant and SKY groups. Authors conclude that SKY can be a potential alternative to drugs in melancholia as a first line of treatment .The authors also examined if the therapeutic potential of SKY is contributed by the hyperventilation component solely. Fifteen each of patients with major depressive disorder were randomly assigned to receive either the partial SKY (procedure sans hyper ventilation part of kriya) or full SKY. Full SKY produced 75% remission where as the partial SKY produced 45% remission . An open trial, examined the normalisation of P300 amplitude following treatment in dysthymia in a group of 15 patients who practiced SKY, compared with 15 controls (depressive episode with somatic symptoms) and who received ECT or antidepressants and 15 normals. The P300 amplitude increased with the symptomatic improvement of dysthymic group and normalised at 3 months. There was no significant difference between the three groups or across the occasions. The next study examined whether P300 ERP amplitude predicts antidepressant response to SKY. 15 dysthymics and 15 melancholics received SKY as the sole treatment and assessed at pre-treatment, 1and 3 months. 22 patients responded favourably to SKY. The pre-treatment P300 amplitude neither distinguished responders and non-responders nor was associated with different rates of response. Researchers concluded that SKY therapy is uniformly effective regardless of the pre-treatment P300 amplitude. In an another study the antidepressant effect in alcohol dependent individuals was studies using SKY. Following a week of detoxification, 60 alcohol dependent individuals were randomly assaigned to receive SKY, or control group for two weeks. Morning plasma cortosol, ACTH, and prolactin were measured before start of therapy and at the end of two weeks, along with clinical rating of the depressive symptoms. At the end of the study period, there was greater degree of reduction of the depressive symptoms in the SKY group. In both the groups plasma cortisol as well as ACTH fell after two weeks but significantly more in the SKY group. Authors conclude that the study results support the antidepressant effects of Sky reported in the earlier studies.In the most recent study, efficacy of yoga therapy as an add on treatment to the ongoing antipsychotic treatment was the focus.61 moderately ill schizophrenia patients were randomly assaigned to yoga therapy, and physical exercise therapy for 4 months. 41 patients completed the trial. Subjects in the yoga therapy group had significantly less psychopathology than those in the physical exercise therapy group. The yoga group had significantly greater social and occupational functioning and quality of life, leading to the conclusion that both non-pharmacological interventions contribute to reduction in symptoms with yoga therapy having better efficacy.
The increased interest in eastern therapies and the availability of measures to study the effects should result in more sophisticated studies of effectiveness of the different therapies in different mental disorders. There is also reexamination of the ancient Indian wisdom to modern mental health practice .
A very striking aspect of the current application of mental health concepts and practices of Hinduism is the large popular use of the techniques among the general population. These have ranged from books addressing the eastern approach to understanding mind-body relationships to popularising of yoga and meditation in various forms. The new age gurus have been marketing the methods to achieve nirvana specially addressed to the urban stressed populations. Unlike the gurus of the past, the current plethora of gurus are trendy, urbane and presenting the ancient practices in a modern way, sometimes referred to as “providing a user friendly designer manual for modern living” .
Human Rights of Persons with Mental illness
A very important development is the recognition of human rights of the mentally ill, by the NHRC. NHRC has carried out two systematic intensive and critical examination of the mental hospitals in India in 1998 and 2008. These reviews have show n the inadequacies of the existing mental hospitals , in terms of services, as well as in upholding of the human rights of the mentally ill(NIMHANS,2000).
An excerpt from the report (NHRC 2008):“Going by the usual rate of change in such Institutions, the changes that have occurred across the 36 mental hospitals is very impressive. Some of the improvements are the following: percentage admissions through courts has fallen from about 70% in 1996 to around 20% in 2008; the number of long stay patients have fallen from 80-90% to about 35%; the custodial care indicators like staff wearing compulsory uniforms ( down to 21 from 28) , cells use has fallen from 20 institutions; recreation facilities have increased from 8 to 29, and rehabilitation facilities from 10 to 23 institutions; budget had doubled in 9 institutions, 2-4 times in 13 , 4-8 times in 4 and more than 8 times in 3 institutions; the use of ECT had reduced and the modified type increased from 9 to 27 institutions. In addition, all the changes, in budget and court cases, were greater in those institutions monitored hospitals as compared to non-monitored institutions. The one area of continuing problem was in the inadequate staff- vacancies continued in spite creation of new positions. The other areas requiring improvement were ‘closed wards in many hospitals’ and ‘limited availability of psychosocial interventions’ . Overall, as the Report notes, the changes were more in the last 10 years as compared to earlier half a Century!(emphasis added)”
An another very important study relating to human rights of persons admitted to general hospitals and the rehabilitation centres in the country to examine is issue, ‘do law and public policy present barriers to community-based mental health services?’ by Cremin (2007). Cremin visited 44 mental health facilities and meticulously document the implementation of the mental health act and the protection of human rights of the admitted persons in these facilities. This study provides the current limitations of the law as well its practice in different settings.
Research
The last significant development is the major contribution of professionals in mental health
research. The ICMR, New Delhi, gave a big push to mental health research in the 1980s. This
research has not only brought to light the importance of understanding mental disorders like
schizophrenia in the cultural context, but also shown the feasibility of developing models involving schools, primary healthcare, general practitioners and working with families. This new knowledge has continuously supported the development of mental health programmes (ICMR,2005, ).
Barriers to Reach NMHP Goals
Though the NMHP came into being in 1982, the subsequent three Five Year Plans did not make adequate funding allocation. Further, even the funds allotted were not fully utilised. It was only in the Ninth Five Year Plan that a substantial amount of Rs 280 million was made available and it was increased in the Tenth Five Year Plan to about Rs 1,900 million and over Rs.10,000 million is expected in the Eleventh Five Year plan . The availability of funds in 1995 for the district mental health programme has shown that once funds are available, states are ready to take up intervention programmes and professionals are keen to take up a wide variety of initiatives for integrating mental health with primary healthcare.
Undergraduate training in psychiatry has not changed in spite of all the efforts in this direction, and this continues to be a major barrier to have adequately trained medical doctors in psychiatry after their basic training. The inadequacy of human resources in mental health is another barrier. Even now, most districts do not have public sector psychiatrists. Some of the medical colleges do not have full departments of psychiatry, especially the government medical colleges. The lacunae of not having enough training facilities for training in clinical psychology, psychiatric social work and psychiatric nursing is a major limitation for non-medical models and community-based programmes to take roots beyond the big cities. The Eleventh Five Year plan addresses this need in a big way by setting up Centres of Excellence.
Barriers to the Implementation of NMHP
. Poor funding in the initial period
. Limited undergraduate training in psychiatry
. Inadequate mental health human resources
. Limited number of models and their evaluation
. Uneven distribution of resources across states
. Non-implementation of the MHA 1987
. Privatisation of healthcare in the 1990s.
Major Changes in Mental Health Scenario in the last Three Decades
The most important changes that have occurred are the availability of increased range of
treatments. Luckily, most second-generation antipsychotics and antidepressants are freely available and extremely inexpensive in India because of the licensing procedures. This has
allowed professionals to use them extensively. India probably represents one of the few developing countries where there is such wide use of these drugs.
The other important development is the growing importance of families in mental healthcare in the country. Families of carers are coming together and forming self-help groups in big cities (Srinivasa Murthy, 2006). There have been two caregivers’ meetings in 2001 and 2003. This development testifies that professionals are looking at families as a major resource for mental healthcare( Shankar and Rao,2005). The community care as a primary approach to mental healthcare has become a reality all over the world. The World Health Report 2001 presented this as the model for mental healthcare for all countries. Large countries like Brazil have opted to shift from institutional care to community care. This is an advantage for a country like India where extremely limited institutional care exists.
The availability of a wide variety of both medical and non-medical care models is another
development in the last two decades. Specifically, the growing role of Non-Government
Organisations (NGOs) who provide suicide prevention, disaster care and school health
programmes, where non-specialists and volunteers play an important role, has tremendous
importance for India as it can bridge the gap of human resources(Kalyanasundaram and Verghese,2000, Patel and Thara, 2003).
Increasing judicial activism, the Persons with Disability Act 1995 and a growing number of
psychiatrists in the private sector, the recognition by the profession of stigma and discrimination due to mental illness and the response to the Erwady tragedy point to a greater awareness among the public.
In addition to all these, at the international level, the focus on mental health provided by the Surgeon General Report in 1999, the World Health Day 2001, the World Health Report 2001, World Health Assembly 2001 and 2002, and the mental health reforms in a large number of countries on a number of mental health areas have made mental health an integral part of public health programmes (WHO,1978,UN,1991, Ustun and Sartorius,1995, DHSS,1999, WHO,2001, WHO,2003,2006).
Criticism of the NMHP
Criticism of NMHP in India is that (i) it is top down; (ii) it is not based on the cultural aspects of the country (iii) it is not effective; (iv) it is driven by WHO policies;(v) the community voices have not been included; and (vi) the programme is a singular approach of DMHP;(Jacob,2001, Kapur,2004, Jain and Jadhav,2009). This criticism is not valid as can be seen from the review of the developments of the last four decades. Community psychiatry in India has been driven by the realities of the country(eg. involvement of families from 1950’s when the rest of the was viewing the family as ‘toxic’). The development of the models of care were based on one decade of field work to understand and meet the needs of the community by two academic centres and not in response to the WHO. These two centres based their interventions on the ‘community voices” and these have been well documented. The development of policies of WHO were as much as influenced by the Indian professionals as Indian movement being driven by WHO. It is salient to note that throughout the last twenty seven years Indian professionals have played important roles in the WHO as regular staff at the Geneva office and the Regional offices. As pointed out in the recent books ‘Mental Health by the People’ and ‘NGO innovations in India’( the community psychiatry in India is not a ‘single model’ programme but a wide variety of initiatives involving community resources) (Ranganatha,1996, Patel and Thara, 2003, Srinivasa Murthy,2006).
Looking to the Future
The importance of mental health as part of public health and current limitations are reflected in the lay press and professional writings. For example, the mental health was described as ‘depressing scene’(Frontline, April 10,2009), ‘The tribune. Chandigarh ran a series of articles under the titles, ‘mental disorders go unattended in country’(September 14,2009), ‘ mental health fights for irs space’(September 20,2009) and an editorial, ‘restoring mental health’(September 14,2009). Leading psychiatrists have called for , making psychiatry a household word’(Reddy,2007), ‘tasks before psychiatry today’(Singh,2007), ‘public mental health, an evolving imperative’(Desai,2005,2009) and ‘mental health care a universal challenge’(Srinivasa Murthy, 1998, 2008).
At the beginning of the twenty-first century when NMHP enters the third decade of
implementation, there is a new awareness in the public about mental health issues. A good
illustration is the response of the public, press, planners, professionals and judiciary to the Erwady tragedy in August 2001. Twenty years earlier, in mid 1980s, an equally dramatic event occurred in the Ranchi Mental Hospital, when patients escaped and the pitiable living conditions of the hospitals were splashed across a leading magazine, India Today. However, there was no public reaction to the event. On the contrary, the Erwady tragedy not only evoked a sense of horror, but also resulted in the examination of human rights of the mentally ill in all aspects. The Parliament, the state legislatures, the Supreme Court and the High Courts are pursuing the matter for active mental health reform. It is in this altered and enlightened setting that the future should be planned.
Firstly, the scope of mental health should include the treatment of mental disorders along with prevention of mental disorders and promotion of mental health. There is a need to think of a paradigm shift in presenting 'mental health' and 'mental disorders' to the general population. Till now, professionals have felt comfortable with the 'deviancy model' which has not allowed the community to see mental health as relevant to each and every individual. This has been unsatisfactory as it does not cover all of the mental health concerns of the community, as noted earlier. It is time for us to move to 'normalcy model' in which everyone recognizes both their vulnerability as well as their ability to address matters of mental health(Wig,1988). Such a shift from illness to behaviour and individual actions is occurring in the areas of nutrition, physical activity. Interestingly, something similar is occurring in sharing of information and skills by practitioners of self-help techniques like yoga, meditation, Art of Living, Vipasana etc. They are both popularizing these measures as well as getting accepted more than the psychiatric care. This approach would require a radical rethink of what is the scope of mental health, the roles of professionals and people, the sharing of skills and most importantly a greater partnership with stakeholders.
Secondly, DMHP has to be given the central place in the planning of mental health programme. DMHP by taking services to the population as closed to their residence has the greatest potential to provide care to the ill population.The current ‘extension clinic’ approach has to be replaced with true integration of the mental health care with primary health care personnel ( similar to that of TB, leprosy etc). There is an urgent need to develop specific indicators to monitor the DMHP. Similar is the urgent need to enhance the technical inputs to organize the programme-the training of PHC personnel, essential medicines, support and supervision of the health personnel by the private sector mental health professionals, the administrative supports needed to monitor and periodically evaluate the programme and the public mental health education. There should be a technical advisory committees at the national and state levels to guide the DMHP on a continuous manner.(See Chapter…….)
Thirdly, the importance given for developing human resources for mental health care, in the Eleventh Five Year Plan, in the form, of setting up of Centres of Excellence is an important initiative. This should be implemented and mechanisms to create employment opportunities to the additional professionals trained in these centres should be created to prevent brain drain of trained professionals(Issac,2008).
Fourthly, there has to a better public-private partnership. The private sector involvement can range from their support to train the personnel, monitor the work locally, take up specific care programmes like the maintenance care of chronic patients, sharing of information of their clinical work so that the state/country statistics reflect the total country and not only that of the public sector( Shaji et al, 2001). A serious dialogue and identification of funded activities should occur in the coming years.
Fifthly, support for NGO initiatives, especially in the areas of (i) setting up of self-help groups of patients/families;(ii) undertake public mental health education to reduce stigma; (iii)providing financial and technical support for setting up a spectrum of rehabilitation facilities such as day care, half-way and long stay homes, sheltered workshops, income generating activities by patients and families(Shaji,2001, Patel and Thara, 2003).
Sixthly, increasing public awareness about the commonness of mental disorders, understandability of mental disorders as illnesses, treatability , the important of acceptance by the family and the community and rehabilitation. India has a tradition of giving importance to mental health in the Hindu philosophy. Yoga, meditation, spiritual ways of understanding adverse life situations are part of the day to day life of Indians. There is need to disseminate new knowledge, strengthen helpful practices so that persons in need feel free to take help.
Sevently, mental disorders and mental health issues are both universal and local. The role of the social-cultural factors are more with regard to mental health issues than in the physical disorders area. It is for this reason that continuous research should be part of the mental health programme. An initiative similar to that of the 1980s should be initiated by the ICMR immediately. This will give rich dividends for the country.
Eighthly, there is an urgent need to create structures to support the mental health programme- this ranges from full time staff and office for the Central Mental health Authority, technical mental health advisory groups at the state and Central levels, transparency of the funding mechanisms and availability of all information to the public. It is by creating these structures, we will avoid the type of problems that we have with the DMHP, mental hospitals, undergraduate medical education, support to voluntary organisations etc.
In conclusion, development of mental health services all over the world, countries rich and poor alike, have been the product of the larger social situations, specifically the importance society gives to the rights of disadvantaged/marginalised groups. Economically rich countries have addressed the movement from the institutionalised care to community care building on the strengths of their social institutions. India has begun this process and made significant progress. There is need to continue the process by widening the scope of the mental health interventions, increasing the involvement of all available community resources and rooting the interventions in the historical, social and cultural roots of India. This will be a continuing challenge for professionals and people in the coming years. India has been in the forefront of addressing mental health problems of its people. The story of mental health care is an unfinished one. There has been much that has occurred during the last three decades. However, there is much more to be done to complete the story.
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ESSAY 3
District Mental Health Programme(DMHP)
Introduction
The District Mental Health Programme (DMHP) forms the central mental health intervention of the Government of India as part of the National Mental Health Programme(NMHP) during the last one decade. Starting with the DMHP of Bellary District in the 1990s, current 127 districts are covered by this programme. The central idea is the integration of mental health care with general health care, through decentralisation of services, deprofessionalisation of services and community involvement. The theme of the World Mental Health day 2009, celebrated on October 10, 2009 was “Mental Health in Primary Care: Enhancing treatment and promoting mental health”(WFMH,2008). The choice of the theme can be seen as significant at the international level, though India choose this path nearly thirty years back. India was one of the first countries in the world to choose to develop mental health services primarily based on integration of mental health with primary health care. This development of consider mental health as part of primary health care is a significant development, as till about the middle of 1970s the growth and development of mental hospitals was the main approach for the provision of mental health services. For India, this approach has special significance due to the extreme paucity of specialised treatment facilities and specialist professionals. As noted India is one of the first countries to initiate the process of integrating mental health with primary health care, as early as 1976. The National Mental Health programme (NMHP) formulated in 1982, has given high importance to this approach in the last three decades.
It is timely to review the historical roots to this approach, the reasons for choice of this method, initial experiences, the experiences of the last three decades, especially the last ten years and the recent evaluation of the district mental health programme. All of these can help in planning for the future. This forms the scope of this essay.
Historical aspects:
The Mudaliar Health Committee in 1962, can be credited with the initial ideas for integration of mental health with general health services. This Committee under the heading of ‘Mental Health’, reviewed the progress made subsequent to the Bhore Committee (1946), i.e., in the period of two decades, as follows:
“reliable statistics regarding the incidence of mental morbidity in India are not available. It is believed that enormous number of patients require psychiatric assistance and service…. As against the total need of the number of beds available in mental hospitals, in India it is only 15,000. There is hardly any provision for the education of mental defectives. Provision for the treatment of psychosomatic diseases in general hospitals.”
The recommendations made were under three heads, namely, general , training, research. In the curative field (i) in-patient departments at lay hospitals; (ii) independent psychiatric clinics or mental health clinics and (iii) institution for mental defectives. In the area of training the following were identified as important, namely (i) training and mental health personnel; (ii) orientation in mental hygiene of such professional groups as pediatricians, school teachers, nurses and administrators; (iii) orientation in mental health for all medical and health personnel;(emphasis added) (iv) for meeting the acute shortage of psychiatrists, upgrading of the Ranchi Mental Hospital into a full fledged training institutions additional to All India Institute of Mental Health, Bangalore and (v) arranging that ultimately each region, if not each state , become self sufficient in the matter of training its total requirements of mental health personnel.
The following observation:
“ the health personnel personnel engaged in such mass campaigns must be trained to tackle all health problems in any area while the overall supervision for particular disease may require special attention through specialists in rural area. It is neither possible not desirable to have separate agencies to deal with separate agencies”.
An important outcome of this Committee recommendations was the setting up of a number of district psychiatric units in the different parts of the country and the creation of a mental health advisory group at the Ministry of Health. However, the development of district psychiatric units recommended by a number of health committees notably the Mudaliar Committee (1962) has been very slow and uneven till the last 10 years.
Nearly a decade later, the Srivastava Committee (1974) reviewing the progress of health in the country, in its Report "Plan For Immediate Action" does not include any specific proposals for developing mental health programmes. However, one of the important outcome of this committee’s recommendation was the Community Health Volunteer (CHV) scheme. The CHV s were to be from the committee and provide services to about 1000 population. The training of CHV’s contained a component of mental health. Out of the total training of 200 hours , one hour was kept for mental health. One of the 12 chapters in the CHV manual was also devoted to the recognition and management of mental health emergencies and problems.
General Hospital Psychiatric Units
The organisation of mental health care beyond the mental hospitals began with the setting up of the general hospital psychiatric units(GHPU).The growth and development of general hospital psychiatric units (GHPU) in India is an important milestone in the development of Indian psychiatry . Wig refers to it as a slow and silent change but in many was a major revolution in the whole approach to psychiatric treatment in our life time (Wig, 1978). The introduction of these units as a method of mental health delivery system has very important implication for the development of mental health service in the country. They have given a big push to not only for the greater acceptance of psychiatric services by general public but also changed the mental health scene in terms of training of mental health professionals and research work. The existence of GHPU in the general hospitals, though resented initially as mental hospitals coming to general hospitals but very soon was accepted as valuable partners in the total health care system. The GHPU have a number of advantages over traditional mental hospitals. Some of them are (i) they are situated right in the community and they are accessible and easily approachable, (ii) families can easily visit and relatives can stay with the patients, (iii) there is no stigma of mental hospitalisation, (iv) there is no legal restrictions on admission and treatment, (v) proximity of other medical facilities ensure thorough physical investigations and early detection of associated physical problems. All these has brought new hope to patients.
International Focus on Mental Health
During the last one decade, mental health has received the highest recognition from international organisations. The most important is the initiatives by the World Health Organisation (WHO) The Director General Dr. Gro Harlem Brundtland organised a meeting of experts on April 28-29,1999, to set the WHO Agenda For Mental Health(WHO,1999). This consultative meeting identified mental health as a priority for WHO s work in the coming years. The group emphasised the need for greater attention to causes of mental disorders, their prevention, as well as identification and implementation of best practices for the treatment of priority mental disorders (WHO,1999).An important expression of this concern is the declaration of the theme for the World Health Day 2001 as Mental Health. In addition the World Health Report 2001 focussed on mental health.(WHO,2001)
An another important development is the publication of the Surgeon General Report on Mental Health from USA in December 1999(Surgeon General,1999).This Report is the first of its kind, in the 40 years of publication of reports by the Surgeon General to be focussing on mental health. This document identifies the following areas for action under the section Vision for the Future (i) continue to build the scientific base;(ii) overcome stigma;(iii) improve public awareness of effective treatment;(iv) ensure the supply of mental health services and providers;(v)ensure the delivery of state of the art treatments,(vi) tailor treatment to age, gender, race and culture;(vii) facilitate entry into treatment and (viii) reduce financial barriers to treatment. Two important messages of the Report are mental disorders are real health conditions; and seek help if you have a mental health problem or think you have symptoms of a mental disorder.
Another important development is the publication by the Institute of Medicine, USA, a monograph on mental and neurological disorders in developing countries. This monograph critically examined the evidence for the magnitude, burden, effectiveness of interventions and the research needs relating to developmental disorders, depression, schizophrenia, stroke and epilepsy. There was an international attempt to address the mental and neurological disorders in the developing and developed countries. The subject of mental health care in general health care is an international priority (Shepherd,1987, Goldberg, 1995,1996, Sartorius,1987, WHO,1996, Srinivasa Murthy,1997,1998, WFMH,2009)
Mental Health in Primary Health Care:
There are many reasons for this integration mental health with primary health care. Firstly, the recognition of the large numbers requiring mental health services, both in the community and in the general medical clinics, especially among those living in the rural areas.( section following section). Secondly, the limited number of psychiatrists and other mental health professionals to provide care. Thirdly, the emerging integration of all health programmes from the vertical programme model to multipurpose model. Fourthly, the international development of primary health care as the approach to organise health services. Fifthly, the recognition of the importance of early recognition and treatment to prevent chronicity. Lastly, the goal of continuity of care and integration of the mentally ill into the community could be achieved better by the integration of mental health with general health services.
Magnitude of Mental disorders in Primary Health Care:
Mental health problems at the general health care has been the focus of research and programme development for the last three decades. In the first field study at Vellore, which assessed psychiatric problems in a general medical clinic of a general hospital using psychiatric interviews, the prevalence was 27%(Srinivasa Murthy et al, 1976). In the WHO study, ‘Strategies for Extending Mental Health Care’ which included Raipur Rani, Haryana centre, a two stage screening used self reporting questionnaire and present state examination to identify psychiatric cases among those seeking health care in different rural facilities. Of the 361 patients screened , 64(17.7%) were diagnosed as having a mental disorder. The most common diagnoses were depressive neurosis, and anxiety neurosis. Few patients offered psychiatric symptoms as presenting complaints. Recognition of psychological problems by primary health care staff was limited.(Harding et al,1980) In an another study of urban private general practitioners , of 882 patients screened using the 12-item general health questionnaire, the prevalence of psychological problems was 35.9% but the general practitioners identified only 25% of the patients(Shamsunder et al,1986). Sheshadri et al(1988) studied a group of 573 patients attending the rural medical clinic art Sakalawara, Karnataka, and found 11.8% of those interviewed had somatic complaints with no definite organic cause. In an another study at the same centre, Sriram et al(1988) studied 1853 new cases and found 17.3% having ‘psychosocial problems’. It was noted that somatic symptoms far outnumbered psychological complaints. Compared with patients having no psychosocial problems, those with psychosocial problems had longer duration of illness, made more clinic visits, and travelled greater distance to see health care. 63% reported stress factors in relation to their illness. Similar reports have been made from other centres in India. In an another WHO international collaborative study, ‘Mental illness in general health care’(Ustun and Sartorius, 1995) of which Bangalore was one of the centres, 1366 patients were screened in three rural health facilities and of these 23.9% were diagnosed as suffering from well-defined psychological disorders as in other studies, prevalence was higher among females. The concordance between the researcher and the physicians assessment was 40%. Drug treatment was prescribed in one or other form in little more than half of the cases. Other forms of treatment were practically absent. (Sen, 1987, Sharma, 1986, Sen, 1987, Amin et al, 1998, Patel et al, 1998, Chaddha et al,2009).
Integration of Mental health with Primary Health care:
The integration of mental health with primary health care occurred at two levels, namely the training of the primary health care personnel working in the rural health services and training of the general practitioners in urban areas. The organisation of essential mental health services as an integral part of primary health care has been a major development in the country. The efforts were started by two centres in the country, namely, Bangalore and Chandigarh.
Rural Mental health Programmes
Bangalore experiences
The programme of community psychiatry was launched in 1976 at the NIMHANS, Bangalore. The aim of the rural project was to develop suitable training programmes for the doctors and the multipurpose workers from the various primary health centres in the state of Karnataka, so that after their training PHC personnel could provide basic mental health care ( detection and management of epilepsy and psychosis).The team initially studied the needs of the rural population in one primary health centre (1975-1980) (Chandrasekar et al, 1981, Parthasarathy et al, 1981). This was carried out by identifying the mentally ill persons in their homes through key informants and those attending the general health facilities (Kapur and Issac, 1978, Issac and Kapur, 1980).
These efforts of understanding the needs and methods of care in the community were followed by pilot experiment to integrate mental health with primary heath care in one PHC with a population of 100 000 (1980-86) (Issac et al, 1981, Issac et al, 1982).
Chandigarh Experiences
The Chandigarh efforts were initiated in 1975. This efforts was the outcome of the observation of the limited utilisation of psychiatric services from the hospital (Khanna et al, 1974, Srinivasa Murthy et al, 1974, Srinivasa Murthy et al, 1977, Wig et al, 1979).The aim was to develop a model for rural psychiatric services. This effort was further supported by the WHO efforts in this area. WHO Project ‘Strategies For Extending Mental Health Care’ (1976-1981) was a multicentered project carried out in 7 geographically defined areas in Brazil, Colombia, Egypt, India, Philippines, Senegal and Sudan and designed to develop and evaluate alternative and low cost methods of mental health care (including training methods) in developing countries (Sartorius and Harding, 1983). The basic approach adopted in this model is to integrate mental health with general health services and provide basic mental health care as part of primary health care.
|Sub Centre |Clinic day |Psychosis |Epilepsy |Depression |Others |Total |
|Ramgarh |Monday |11 |19 |7 |5 |41 |
|Kot |Wednesday |2 |33 |11 |2 |38 |
|Rattewala |Wednesday |6 |9 |4 |- |19 |
|Barwala |Monday |5 |12 |7 |2 |26 |
|Mouli |Monday |12 |14 |7 |3 |35 |
|Piarewala |Friday |12 |14 |7 |1 |34 |
|Khatoli |Saturday |1 |1 |1 |1 |4 |
|Raipur Rani(PHC) |Friday-about 50 | | | | | |
| |patients per clinic| | | | | |
At the Chandigarh Centre this project provided opportunities to understand the needs of the rural mentally ill and methods of proving care to them utilising the existing primary health workers and physicians (Srinivasa Murthy et al, 1978, Wig and Srinivasa Murthy, 1978, Wig et al, 1980, Wig and Srinivasa Murthy, 1980, Wig et al, 1981a, Wig et al 1981b, Srinivasa Murthy and Wig, 1983, Ignacio et al, 1983, 1989).
ICMR-DST Project(ICMR-DST,1987)
Following these initial experiences at Bangalore and Chandigarh, the Indian Council of Medical Research(ICMR) and Department of Science and Technology(DST) support a nationwide, multicentric field trial to implement the integration of mental health with general health care under the title ‘Collaborative Study on Severe Mental Morbidity’. Four centres, one each from South, North, East and West(Bangalore, Patiala, Baroda and Calcutta) were selected. Each of the centres covered a population of 40,000 to 60,000. The project had an evaluative design which included baseline observations-intervention-repeat population survey. The main essence of the study was the intervention by trained PHC personnel to integrate mental health with their routine work. It was an effort at task oriented operational research. Following about one year period of intervention, about 20% of the actual cases in the community were identified and treated by the PHC team.(TABLE......)
| |Bangalore |Baroda |Calcutta |Patiala |Total |
|Cases in Final survey |395 |181 |285 |517 |1378 |
|Identified and treated|72 |36 |58 |66 |232 |
|by PHC team | | | | | |
|% cases managed by PHC|18.2 |10.0 |20.4 |12.8 |16.8 |
|team | | | | | |
There were noticeable changes in the social functioning of those cases who were treated by the PHC team. There were also changes in the attitude of the community towards mental disorders in the positive direction. This study also provided a number of practical insights regarding integration, like the period of training, the type of records to be maintained by the PHC team, need for regular support and supervision and the importance of administrative support.
Gautam (1985) from Jaipur, Rajasthan, took up two PHCs and completed a comparison of two different training programmes and its effectiveness. The main observation of this study was that the training is not the only important aspect but the importance of the follow up support to the trained staff. Those who were supported and supervised did better in service than the control group.
|Diagnosis |PHC Jahota |PHC Bichun |
|Epilepsy |24 |24 |
|Mental Retardation |42 |23 |
|Psychosis |26 |14 |
|Depression |32 |30 |
|Other neurosis |12 |39 |
|TOTAL |136 |130 |
ICMR Project ‘Mental Health in PHC- Solur project(1985-1987)
The earlier experiences of Bangalore, Chandigarh and Jaipur had provided information about the quantum of the care that could be provided by the PHC team. There was a need to increase the size of the population covered (from 40,000 to 100,000) and to record systematically the quality of the care( accuracy of diagnosis, adequacy of treatment, follow up etc). It is for this reason the Solur project was organised by the ICMR Advanced Centre for research on Community Mental health(Community Mental health News, 1986). The design was analytical rather than the experimental design of earlier project and the intervention was for 18 months. The quantum of patients identified was larger and there was evidence that the diagnostic and treatment accuracy and adequacy was about 80%. It was noted that participating in the monthly meetings and review of the programme was important to maintain the motivation of the team. For the medical officers, at least once a month contact was considered useful to maintain their skills and motivation.
|Period |Total |Epilepsy |Psychosis |Other |
|First Quarter |213 |153 |20 |40 |
|Second Quarter |128 |80 |34 |14 |
|Third Quarter |45 |28 |6 |11 |
|Fourth Quarter |32 |29 |3 |- |
|Fifth Quarter |24 |17 |6 |1 |
|Sixth Quarter |50 |31 |5 |14 |
|TOTAL |492 |338 |74 |80 |
General Practitioners (GP) Training:
Professionals have made systematic attempts to develop approaches to provide mental health training to the general practitioners. This method is specially suited to the needs of the urban populations.(Shamsunder et al, 1978, Shamsunder et al, 1980, Gautam et al, 1980, Shamsunder et al, 1983, Devi, 1993, Bhattacharya et al, 1993). General practitioners form a major part of the total number of more than 300,000 doctors in the country. They are providing care in the private sector and form an important resource for mental health care in India. They work both in rural and urban areas and their services are utilised both by the rich and the poor. In India, involvement of GPs have been carried out both in an organised manner and by informal contacts. The latter takes place in the form of (a) courses by psychiatrists organised by such professional agencies like the Indian Medical Association, (b) informal discussions that naturally take place between the referring general practitioner and the psychiatrist either in service or in private consultation. When there is a healthy mutual professional liaison it further strengthens the efficacy or formal, organised training programmes. The more formal continued effort in training GPs in psychiatry has been going on at NIMHANS, Bangalore from 1975 (Shamsunder et al, 1978, Shamsunder et al, 1980, Gautam et al, 1983, Shamsunder et al, 1983, Shamsunder, 1986) with accumulated experiences of about 10 courses of varying types. They varied in the form, frequency and duration. In addition, an ICMR collaborative research effort was undertaken in 1982-84 involving 3 centres (namely Bangalore, Hyderabad, and Vellore) successfully testing the method and material developed at NIMHANS, Bangalore. (ICMR,2002).
The findings of these experiences are (i) GPs are generally poor corresponders, responding poorly to postal and/or newspaper communication with a response rate of about 20%. However, they respond more positively on personal contact. This was specially effective when liaison service was available; (ii) a GP tends to jealously protect his unique professional freedom and dreads to function as an extension or extra pair of hands of specialists; (iii) the GP expects their patients to be referred back to their care when they refer patients, (iv) specialists plan of management is often not practicable in the primary care setting of general practice, (v) neurosis, depression, alcohol related problems, sexual problems, psychosomatic and somatopsychic problems are overwhelmingly represented in clients of general practice, and (vi) the GPs seek to acquire practical skills rather than acquire theoretical knowledge .
This area was recognised as important for the mental health planning of the country, as it offers a major avenue to enhance the mental health manpower in the country with comparatively minimal inputs. Working in this field is easier compared to similar work in public sector because the GPs are eager to acquire skills by which to achieve both professional and consumer satisfaction. Therefore, it is much easier for the health professionals to establish a working and teaching relationship with the GPs to the ultimate benefit of the community.
The results of the different experiences of the first phase of integrating mental health with general health care, completed in 1981, demonstrated the feasibility to integrate mental health with general health services by choosing priorities and developing proper training programs for the health personnel. However, this requires (i) the commitment of health authorities to include mental health as part of PH care; (ii) provision of adequate drugs, (iii) the availability of support and supervision from the PHC doctors and (iv) further crystallization of knowledge regarding the treatment schedules to be used in the community without daily and continuous supervision of specialized staff.
Training Resources
Manuals of mental health were prepared at the different centres namely, Bangalore (Wig and Srinivasa Murthy, 1980, Wig and Parhee, 1984, Sharma, 1986, Srinivasa Murthy et al, 1987, Issac et al, 1988, Srinivasa Murthy et al, 1988, Sell et al, 1989, Sriram et al, 1990, Issac et al, 1994). Systamatic efforts were made to evaluate the effect of the training programmes utilising different methods (Sriram et al, 1989, Sriram et al, 1990a, Sriram et al, 1990b, Sriram et al, 1990 c) Bangalore centre has also prepared training video for use in the above training programmes along with a variety of evaluation tools.
More recent studies have examined the cost effectiveness of the approach(Chisholm et al, 2000, James et al, 2002).In this study it was noted that the use of the integrated mental health care modest. Principal supply side factors were the cost of care, distance from the treatment centre, a perception that care would not be effective, and concerns regarding stigma. Perceptions improved over three months, accompanied by an increased preference to public over private providers, but this was not restricted to the integrated care localities.
Thara et al(2008) in a five year follow up study of a ten year community mental health programme conclude “community based initiatives in the management of mental disorders however well intentioned will not be sustainable unless the family and the community are involved in the intervention program with support being provided regularly by mental health professionals”.
DMHP-Bellay Model(Community Mental health News, 1988):
The pilot projects reviewed, till 1984, above had utilised population units of 40,000 to 100,000. These population units formed only 5-10% of the larger administrative unit in the country, namely , the district. In 1984, it was realised that for a viable model of integration of mental health with PHC, it is necessary to scale of the model to a district level. Bellary district located 320 kms from Bangalore was chosen. Of the many initiatives, the integration of mental health with primary health care at the level of the district is the most important. This initiative has the community based and community intensive approach. (Issac et al, 1986, Naik et al, 1994, Naik et al, 1996, Srinivasa Murthy, 1992).
The essentials of the District Mental Health Programme were:
1. A decentralised training programme for the existing health personnel on essentials of mental health care at the district level;
2. Provision of mental health care in all general health facilities;
3. Involvement of all categories of health and welfare personnel in mental health care;
4. Provision of essential psychiatric drugs at all health facilities;
5. A simple record keeping;
6. Mechanism to monitor the work of primary health care personnel in the provision of mental health care,
7. A mental health team at the district level, for training of personnel,
8. Referral support
9. Supervision of the mental health programme and
10. Administrative support of local government and Health Department.
There were a number of innovations in this historic first attempt at developing a district mental health programme in the country. Firstly, the programme was a tripartite activity- with the Department of health of Karnataka providing the infrastructure, training support, the Zilla Parishad of the district supporting medicines and public support and National institute of Mental Health and Neurosciences(NIMHANS) , Bangalore providing the technical support for training and monitoring of the programme. For example, an annual meeting to review the programme, on each of the five years was undertaken involving all of the partners and mid course corrections that were required taken in these review meetings.
Another important feature was the development of a data base to understand the mental health care. For example the following information was compiled year by year to understand the mental health care, namely,
psychiatric patients been taluk by taluk , year by year;
Diagnostic distribution of the patients;
Mode of referral of cases;
Distance travelled by the patients to seek help;
Duration of illness at contact for care;
Regularity and outcome of treatment;
Comparison between various types of institutions and the care outcomes like regularity to treatment, drugs used, outcome within a short period of contact.
In addition there was a massive public awareness campaign using a wide variety of measures like posters, pamphlets, cinema slides, involvement of different categories of government functionaries like social workers, mass media, orientation meetings with the community leaders. The following Tables illustrates the findings of the 5 year work. The data presented in these tables are important as an illustration of the type of clinical data that should form part of the reporting system for DMHP and that such an effort was made in the early phase of the development of DMHP but neglected in the last 10 years of DMHP programme.
Table: Mode of referral
|Source of Referral |Psychoses(1202) |Neurosis(743) |Mental Retardation(383) % |Epilepsy(3524) |
| |% |% | |% |
|Health worker |12 |8 |25 |13 |
|Doctor |22 |30 |13 |9 |
|Self |23 |26 |22 |34 |
|Other patients |10 |10 |9 |7 |
|Clinic |5 |6 |3 |5 |
|Community leaders |12 |13 |28 |4 |
|No information |16 |7 |10 |28 |
Table: Distance travelled to seek treatment
|Distance from the clinic |Psychosis(1202) |Neurosis(743) |Epilepsy(3524) |
| |% |% |% |
|Within 5 kms |58 |61 |71 |
|6-10kms |11 |6 |14 |
|11-30kms |9 |8 |10 |
|More than 30kms |23 |25 |5 |
It is striking to note that majority of the people came from nearby areas to the clinic.
Table: Duration of illness at first contact
|Duration of illness |Psychosis % |Neurosis % |Epilepsy % |
|Within 1 month |21 |15 |2 |
|1-6 months |24 |24 |22 |
|7months to 1 year |6 |8 |10 |
|1-3 years |18 |30 |23 |
|More than 3 years |22 |14 |26 |
|No information |9 |9 |17 |
The differing duration of illness at first contact and the significantly number of ill persons with duration of illness of more than one year is significant in planning of services. The decreasing duration of illness can also be utilised as indicator of changes in the service utilisation.
Table: Regularity to treatment
|Regularity and outcome |Psychoses % |Epilepsy % |
|Symptom free or reduced symptoms |42 |54 |
|Irregular |47 |45 |
|Completed treatment |10 |1 |
In addition data was analysed to compare the treatment outcome in the different levels of health care, which showed that that it was possible to provide mental health care at all levels of health facilities.
Progress of DMHP at the National level:
During the late 1990s, the District Mental Health Programme (DMHP) was launched at the national level. This was the outcome of the meeting of the Central Council of Health in 1995, and the recommendation of the Workshop of all the health administrators held in February 1996 at Bangalore. The DMHP was launched in 1996-1997 in four districts, one each in Andhra Pradesh, Assam, Rajasthan, and Tamil Nadu, with a grant assistance of 22.5 lakhs each. A budgetary allocation of Rs.28.00 crores has been made during the Ninth Five Year Plan period for the National Mental Health Programme.
The programme envisaged: " a community based approach to the problem, which includes (I) training of the mental health team at the identified nodal institutes within the State;(ii) increase awareness in the care necessity about mental health problems; (iii) provide services for early detection and treatment of mental illness in the community itself with both OPD and indoor treatment and follow-up of discharged cases and (iv) provide valuable data and experience at the level of community in the state and Centre for future planning, improvement in service and research. The training of trainers at the State level is being provided regularly by the National Institute Of Mental Health and Neurosciences, Bangalore under the NMHP"(GOI,2000).
The DMHP was extended to 7 districts in 1997-1998, five districts in 1998 and six districts in 1999-2000.Currently the programme is under implementation in 22 districts in 20 states as follows. Andhra Pradesh (Medak; Assam (Nagaon and Goalpara) ; Rajasthan (Seekar); Tamil Nadu (Trichy); Arunachal Pradesh (Naharlagun); Haryana (Kurukshetra); Himachal Pradesh (Bilaspur); Punjab(Muktsar); Madhya Pradesh (Durg); Maharastra (Raigad); Uttar PPradesh (Kanpur); Kerala (Thiruvanthapuram, Thrissur); West Bengal (Bankura); Gujarat (Navsari); Goa (South Goa); Daman and Diu; Mizoram (Aizwal); Chandigarh ; Manipur (Imphal East); Delhi (Chhatarpur). The recently initiated programmes all over the country can be expected to provide information about the practicability of this approach in different states with varying levels of primary health care infrastructure.
During the Tenth Five Year Plan, the DMHP was extended to 127 districts in the country.
DMHP Experiences:
There are limited reports of the functioning of the DMHP from the published reports.
Hyderabad: Krishna Murthy et al(2003) report on the role of medical officers based on the training experiences. There was gain in knowledge following the training. Increase in knowledge was greater with case demonstrations. Two weeks training does not give confidence to care for mentally ill persons independently. However, ‘the gain in knowledge does not translate into better service delivery’ when the medical officers are requested to function independently and conduct weekly mental health clinics at PHC level. There is need for greater liaison with the district health team. Authors conclude ‘ DMHP in its present form caters only for patients with severe mental disorders and is not of much benefit to the large segment of population with minor mental health problems like anxiety, depression etc.....it can be stated that there is need to effect changes in the training and modalities of involving medical officers in implementation of DMHP , if better mental health care has to be delivered in the rural areas’.
Ranchi: Soren et al(2007) present the socio-demographic characteristics of patients attending DMHP at Dumka for the period of Feb 2006 to 31 Jan 2007.1036 patients had sought treatment. Of this group, 80% had no prior treatment and only 7% were on regular treatment. More than 30% had an illness of more than 2 years, and percentage of patients with 6 months or longer were 65%.No treatment outcome data is reported.
Kanpur: Jain and Jadhav (2009) has reported on the largely bio-medical orientation of the treating team and how pills have come to represent the DMHP centre at Kanpur. Based on clinical ethnography of a community psychiatry program in Kanpur, North India, authors report on the biosocial journey of psychotropic pills from the centre to the periphery. As the pill journeys from the Ministry of Health to the clinic, its symbolic meaning transforms from an emphasis on accessibility and participation to the administration of a discrete ;treatment.' Instead of embodying participation and access, the pill achieves the opposite: silencing community voices, re-enforcing existing barriers to care, and relying on pharmacological solutions for psychosocial problems. They conclude that the symbolic inscription of NMHP policies on the pill fail because they are undercut by more powerful meanings generated from local cultural contexts. An understanding of this process is critical for the development of training and policy that can more effectively address local mental health concerns in rural India.
Delhi: AnanthKumar (2005) carried out in-depth qualitative insights, the study was undertaken using observation technique at the Psychiatric OPD at Babu Jagjivan Ram Memorial Hospital (BJRMH)] and in-depth case studies were conducted with nine patients visiting the DMHP clinic at Jahangirpuri in Delhi during September -December 2000. In observation the emphasis was on service delivery, doctor-patient relationship, infrastructure availability, and problems in service delivery in the background of DMHP guidelines and objectives of DMHP and NMHP. Informal interviews were also done with 25 patients and 25 family members (care-givers) about the services available at Psychiatric Unit (DMHP, Jahangirpuri) and their understanding and perception of mental health and illness. Apart from these, secondary data was collected from various sources and in some cases informal unstructured interviews were also carried out. Presently the service is available once a week on Wednesdays, between 10 a.m. and 2 p.m whereas the programme specifies daily OPD service. Consequently, there is a lot of overcrowding on Wednesdays. This affects the quality of treatment, as the doctor is not able to allocate adequate time to each and every patient. Even the doctor corroborated the facts and felt constrained and suggested the extension of the OPD service on a daily basis. Due to the non-availability of daily OPD services, the programme is not accessible to majority of the working population. As has been mentioned earlier, most of the inhabitants of the area are engaged in petty activities like vending, rickshaw pulling, masonary, daily wage labour, or government servants. It is difficult for most of them to miss out their daily labour. People expressed the need to make the service available either in the evening or on Sundays. The present emphasis of service is only curative, whereas the patients also need guidance and counselling to adjust with families and other rehabilitative measures. This is presently not possible due to crowding and it is practically impossible for the doctor to give enough time to each patient. Author concludes the following:
Some of the salient observations based on the case studies, and in-depth interviews are as follows: ‘ there is no provision for guidance and counselling. It is found that at times
patients and family members need guidance and counselling to cope with illness; the service available is run by a psychiatrist and a social worker. There is no comprehensive approach and teamwork with the inclusion of professionals like clinical psychologist and physician; due to crowding, the doctor is not able to give adequate time to each patient; there is no coordination between the facilities and various agencies, especially the NGOs working in the area; there is no integration of mental health care with primary health care; no attempt is made to include the community leaders, workers at the grass root level such as ANM's, anganwadi workers, and the local NGOs in training programmes organised by the nodal institute; there is no provision for early detection and treatment of patients within the community. Presently services are available to those visiting psychiatric OPD themselves; there is no awareness programme to reduce the stigma attached to mental illness through change of attitude and public education; there is no provision to treat and rehabilitate mentally ill patients discharged from the mental hospitals within the community; there is no effort to undertake community surveys on mental illnesses and other associated factors, although it is feasible and at times some medicines are not available and patients have to buy them from market and there is no provision for reimbursement’.
Chandigarh: Warraich et al(2003) report their experience of DMHP for six months. A total of 527 patients were seen in the first six months. 52% of the males presented with substance use disorders while a majority of the females (40%) presented with mood disorders. In patients with illness of duration more than one year, upto 51.9% had no past psychiatric treatment and 27.6% were on irregular treatment. Authors conclude,’ it was seen that decentralisation was a felt need of the community and required not only in rural but urban areas as well’.
Thiruvanthapuram: The DMHP has been functioning since 1999(WHO,2008).Starting from 2002, ‘primary care centres began to assume responsibility for operating their mental health clinics with minimal support from the mental health team’. Majority of the patients are seen for depression, bipolar disorder, schizophrenia or epilepsy. Around 1200 patients are registered annually and a total of over 11700 have come into care over 9 years(WHO, 2008). However, there is no analysis of the patients in terms of their treatment status at first contact, duration of illness, regularity to treatment, outcome of treatment contact and effectiveness of the different interventions and the referral support needed by the PHC team. The team observed, ‘the district mental health team’s training, referral and support services were crucial to the success of the programme...lack of ongoing primary care worker training impeded progress and forced some clinical responsibilities back onto the mental health team’
Idukki district : The clinics at the taluk hospitals are organised by the visiting mental health team on a periodic basis. The involvement in the direct care of the mentally ill persons by the primary health care team in minimal or absent.
Karnataka Experiences:
During the last 5 years, four districts have been covered by DMHP at Chamarajnagar, Shimoga, Gulbarga and Karwar. The DMHP’s are different stages of development in terms of availability of the psychiatrist/programme officer/the team members etc. A review carried out during 2008 showed the following salient features. The training of the doctors and health workers have been carried out by the professionals from Bangalore. The local level staff have not been adequately used to train the PHC personnel. The adequacy of the mental health care and the effectiveness of the mental health care by the PHC team is extremely limited. The minimal care that is occurring in the DMHP seems to be a reflection of the incomplete training, lack of a full time programme officer, etc. There has been almost no limited technical guidance and monitoring of the district mental health programme(as reflected in the extremely inadequate record maintenance, few patients registered, lack of follow up of drop outs, etc).For example, in Thirthahalli with a population of 150,000 about 300 patients with schizophrenia have been identified and treated while the number of persons with schizophrenia in the whole district with over a million population is only 400( including the 300 of Thirthahalli). The availability of essential psychiatric medicines is the only positive aspect of the DMHP. The public mental health education activities are minimal or absent. The inadequacy of record keeping was most striking. The district hospital is providing only OPD care, with limited admissions, as no specific ward is available for psychiatric admissions. There is urgent need for the revision of the PHC level records, along with its computerization for easy analysis and feedback to the user community. Appointment of a full time programme officer is a priority in some of the districts. There is greater need for development of the responsibilities of the psychologist/social worker. There is greater need for support, supervision on a monthly basis/nurse in the DMHP team. Specific measures to fully utilize the private psychiatrists has to be developed and implemented.
Tamil Nadu Experiences:
1 There are 16 district covered under this programme in Tamil Nadu. Directorate of Medical and Rural Health Services (DMS), Directorate of Medical Education (DME) and Directorate of Public Health (DPH) are involved in the implementation of DMHP. District Psychiatrist, district mental health team psychiatrist, organizes satellite mental health clinics at all the Taluk Hospitals. Supply of medicines etc., come under DMS. Institute of Mental Health and Dept. of Psychiatry attached to Medical College, are in-charge of training programs and IEC activities, under the control of DME. The PHC medical officers and paramedical personnel who are trained under the programme and PHCs, which will ultimately become the mental health providing centres, are under the supervision of DPH. Hence the success of the DMHP at the state level depends on the coordination between the three directorates.
During the 13 years, over 5000 personnel have been trained in mental health care. The 10 bedded Psychiatric wards opened at all the Head Quarters Hospital. Currently all the posts of Psychiatrist in 16 DMHP implementing Districts have been filled up.(except Kancheepuram District). All the posts of psychologist and psychiatric social worker in 16 DMHP implementing Districts are in position. Recently, a 3 months intensive training for Psychologist, Psychiatric social workers at NIMHANS, Bangalore (Feb 2009 to April 2009) was completed. Mobile Psychiatric Team in all the districts are functioning. They visit one taluk centre each day and conduct psychiatric out patient. Each team cover six taluk centres in a week. Medical officers are encouraged to tackle minor psychiatric problem in primary health centres. Basic psychiatric drugs worth Rs. 3000/- made available to each PHC. Difficult cases are referred to the mobile team and unmanageable cases are referred to the district headquarter hospital. District Level Mental Health Society has been formed under the chairmanship of District Collector of 16 Districts.
TOTAL NO. OF PATIENTS TREATED (old & new)
|District |Year | Old | New |Total |
|Trichy |1998-09 | 277219 |7229 |284448 |
|Ramnad |2001-09 | 100461 |5137 |105598 |
|Madurai |2002-09 | 100334 |4129 |104463 |
|Theni |2005-09 | 48013 |3078 |52828 |
|Erode |2006-09 | 60000 |4345 |64345 |
|Nagapattinam |2006-09 | 21807 |2140 |23947 |
|Kanniyakumari |2007-09 | 456 |242 |698 |
|Dharmapuri |2008-09 | 2886 |1192 |4078 |
|Namakkal |2008-09 | 1347 |356 |1703 |
|Perambalur |2008-09 | 1241 |235 |1476 |
|Cuddalore |2008-09 | 12016 |476 |12492 |
|Virudhunagar |2008-09 | 809 |140 |949 |
|Total | 626589 | 28699 | 655288 |
BREAK UP DETAILS OF CLASSIFICATION OF CASES REGISTERED AND TREATED.
|Sl. |Name of the Diseases |Madurai |Ramnad |Theni |Virudhunagar |Dharmapuri |
|No | |2002-09 |2002-09 |2006-09 |2008-09 |2007-09 |
|1 |Schizophrenia |23699 |22315 |9184 |194 |460 |
|2 |Psychosis |13203 |5190 |2388 |69 |697 |
|3 |Mood Disorder |19060 |12150 |6240 |195 |213 |
|4 |Conversion Disorder |1394 |565 |440 |23 |- |
|5 |Obsessive disorder |1813 |263 |220 |- |67 |
|6 |Anxiety |10724 |7889 |4392 |120 |516 |
|7 |Alcoholism |2429 |1976 |1848 |73 |143 |
|8 |Drug Dependence |1706 |- |1369 |- |- |
|9 |Dementia |2479 |636 |1320 |- |35 |
|10 |Epilepsy |19433 |18223 |20116 |77 |1007 |
|11 |Mental Retardation |7301 |16335 |3588 |116 |172 |
|12 |Childhood MI |23 |279 |- |21 | |
|13 |Others |2323 |7464 |1728 |61 |29 |
|Total |1,01402 |93,285 |52833 |949 |3339 |
However, in spite of over 0.6 million patient contacts, information about the patient characteristics, clinical details beyond diagnosis and most importantly, the treatment utilisation record and outcome of treatment are currently not available.
DMHP EVALUATION:
The main objective of the evaluation carried out during 2008-2009,by the Indian Council of Marketing Research(ICMR), New Delhi, covering 20 of the 127 districts, was to assess the functioning of DMHP objectively and critically and to suggest future expansion of the scheme along with improvement in implementation if any, based upon the evaluation.
ICMR, a division of Planman Consulting (India) Pvt. Ltd. visited 20 DMHP districts and 5 Non-DMHP districts (as control) for the above purpose. The DMHP beneficiary Districts were chosen proportionately from 9th and the 10th plan period. The following are the main findings of the evaluation:
“One third of the districts under the 9th plan have utilized over 99%, one third has utilized 63-91%, and rests have utilized 37-47% of the total amount they have received. This is mainly due to administrative delay, difficulty in recruiting and retaining qualified mental health professional, low utilization in training and IEC components. In Case of the 10th plan districts, most of the districts had received only the 1st instalment under DMHP. Of the grant received one third have utilized more than 90%, half of the districts spent 51-87% and rests of the districts the programme has recently started. This again is due to above mentioned reasons. Most of the districts had not utilized the full amount for training due to delay in implementation. Only 10% of the districts, utilized funds allocated for IEC activities. 20% of the districts did not utilize funds under IEC and rest 70% district had partially utilized. Overall, 55% of the health personnel confirmed that they had received training. Regarding the satisfaction with the training program, more than half of the health personnel (54.7%) trained were satisfied with the training program. However, rest of the personnel suggested training in the simple language and making the content simple by using case studies, increase training frequency and refresher training. The expenditure on above two components i.e. training and IEC components which requires a lot of ground work, coordination and networking in the community is below par in most of the districts(emphasis added). This is mainly due to lack of organizational skills in the DMHP team, low community participation in the programme and lack of coordination with the district health system which comes under a different department. About 85% of the health personnel stated that spreading awareness is the main purpose of DMHP, followed by integrating mental health and general health services is the second most important purpose (69.9%). However, designation wise analysis showed that Psychiatrists and Clinical Psychologists stated the main purpose of DMHP is capacity building of the health system for mental health service delivery. Regarding availability of drugs, only 25% of the districts reported that there has been a regular inflow of drugs. Rest of the districts faced difficulties in maintaining regular availability. This is because of lack of dedicated drug procuring mechanism for DMHP and financial authority to the nodal centre. Though 80% beneficiaries across all the districts also indicated having received at least some medicines from the health centre. About 61% of the beneficiaries accessed the district hospital as their first point of contact. The percentage of patients accessing CHCs (12.7%) and PHCs (11.5%) were found to be low. Again 18% of the total respondents confirmed that they were referred to district level for treatment. Regarding diagnosis 90% of the patients were of the opinion that diagnosis was explained to them. Rest 10% of the patients or their family members reported that the diagnosis was not at all explained to them. About 61% of the beneficiaries confirmed that the possible side effects of the medicines were explained to them. Overall, 75.7% of the patients also reported that they were treated with respect and dignity. With respect to trust and confidence, overall 72.8% reported that they had full trust and confidence with the medical personnel who treated and another 25.3% stated that they had trust and confidence to some extent. One fourth of the beneficiaries contacted also indicated having received counseling services under DMHP. Comparative analysis of satisfaction with quality of service provided under DMHP revealed that on 1 to 10 scale, District Madurai in Tamil Nadu attained the highest score at 9.6. The other districts which are rated higher than the average of 7.3 are Raigarh in Maharashtra, Tinsukia in Assam, Navsari in Gujarat, Delhi, Nagaon in Assam and Buldana in Maharashtra. In DMHP districts, 86.9% of the community members contacted knew about mental illness which is higher than non-DMHP districts (74.7%). Nearly half of the respondents (48%) had reported sadness and depression as the symptoms of mental illness, followed by fear and nervousness (42%), lack of sleep (41.6%) and over excitement and mood swings (41.4%) in DMHP districts. On the contrary in Non-DMHP districts, gross behavioral symptoms like hallucinations (36%), fits (45%) and fear and nervousness (44%) which are easy to recognise were found to be higher. Awareness about the types of mental illness namely psychosis, neurosis, epilepsy etc. were found to be significantly higher in DMHP districts as compared to non-DMHP districts. More than half of the respondents from the DMHP districts agreed that proper medications and counselling can help in the treatment of mentally ill people against only 30% in Non DMHP districts. 70% of the respondents in DMHP districts also recommended cure at a hospital. The difference in approach of respondents of DMHP and non DMHP districts is clearly evident as far as conservative methods and beliefs are concerned. For example consulting occult practitioners was suggested by only 47.3% of respondents from DMHP districts as against over 70% of non-DMHP respondents. The lower responses from the DMHP districts, in comparison to the non-DMHP districts, on mental illness is due to evil spirit, black magic, mentally ill people are harmful and should be avoided and mentally ill people can not be taken care at home clearly indicates that DMHP has been able to spread awareness in the districts where it was being implemented”
The evaluation report recommended:
“to strengthen the services at subcenter, PHC, CHC level so that the services become more accessible to the patients. Central Government in consultation with State Governments should ensure continuity of DMHP beyond the plan period. It is suggested to gradually shift financial burden to State Government to be ensured by an undertaking to this effect and integration of mental health services in State and District Programme Implementation Plan (PIP).Ensure regular flow of allocated funds. Irregular flow of fund has affected the implementation of programme adversely. Initiation of programme should be ensured in time bound manner after the receipt of funds. Ensure appointment of Psychiatrists and other staff exclusively for DMHP and their continuity by ensuring remuneration at the prevailing market rate. It is recommended to increase the PG training seats (M.Phil., Clinical Psychology, PSW, etc.) in the country so that more qualified manpower will be available for the programme. Training should be imparted regularly. Increase the frequency and ensure it is imparted to all the personnel implementing the programme. The trained personnel should be retained or if transferred to other DMHP districts only. The DMHP team needs to be trained on Programme Management and organizational activities. Also ensure refresher training and on-job training with the focus on local challenges. Special training for ANMs and PHC level – for diagnosis, treatment and ensuring the involvement of family members and community. Ensure effectiveness of treatment through proper mix of medication and counselling. Evolve proper mechanism for drop out cases by ensuring availability of psychiatric social worker and community nurse to follow up the drop out cases. Active involvement of community based organisations/leaders for organising awareness programme with regard to place, time and maximum impact area. A need for strong IEC for awareness creation/stigma reduction was noted. Mass publicity of awareness programme using local media – print, audio (community radio) and visual (local TV channels). Organising camps/ classes in schools, colleges & other Educational Institutions. There is felt need for promotive components like suicide prevention, workplace stress management, school and college counseling services.Integration/ coordination of mental health programme with other health programme viz. ICDS, NRHM. There is need for regular inflow of medicines and availability at health centre. Drug procurement mechanism should be streamlined to reduce delay in procurement and achieve economy of scale (e.g. Tamil Nadu model).Ensuring proper organisational structure. Supervision and monitoring of DMHP activities by State Health Society. It was observed that implementation of DMHP has resulted in availability of basic mental health services at district/sub-district level. As such it is recommended to expand this programme to other districts of the country. Central and State Mental Health Authority are statutory bodies under the Mental Health Act, 1987 for regulation, development, direction and co-ordination with respect to Mental Health Services. However, it has been observed that due to lack of secretarial support these bodies are not able to discharge their role effectively. Adequate support should be provided to them. Continuous monitoring and reporting as well as regular external evaluation is recommended for mid-course correction. This could be addressed by training the DMHP team in organizational skills, networking and involvement of all stakeholders (district health system, district administration, PRIs, CBOs, etc.) in the programme” .
The chief limitation of the recently conducted evaluation is the missing clinical information about patients and treatment outcomes.
Reasons for the current limitations of DMHP:
The DMHP has the following objectives (Table)
TABLE-Objectives of DMHP( GOI, 2006)
1.To provide sustainable basic mental health services to the community and to integrate these services with other health services;
2.Early detection and treatment of patients within the community itself;
3. To see that patients and their relatives do not have to travel long distances to go to hospitals or nursing homes in the cities;
4. To take pressure off the mental hospitals;
5. To reduce the stigma attached towards mental illness through change of attitude and public education;
6. To treat and rehabilitate mental patients discharged from the mental hospitals within the community.
From the limited published reports of the experiences of the DMHP, reviewed earlier, and the recent evaluatio0n by ICMR, it is clear that the full potential of the DMHP has not been realised and the objectives outlined have not been achieved. It is important to understand the reasons for the current state of programme to be an ‘extension’ service rather than integration of mental health with general health care.
The following are the seven reasons for the current state of the DMHP.
Limited development of the DMHP in its operational aspects by the Central agency: the core idea of integration has not been fully developed to operational level so that the states could follow the guidelines. The components of the programme like the training manuals, treatment guidelines, IEC activities have been developed to a limited extent and poorly disseminated.
Limited state level capacity to implement the DMHP- in most states the mental health programme is under the responsibility of non-psychiatrists and often as one of the many other responsibilities. As a result the technical inputs required for the programme have not been invested in the programme. This is all the more important as there has been inadequate central guidance.
Location of the DMHP with teaching centres: This is a serious barrier to integration of mental health with the general health care. The teaching centres did not have the knowledge of public health as well as did not work with the field level personnel to make the programme effective. Examples of this disconnect can be seen in the training at medical colleges, without involving the DMHP team. The expected technical support did not come medical colleges as they did not accept the core idea of integration of mental health with primary health care.
Inadequate technical support from professionals: At the initial stages of the programme, NIMHANS, Bangalore and few other centres provided the technical inputs and field level experiences of implementing programme on a regular basis. For example a number of centres like Bangalore, Delhi, Ranchi developed training manuals for PHC personnel. The ICMR, New Delhi set up a Centre for Advanced Research in Community Mental Health to develop supports to the NMHP. As noted in the earlier section a number of inputs to the programme like record system, health education material, manuals for the different categories of health personnel were developed. However, all of these developments needed further field level application, modification when the DMHP moved from demonstration project to programmatic stage of expansion to a large number of centres. This should have been a continuous process and it did not occur. This is also one of the reasons for the programme to be psychiatrist centred rather than medical officer/health worker centred.
Lack of emphasis on creating awareness in the community: As noted in the DMHP evaluation,. IEC activities ids the most important need and least emphasised till recent times. However, the last few months, massive national and state level mental health messages are broadcast on radio and TV, which should go a long way to increase the demand and the utilisation of the services.
Lack of mental health indicators: The programme did not develop simple indicators to address the objectives and for want of these there was only emphasis on training and drug supply and not the clinical outcome. A simple list of indicators is attached as Appendix 1.
Lack of monitoring: There was no central/state level technical advisory committees to monitor the programme and carry out the evaluation.
Looking to the future:
DMHP will have to be the flagship programme of the NMHP for the following reasons , covered in detail earlier: (i) currently large proportion of the mentally ill are without care , along with poor awareness of the illness dimension of the mental disorders, especially in the rural areas; (ii) significant proportion are already seeking help from the existing primary health care facilities; (iii0 most rural population will not travel long distances to seek help; (iv) those seeking help will not continue the care unless it is available close to their places of residence; (v) the limited specialist manpower limits the reach of specialist services; (vi) it is possible for the health personnel to provide essential mental health care; and (viii) when care is provided patients can recover/function better with better quality of life to the patient and decreased burden to family and society.
It is ironic that with so many advantages the DMHP has not succeeded to the extent expected for the reasons outlined earlier.
At this point there is need for mid-course correction along the following lines:
(i)Clinical review of the existing DMHP in selected districts, to understand the current state of the clinical care in the DMHP and to develop mechanisms to emphasise on the outcomes rather than numbers;
(ii) Enhance the technical inputs to organize the programme-the training of PHC personnel, essential medicines, support and supervision of the health personnel;
(iii) Take up feasibility DMHP in one district of each state so that they can reflect the general health realities of the state and develop models for further extension in the respective state;
(iv) Increase massively the IEC activities and integrate mental health messages and information as part of all community messages through mass media and local level community radios;
(v) There is an urgent need to develop specific indicators to monitor the DMHP;
(vi) Private sector mental health professionals, the administrative supports needed to monitor (vii) setting up of a technical advisory committees at the national and state levels to guide the DMHP on a continuous manner.
For a long time to come the core ideas of DMHP will be relevant to the NMHP in India. The challenge is to make it operationally effective with the support of technical and administrative inputs.
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APPENDIX 1:
Suggested Indicators for monitoring and evaluation of the DMHP.
Baseline studies:
Description of the District in terms of the available mental health facilities (general health facilities, psychiatrists, psychiatric beds, mental health NGOs, number of persons in mental hospitals, wandering mentally ill persons, suicide rate etc)
Current knowledge of the health, welfare and education sector personnel about essentials of mental health care;
Attitude of the community to mental health and mental disorders- either through focus groups or through survey of sample population of the population using a questionnaire /case vignettes with key informant interviews. Alternatively the data from the health workers, teachers and anganwadis can be used as the reflection of the community knowledge, attitude and practices).
Training of Personnel:
Immediate impact of the training (pre-post training evaluation) in each of the trained groups;
Record of questions raised by the trainees during the training;
Care activities:
Number of persons with mental disorders seen month by month- by individual health workers,(from the catchment area and outside the catchment area) individual health facility;
Diagnosis of the persons with mental disorders;
New cases
Duration of illness at the time of first contact with psychiatric services
Past treatment record
Severity of symptoms
Degree of disability, at first contact
Outcome of initial Contact:
Follow-up cases/ once a month (since medicines are expected to be given once a month)
Admission details, if admitted
Outcome of first contact with psychiatric care- drop out, irregular, completed/continuing treatment, recovered (at 6 months and one year)
Final status regarding symptoms and disability
Support programmes for the family members
Review of the case Records by the DMHP officer/ team:
Completeness of the records;
Correctness of the diagnosis
Appropriateness of the medicine used
Appropriateness of the dosage of the medicine (depending on age, severity of illness)
Follow-up record-completeness,
Follow up -appropriateness of changes in the treatment
Medicine stock-
Checking of the stock as per records;
Linkage with the use from records and the remaining stock
Drugs and their expiry dates
Record of health workers
Meeting with health workers to evaluate their work- public education, follow up care, problems encountered etc)
Identification of problems of care programme.
Other activities undertaken by the DMHP Team:
Training activities
Organization of camps for issuing disability certificates/ ID cards
Community level activities
Support to families of persons with mental disorders
Follow up of individual patients (about 10% of cases to be followed up for detailed evaluation of the different points identified in the case record)
Coordination with the monitoring team
Monitoring Team:
Review of doctors skills in caring for the persons with mental disorders;
Review of the skills of health workers in caring for persons with mental disorders;
Checking of a LIMITED /SPECIFIED number of patients in the clinic/community- adequacy of the records, diagnosis, treatment and follow up
Identification of the areas requiring strengthening of the cases .
ESSAY 4
( for the Souvenir of the Annual Conference of the Indian Psychiatric Society,Jaipur, January 18-20,2009)
Care of mentally ill in the community: Role of families-from inclusion to empowerment
“In India most of persons with mental disorders live with their families. Family takes care, ensures provision of services and plans and provides for their future. Thus, our family care model is very important. The role of the family, therefore, becomes crucial when one takes cognizance of acute shortage in India of affordable professionals, rehabilitation services and residential facilities, whether in the private or government sector. One should also take note of absence of welfare facilities or benefits for persons with mental disorders”-SAA, Pune (2009)
ABSTRACT
Family has been an essential part of the mental health care programmes in India. The emphasis on the family as the single most important source of care is fairly unique for India and contrasts with the emphasis on the professionals and institutions in mental health care in the developed countries. The following aspects are considered in this article, (i) community mental health care in India; (ii) evolving role of family in mental health care in India,(iii) international developments (iv) changing families in India and (v) future action towards empowerment of families in India.
Introduction
As I started thinking about the article for the IPS 2010 Souvenir, on the topic of community mental health and families, I looked back on the last 40 years of psychiatric experience. I tried to identify the most important and enduring aspect of Indian psychiatry of the last 60 years and came to the conclusion that it is the ‘enduring commitments of families of the persons with mental disorders’ that has made my practice of community psychiatry possible. I recognize that I have a bias towards family oriented mental health care, as I started my initiation to psychiatry at the Mental health centre, Vellore, where families form an essential part of the routine care programme. However, along with the positive feelings, I could not help feeling that as a group, we mental health professionals in India, have taken families for granted and not done enough to address all their needs. I thought I will reflect on this for this contribution.
Community care of persons with mental disorders in India
There are very limited institutional infrastructure in the form of formal psychiatric institutions like mental hospitals, the general hospital psychiatric units, alternative community care facilities to meet the needs of the millions of the mentally ill persons needing care. Families have continued to be the primary carers of the ill persons.
The efforts in the past have addressed to fill the void in services by a number of community mental health initiatives. These have included, (i)integration of mental health care with general health services, the most important of this initiative is the district mental health programme; (ii) training of the general practitioners; (iii) training of non-professionals like teachers, anganwadis; (iv) training of a cadre of non-specialist mental health professionals like lay counselors, volunteers , especially in the areas of suicide prevention, disaster mental health care; (v) care responsibilities taken by the ill persons themselves like in the areas of substance abuse; (vi) setting up of half-way homes, long stay homes for those who need care in semi-institutional settings; (vii) supporting families for care their family members , especially in the areas of mental handicap, chronic schizophrenia, substance abuse and dementia(considered in detail below) and (vii) public mental health education. The overall effort has been to decentralize the services, deprofessionalise the services so that there is greater reach of the services. It is very gratifying that there has been government support in terms of funding for these initiatives.
There are three conclusions that can made of the community mental health care in India are the following: firstly, there is a very high ‘unmet need’ for services in the community ranging from 40-60% of severe mentally ill persons. Secondly, initiatives to reach the unreached by extension of the services to the community can be effective (Srinivasa Murthy et al.2004, Chatterjee et al, 2004, Thirthahalli et al,2009).Thirdly, there is a need to go beyond extension of the services, as recently noted by Thara et al (2008)
“community based initiatives in the management of mental disorders however well intentioned will not be sustainable unless the family and the community are involved in the intervention program with support being provided regularly by mental health professionals”
Family in mental health care in India
The subject of family and mental health care has been extensively reviewed in recent times (Radha Shankar and Kiran Rao,2005, Srinivasa Murthy,2007) (the complete list of over 100 references is available from the author).In view of these available reviews, the next section only summarises the major trends of the last 60 years.
Indian initiatives relating to families and mental health care have depended on the family support for the mentally ill persons. Since 1950s families have been formally included to supplement and support the psychiatric care by professionals. During the 1970s and 1980s, efforts were made to understand the functioning of families with an ill person in the family and their needs. Along with this there was study of factors contributing positively/negatively to the course and outcome of schizophrenia. During the last 10 years, a more active role for families is emerging in the form of formation of self-help groups and professionals accepting to work with families in partnership. However, many of the leads provided by pilot studies and successes of family care programmes have not received the support of professionals and planners to the extent it could become a routine part of psychiatric care. In the 21st Century.
Reviewing the scene, Radha Shankar and Kiran Rao (2005), opine that ‘professional inputs have not kept pace’ and conclude that the ‘family movement in India is one of ‘unfulfilled promises or great expectations for the future’ as follows:
“ the vision for the family movement in India would see families from passive carers to informed carers , from receiving services to proactive participation, from suffering stigma to fighting stigma. And it is the responsibility of the mental health system to facilitate this journey of care givers from burden to empowerment”.(p.285)
Changing families in India
The issues relating to the families in India are (i) growing urbanization of India, (ii) breaking down of the traditional joint and extended families, (iii) increasing numbers of nuclear families, single parent families,(v) families with working parents, (vi) families in distress due to economic deprivation, social exclusion, alcohol dependence and chronic illnesses, (vii) growing numbers of elderly persons and families of mentally ill with elderly caregivers, (viii) increasing influence of mass media in shaping the aspirations of young people and family life. All of these changes have mental health implications.
International Developments
There have been many barriers to involvement of families both from the patients and their families and the professionals in the West. Till recent times , families were considered ’toxic’ to the mentally ill persons. However, gradually the challenge of caring for patients without families is receiving attention in the developed countries. This need is highlighted by Leff (1996) as follows:
“Our problem in the West is, that somehow or other we have to make up for the families (emphasis added) who have disappeared and create a supportive structure – not for the patients but for the single relatives who are often desperately trying to cope with schizophrenia. It is, of course, very expensive to create a network of professionals who act as a SURROGATE FAMILY (emphasis added), but we have to provide that form of support, because it is even more expensive to keep 26institutional patients.”
With the availability of newer treatments, recognition of the rights of the ill persons and growing awareness of the psychosocial factors that contribute to the course of illness, there is real re-examination of the role of families in the care programmes in the West. In August 2007, in the American Journal of Psychiatry, I read a report titled 'Making treatment for bipolar disorder a family affair' .The report covered the benefits of family involvement, the goals of family focused therapy, guidelines for family interventions, benefits to the family members and importantly the barriers to family involvement. The barriers identified included (i) the patient has no family locally; (ii) the family doesn't want to be involved in treatment ;(iii) he patient doesn't want his family to participate in treatment; (iv) concerns around confidentiality; (v) clinician lacks experience in family-focused therapy and (vi) some clinicians view family intervention as counter to the psychoanalytic tradition of focusing on the patient's personal insight and autonomy. We in India, addressed many of these issues 50 years back and continue to work with families as part of everyday mental health care.
Family empowerment
I have referred to three observations from the community mental health movement in India (Thara et al,2008), the review of the family movement in India (Radha Shankar and Kiran Rao,2005) and the international development(Leff,1996) which all point to the need for empowerment of the families.
To shift the paradigm from caring to empowerment there is need for four initiatives.
Firstly, increased acceptance of the central role of the families in mental health care in India, by the mental health professionals. I must admit that our past sixty years of attitude has been passive rather than active. The choice of family as the theme of the ANCIPS-2010, “Preserving mental health through family and culture” is timely. The profession has to carry forward the issue by action programmes.
Secondly, there is need for a greater understanding of the current ‘live-in’ situation and practices of Indian families living with a mentally ill person, across different social and economic groups, to provide care that is appropriate to the ill persons and their families. The urgent need for understanding the ‘live-in’ experiences of the people and families with schizophrenic illness is much voiced concern among Indian psychiatrists. This information becomes all the more important, as we move from inclusion of families to empowerment. Empowerment has to occur in the ‘local’ situation and not in abstract terms. The areas for research in this field was voiced by Kapur(1992) and they continue to be relevant even today:
“There is considerable amount of ethnographic literature on Indian families but it hardly touches on those aspects which are of interest to a mental health professional. On the other hand, there is an excellent intuitive clinical literature on interpersonal relationships, role boundaries, development of self and ego but the insights which these studies reveal have not been examined through properly designed field research.” He further adds “research is required for preparing psycho-educational material suitable to Indian ethos. One can not just transplant the western psycho-educational material. For example, the material prepared by Leff et al(1982) which advocates reduction in face to face contact between the patient and the relatives, will be impractical and meaningless in the Indian setting. Indian houses do not have enough space to prevent face to face contact. Further, a lot of intense emotional interaction goes on in the Indian families without face to face contact; just consider the daughter-in-law of the house who wears a veil or think of lovers who have never met!...Studies of the burden on the family need to be carried out and it should be examined if the burden id felt differently in families of different socio-economic as well as educational background”.
It is important that we collaborate with demographers, sociologists and anthropologists in these research efforts to mutually benefit from the disciplines strengths.
Thirdly, and most importantly, organized and greater sharing of the currently available mental health information, caring skills along with crisis management and rehabilitation, and development of mechanisms to disseminate the relevant information to all rural and urban families. I would like to elaborate this, taking the example of the illness of schizophrenia.
The needs of the families with a person suffering from schizophrenic illness range from early identification, early intervention, diagnosis, treatment(both pharmacological and psychosocial),rehabilitation, employment, emotional support and to family members and long term care for limited numbers in an institutional setting. The challenge is to organize sharing of knowledge and services, so that families feel ‘continuously supported” and thus empowered in the caring process. Most of the current care programmes expect the ill person/family member to seek services in a one to one situation and often this is not possible due to various practical reasons(Srinivasa Murthy et al, 2004, Chatterjee et al, 2004,Thara et al,2008, Thirthahalli et al,2009).
There is need for a new approach to develop interventions towards providing seamless, integrated, continuous and user friendly services for the persons suffering from schizophrenia and their families. The focus is to empower the patients and their families with both information, skills and services. It is expected that this will result in greater utilisation of services and better outcome in terms of clinical improvement and better quality of life for the ill persons.
Such a programme would use the following measures:
Sharing of skills: There are so many skills needed by families in day to care of the ill persons. We have not expended the type of energy required through innovation, to share these skills available with professionals with families. If these skills of caring are converted into family activities like games, activities of fun so that the families are bound by caring rather than burdened by caring it will be of great value. In addition, this sharing should occur with each family and on a continuous manner. A big challenge and opportunity for Indian Psychiatric Society is to invest in this activity so that material and methods are available in each of the states in the local languages and formats suitable to different population groups.
Website: The website should be accessible to patients, families in a manner that will fully inform them, give them skills to monitor the progress of their clinical condition, the side effects of medicines, use of psychosocial interventions. The website also will be a way for the patients and families to seek help and share their experiences. A good example of such a website is of UK. The Indian website will go farther than the other websites buy including audio0-visual materials to share skills of caring(self-care and family care).
Community Radio: This new opportunity for local level community involvement and community education, can be the mechanism to knit the patients and families, to give voice to the voiceless, in a locally relevant language and cultural context, and also to disseminate information. A weekly radio broadcast of half to one hour on a regular basis could reach the benefits of information and skills, patients and families and professionals could be immense benefit, besides fighting the stigma of mental illness.
Decentralised mental health care: This is central in any care programmes in India, as reviewed earlier. This will be through linking of the continuous care need with the local facilities like PHC personnel, private doctors, psychiatrists and other mental health professionals, with the support of a specialist mental health team. These service providers will be linked through mobile phone network with the specialist to support their work.
Self-help Groups: The formation of self-help groups can be great support to families to address day to day needs and for mutual sup[port. These should be located as close to the groups of patients as feasible- one for every 10-40 patients/families so that they can meet and use the support network easily. These self-help groups should be supported by the website, community radio, volunteers and mental health experts
Volunteers: Bhaskaran(1970) his his Presidential address, had suggested “launching pilot projects engaging college students as volunteers in the resocialisation of chronic schizophrenics”. Local level volunteers with specific supportive skills to work with the self-help groups and the core group of professionals and to support the patients and families. Similar support has worked well with the initiatives to address the needs of the elderly persons(Dignity Foundation).
NGOs: The complex and lifelong needs of many of the families require a number of initiatives by the NGOs. They can play an important role in developing community based rehabilitation services and support to the self-help groups.
The above is presented in a Table below.
Towards Empowerment of Families of persons with Schizophrenic illness
Needs of Persons/families Interventions
Information - Website
Community Radio
Helpline
Early identification - Website
- Medical personnel
- Community
Volunteers
Diagnosis - Professional Services
Personal care - Website/Telemedicine
Skill for care of family members - Self-Help groups
- Professional help
- Website
Community radio
Helpline
Volunteers
Continuous care over the life cycle - Self Help Groups
- Community Radio
- Volunteers
Professional Help
Helpline
Wide range of services(community care
facilities) - Government
NGOs
Self-help and mutual support - Self-help groups
- Volunteers
Website
Welfare support/Employment - Government
NGOs
Long term care - NGOs
Is this possible to achieve?
In a number of other sectors, namely banking (microfinance) education(distance education), agriculture(use of mobiles and IT technology for change in agricultural practices-microsoft), sale of consumer goods(TATA tea. Everyday Lite) these methods have been used to the mutual benefit of the people and producers. It is the philosophy of building from the bottom of the pyramid.
Fourthly, joining hands with persons with mental illness and families of the mentally ill persons, for greater social support and welfare measures. We should be moving towards ‘cushioning’ the responsibility of the caring responsibilities of the families( eg. medical insurance, welfare benefits like pension, support for local support networks like self-help groups) . Even today there are great disparities in the availability of even basic supports like disability pension. For example, in Tamil Nadu, mentally ill persons are not receiving the disability pension similar to other disabilities. Some of the needs, in addition to treatment and rehabilitation, are for the questions of families like, ‘who will look after my ward after me?’ . There are some leads from the area of mental handicap , where parents and professionals have made significant progress , through National Trust, to address these needs. We need to both learn from these examples and also join hands with other groups working with disabled to address these issues.
In conclusion, I want to recall a paragraph from the National Mental Health Programme (1982) document
“Most mental health facilities in India actually function as passive recipients of patients. They become operational only where coping mechanisms in the community fail. These institutions have little knowledge and hardly any impact on the coping mechanisms as they exist and operate in the community. It is essential that the role of all mental health institutions in India become more active with the social mechanisms involved, not only in the development of mental illness, but also in the more important issue of maintaining mental health”- NMHP (1982).
A recent reference to emerging India, (Forbes India, January 9,2010) noted “first world India is an increasingly popular concept. Much has been made of how out time as a country has arrived; of how we are at an inflection point in our history. But how are we going to translate this potential into performance?” India has the opportunity to build upon the strength of the Indian family system. The emphasis now must be on empowering the family in providing care to the ill individual. This could be India`s most important contribution to the rest of the world.
Acknowledgement: My sincere thanks to Ms. Ratna Chibber, Aasha, Chennai, Captain.Johaann,Bangalore, Mr.Mukul Goswami, Ashadeep,Gauhati, Mr.Anil Vartak, SAA, Pune for their suggestions about the draft of the manuscript.
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