NATIONAL MENTAL HEALTH PROGRAMME

1. NATIONAL MENTAL HEALTH PROGRAMME

2. Moving Away from Mental Institutions - Towards Community Mental Health Care • Mental disorders figure among the leading causes of disease and disability the world over. Depressive disorders are already the fourth-leading cause of the global disease burden; they are expected to rank second by 2020, behind Ischemic heart disease1,2. Meta-analysis studies indicated high prevalence rate of mental disorders in the community (58.2 per thousand). Mental disorders affect one in four persons. msc ii year

3. Contd… • The year 2001 was a landmark in the development of mental health services. Since the problem of mentally challenged is a global problem, WHO has chosen the theme: "Mental Health: stop exclusion - Dare to Care" during the year 2001, to focus worldwide attention on the issues related to mental health4-9. The past, in the history of mental health services has been a gloomy, but nevertheless it has taught us many lessons. Past experience of mental health built a strong myth and perception in the community and the common man perceived mental illnesses as stigma, admission in asylum or mental hospital, electric shocks and confinement in institution with sub-human conditions. The picture has changed drastically and the modern mental health care goes far beyond the institutions and in a way it is trying to restore and build confidence of common man and by changing his/her perception through educational programme. Mass media continues to focus on miserable conditions of asylums and mental hospitals and sub-human conditions of these hospitals, to draw the attention of authorities for improving these conditions. Directives of Honourable Supreme Court have made substantial contribution in the area of mental health programme. msc ii year

4. . Introduction • Psychiatric symptoms are common in general population in both sides of the globe. These symptoms – worry, tiredness, and sleepless nights affect more than half of the adults at some time, while as many as one person in seven experiences some form of diagnosable neurotic disorder msc ii year

5. Programme •   The Government of India has launched the National Mental Health Programme (NMHP) in 1982, keeping in view the heavy burden of mental illness in the community, and the absolute inadequacy of mental health care infrastructure in the country to deal with it. msc ii year

6. DMHP • Mental health care in India over the last 25 yr has been an intense period of growth and innovation. Prior to the formulation of the NMHP in 1982, the major initiatives included setting up of mental hospitals during 1950s and early 1960s and general hospital psychiatric units in the 1960s and 1970s8. Simultaneously, involvement of the families in care of the mentally ill was also initiated in a number of centers. Another major step in mental health care was to integrate mental health care with general health services. Followed by the initial demonstration projects at Chandigarh and Bangalore9-11, in the last two decades, the pilot programmes of integration of mental health with primary health care were initiated at several centers. The district model of mental health (DMHP) care was developed by National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore during the latter part of 1980s12. The next big step was extending of DMHP to 25 centers around the country with central funding during the 9th Five Year Plan13. Currently, during the 10th Plan period, the goal is to cover 100 districts with about 150 million population. msc ii year

7. India and new millanium • India enters the new millennium with many changes in the social, political, and economic fields with an urgent need for reorganization of policies and programmes. The mental health scene in India, in recent times, reflects the complexity of developing mental health policy in a developing country. There has been a critical examination of the existing mental hospitals in the country by the National Human Rights Commission of India16. The Supreme Court of India is continuously examining the wide variety of issues relating to mental health care, following the Erwadi Tragedy in which 28 mentally ill persons were burned to death while chained to pillars. The National Health Policy17 clearly spells out the place of mental health in the overall planning of health care. These developments have occurred against the over 25 yr of efforts to integrate mental health care with primary health care (from 1975), replacement of the Indian Lunacy Act 1912 by the Mental Health Act 1987, and the enactment of The Persons with Disabilities Act 1995 focusing on the equal opportunities, protection of rights and full participation of disabled persons' msc ii year

8. Contd… • The growth of voluntary action for mental health care in the areas of suicide prevention, disaster mental health care, setting up of community mental health care facilities, movement of family members (care givers) of mentally ill individuals, drug dependence, public interest litigation to address the human rights of the mentally ill; research in depression, schizophrenia and child psychiatric problems are other major developments. The rapid growth of private psychiatry with associated spread of services to peripheral cities and small towns and challenges of regulation is an another significant development of the last 10 yr. msc ii year

9. Aims •  1. Prevention and treatment of mental and neurological disorders and their associated disabilities.2. Use of mental health technology to improve general health services.3. Application of mental health principles in total national development to improve quality of life.  msc ii year

10. Objectives •  1. To ensure availability and accessibility of minimum mental health care for all in the forseeable future, particularly to the most vulnerable and underprivileged sections of population.2. To encourage application of mental health knowledge in general health care and in social development.3. To promote community participation in the mental health services development and to stimulate efforts towards self-help in the community.  msc ii year

11. Strategies •  1. Integration mental health with primary health care through the NMHP;2. Provision of tertiary care insitutions for treatment of mental disorders;3. Eradicating stigmatization of mentally ill patients and protecting their rights through regulatory institutions like the Central Mental Health Authority, and State Mental health Authority.  msc ii year

12. Mental Health care •   1. The mental morbidity requires priority in mental health treatment2. Primary health care at village and sub center level3. At Primary Health Center level4. At the District Hospital level5. Mental Hospital and teaching Psychiatric Units msc ii year

13. District Mental Health ProgrammeComponents •   1. Training programmes of all workers in the mental health team at the identified Nodal Institute in the State.2. Public education in the mental health to increase awareness and reduce stigma.3. For early detection and treatment, the OPD and indoor services are provided.4. Providing valuable data and experience at the level of community to the state and Centre for future planning, improvement in service and research. msc ii year

14. Contd… • Agencies like World Bank and WHO have been contacted to support various components of the programme. Funds are provided by the Govt. of India to the state governments and the nodal institutes to meet the expenditure on staff, equipments, vehicles, medicine, stationary, contingencies, training, etc. for initial 5 years and thereafter they should manage themselves. Govt. of India has constituted central Mental Health Authority to oversee the implementation of the Mental Health Act 1986. It provides for creation of state Mental Health Authority also to carry out the said functions. msc ii year

15. The National Human Rights Commission also monitors the conditions in the mental hospitals along with the government of India and the states are currently acting on the recommendation of the joint studies conducted to ensure quality in delivery of mental care.  msc ii year

16. Burden of Disease •   The World Bank report (1993) revealed that the Disability Adjusted Life Year (DALY) loss due to neuro-psychiatric disorder is much higher than diarrhea, malaria, worm infestations and tuberculosis if taken individually. According to the estimates DALYs loss due to mental disorders are expected to represent 15% of the global burden of diseases by 2020. msc ii year

17. During the last two decades, many epidemiological studies have been conducted in India, which show that the prevalence of major psychiatric disorder is about the same all over the world. The prevalence reported from these studies range from the population of 18 to 207 per 1000 with the median 65.4 per 1000 and at any given time, about 2 –3 % of the population, suffer from seriously, incapacitating mental disorders or epilepsy. msc ii year

18. Most of these patients live in rural areas remote from any modern mental health facilities. A large number of adult patients (10.4 – 53%) coming to the general OPD are diagnosed mentally ill. However, these patients are usually missed because either medical officer or general practitioner at the primary health care unit does not asked detailed mental health history. Due to the under-diagnosis of these patients, unnecessary investigations and treatments are offered which heavily cost to the health providers.  msc ii year

19. Thrust areas for 10th Five Year Plan •   1. District mental health programme in an enlarged and more effective form covering the entire country.2. Streamlining/ modernization of mental hospitals in order to modify their present custodial role.3. Upgrading department of psychiatry in medical colleges and enhancing the psychiatry content of the medical curriculum at the undergraduate as well as postgraduate level.4. Strengthening the Central and State Mental Health Authorities with a permanent secretariat. Appointment of medical officers at state headquarters in order to make their monitoring role more effective;5. Research and training in the field of community mental health, substance abuse and child/ adolescent psychiatric clinics. msc ii year

20. Comments •  1. For the first time in the last 40 years mental health has been chosen as the theme for the World Health Day 2001: “Mental Health: Stop Exclusion – Date to Care”, Why? The recent evidence for the importance of mental health has been so striking that the WHO decided to give it a priority during year 2001, the beginning of 21st century. 2. There is no initiative from the mental health professional to take active part in this programme. Most of them are not aware of the programme.3. There is shortage of professional manpower and training programmes are not able to meet the demand in providing all medical private practitioners and medical officers.4. Appropriate mental health can be provided at the subcentre and village level by minimum training of the health workers that will help in providing comprehensive health care at the most peripheral level. msc ii year

21. Contd… • 5. The targets set for the programme are not achieved till today after lapse of more than one decade. This indicates that there is a poor commitment of the government, psychiatrists, and community at large.6. The programme has given more emphasis on the curative services to the mental disorders and preventive measures are largely ignored. More public awareness programmes are required.7. The medical care in the hospitals are custodial in nature and this needs to be changed to a therapeutic approach. msc ii year

22. NMHP • National Mental Health Programme initiated in 1981 has ultimately come out with community based approach for sustainability of actions as also enhanced accessibility. Development of district mental health programme is a step in the right direction, but the progress and coverage is too slow to make any mark on amelioration of the problem. Nodal agency has been identified in each state to undertake in-service training programme of the Medical Officers and paramedical workers as also to provide technical support to district training programme; it adheres to prescribed manual by NIMHANS, Bangalore5,6. Two weeks training programme is being perused at the level of Medical College by the department of Psychiatry (a tertiary level of care). This decision undermines the capacity of district health agencies or district training teams developed recently as a training institution for continuing education programme of medical and paramedical personnel. msc ii year

23. Contd… • It is recognized that effective delivery of primary health care including mental health care would largely depend upon the nature of education and appropriate orientation towards community health of all categories of medical and health personnel and their capacity to function as an integrated team. Basic training curriculi of all categories should incorporate sufficient time for building essential skills of medical and paramedical personnel so that they are able to deal with the problem of mental health within the framework of primary health care. In general, we must address the issues of quality of medical education for undergraduates and specifically to the training of students in the discipline of Psychiatry, to lay firm foundation for development of mental health services at primary health care level7-9. This should be considered as real investment in development of psychiatric health services in the community. msc ii year

24. Training of Trainers (TOT) • Training of Trainers (TOT) is essential to impart need based and relevant training on the key areas of mental health and counselling. Training needs assessment and pursuing the hands on the training with case material and community should become the primary focus with trainers of medical and paramedical personnel. Medical education cell and State Institute of Health and Family Welfare can be entrusted with the task of training of trainers. National Health Policy and programme on mental health and its key strategies must be made available to the trainers. To maintain the uniform standard of training, manuals prepared by NIMHANS, Bangalore be distributed in local languages. msc ii year

25. Training • Focus of the training of necessity should be on the methods of interviewing and contact with the individuals and families, skills of listening to clients, assessing their needs, counseling and identification of high risk families and clients as also group meetings and dynamics besides community organization and mobilization of resources. Continuing education should be part of routine meetings. Health teams (multipurpose health workers, anganwadi workers, gram sewikas and health guides) should be trained together for better understanding of each other's role and responsibility. msc ii year

26. Mental health literacy • Awareness generation and mental health literacy drives at the level of community through active involvement of Panchayati Raj Institutions, influential groups, non-formal leaders and other organized groups on regular basis can be most productive. Awareness generation campaign must have the support of district mental health services, Community Health Centre, Primary Health Centre and Sub centre system. • Ownership of the programme by district health orgnization and the area is essential for sustainability and endurance. If the training programme and development of strategies are evolved far away from the real situation, this may create a negative impact and generate a sense of dependency and kills local initiatives. Building district capacity for training and continuing education as also for developing services should be the real role of nodal agency. msc ii year

27. Stigma • If one looks at the basic curriculum of MBBS students and paramedical (multipurpose health workers male and female) one finds that subject of Mental Health is covered adequately but the implementation thereof is questionable. • Even the available services for mental disorders are being poorly utilized. Nearly two third of persons with known mental disorders never seek help from health professionals and most clients utilize the services of other agencies and resort to harmful practices and keep on visiting faith healers and delay the treatment till the condition deteriorates which compels them to seek the treatment from established government institutions. Stigma, discrimination and neglect prevent care and treatment reaching people. Mental health literacy needs to be built strongly in the community to scale up the utilization of available mental health services. msc ii year

28. Mental health promotion • In the first instance, the services and infrastructure for mental health services in public sector are inadequate and mostly confined to bigger cities and hospitals. Distt. programme of Mental Health Services has just taken off, primary health care infrastructure on the other hand is reasonably well developed and is almost universally accessible to rural and urban areas. Minimum package of mental health services for all can be best delivered through primary health care system. Preventive and promotive programme along with awareness generation can be undertaken on sustainable basis through this infrastructure. • System of Integrated Child Development Services (ICDS) which is poised for universal coverage has played a pivotal role for mother and child development in rural, urban and tribal areas. Non-formal education component and early childhood stimulation through play way activities have laid down firm physical, mental and psychological development foundation. msc ii year

29. ICDS • In a way, the institution of anganwadis has been recognized as sheet anchor in personality development of young children. This is one of the finest examples of development of positive mind and mental health. International programme developed by WHO to stimulate mother-child interactions has much more chances for success if persued actively in the family through ICDS system. This system involves families in total child development through integrated services of nutrition, health and education and relies on inter-sectoral co-ordination. NIMHANS has rightly picked up ICDS system to involve them in National Mental Health Programme through District Mental Health Services. They are being imparted 5 days training programme at distt. level. Their training would be critical, as these workers will serve as link workers between community and the formal health services system. msc ii year

30. Contd… • Since anganwadi workers are locally resident voluntary workers, deeply rooted in the community they can be most effective in dissemination of knowledge on mental health programme besides identification of clients at the earliest stage of morbidity, because of their continuous contact with families. Strengthening of this institution can be most rewarding and will have high payoff effects in the long run. National Population Policy envisages enlarging the sphere of ICDS to cover school going children upto the age of 9 years. Continuous on the job training of anganwadi workers through supervisory support can further enrich the non-formal education programme. The in-service training on mental health should be undertaken by supervisors or trained Child Development Programme Officers and it should focus on child development, personality development and learning by play way activities. msc ii year

31. DMHP • Adolescent boys and girls who are the future parents need greater degree of mental health services to develop value based learning and balanced personality. Teachers training programme for balanced development of physical, mental and social faculties of school going children is essential for healthy life styles. Teachers along with parents can shape balanced personality. District Mental Health Services Programme should have incorporated this programme very strongly and entrust the responsibility of teachers training to district health teams. Though the teachers are trained during their teachers training programme on Child Psychology but they need continuous education on balanced personality development of child. District mental health programme should not lose the opportunity, as it would be a real investment in preventive, promotive and positive mental health or extended community mental health. msc ii year

32. "Life Skills" educational curriculum • The outreach district mental health services should embody this component of the programme on sustainable basis. WHO's "Life Skills" educational curriculum which attempts learning of wide range of skills amongst school children to improve their psycho-social competency through problem solving, critical thinking, communication, equity, tolerance, interpersonal skills, empathy and methods to cope with emotions can be made effective through school teachers and parents teachers interaction on continuous basis and much more through "child friendly schools". msc ii year

33. Indian System of Medicine • Government or Public Mental Services is just one resource for mental health services, Private sector and Non-Governmental Organizations, as also diverse health care providers such as practitioners of Indian System of Medicine should be considered as potential resource for primary health care including mental health services. Their involvement can increase the base of accessibility of services to masses. Some of the technologies of Indian System of Medicine can be exploited for treatment of mental disorders. District programme of mental health services may be given liberty to utilize the services of these agencies. Resource mapping for primary health care, as also mental health care should not lose sight of other available organizations contributing to the care or services related to mental health programme. Partnership between government and private sector is an important area for development of mental health services programme at community level. msc ii year

34. Community care • It is widely acclaimed that community care is more effective as well as more humane than in-patient stays in mental hospitals. It is, therefore, essential to develop mental health services in the community settings as an integral part of primary health care; to root out stigma, myths and misconceptions and discrimination against mental disorders. The World Mental Health report 2001 advocates community based mental health programmes and active involvement of families and consumers and community in the delivery of programme. msc ii year

35. People and the community • People and the community are the biggest resources available in India. Many of the problems in the area of mental health can be effectively dealt with by the people and within resources available close to them. Large-scale dissemination of knowledge and simple skills to people and health volunteers should be addressed through primary health care. Capacity of family must be built and primary health care infrastructure should support the family to build their capacity to prevent and manage the mental health problems within the available means. What people do with their lives and those of their children affects their health far more than anything that government does. msc ii year

36. Contd… • Building knowledge and awareness of families can make the real difference. Health guides, anganwadi workers and health workers as also Non-Governmental Organizations (NGOs) should raise the level of awareness of people on sound mind in sound body and attainment of positive mental health, through their own actions and practices as also utilization of available services. msc ii year

37. Operational research studies on community based mental health services • We have just two models evolved long back at Chandigarh and Bangalore in 1975 which are indeed insufficient. These two models limited their approach to curative services at the community level through primary health care. District mental health programme was initiated at Bellary (Karnataka). Success of operations in programme conditions at the ground level needs to be documented further. Outcome and impact of district training programme in terms of coverage of mental health services and awareness level; of community needs to be explored through operational research studies. The task can be undertaken by nodal agency or independent institution can be entrusted this tas msc ii year

38. Conclusion • Built in system of monitoring and evolving parameters of mental health in the community could be another area of interest. Similarly, longitudinal follow-up of pre-school children and school children for personality development could be another worthwhile area of research. Many more interventional studies can be evaluated in adolescents in and out of schools in community settings, Delineation of role of NGOs, Panchayati Raj Institutions and partnership of public and private sector in delivery of mental health services can be thought of as an area of exploration. Working of drug de-addiction centers, their cost benefit ratio and impact should form part of community based operational research. msc ii year

39. Ministry of Health and Family Welfare, • Early this year, the Ministry of Health and Family Welfare, Government of India, invited "research proposals for funding as part of the ongoing National Mental Health Programme (NMHP) which aims at providing community based mental Healthcare using the existing public health infrastructure. The proposed research should be relevant and translational in nature, i.e., it should conform to the aims/objectives of the NMHP and should translate into more effective/cost-effective mental health interventions/service delivery"1. This Rs 10 crore(US$22.2 million) is an unprecedented research support to the NMHP for "phased implementation of the District Mental Health Programme, strengthening of medical college departments of psychiatry, modernization of mental hospitals, focused IEC initiatives, research and training". msc ii year

40. Epidemiologicai studies • Commencing with the first epidemiologicai studies at Bangalore in the 1950s and at Agra in the early 1960s, the Indian Council of Medical Research (ICMR) has been in the forefront of mental health research2. The other major studies include the multicentered research cum intervention project titled "Severe Mental Morbidity" in four centres3. The "Strategies for Mental Health Research", based on six task forces that identified research priorities in mental health in 1980 was a major milestone. Two of these task force projects focused on acute psychosis and course and outcome of schizophrenia4,6. Findings of the studies have not only influenced mental health care in India, but contributed to the inclusion of acute psychosis as a separate diagnostic category in International Classification of Diseases (ICD) 10th Edition, of the World Health Organisation. Other studies were mental health care of the aged and child psychiatric problems. msc ii year

41. community mental health training programmes • Many of the trainees who participated in the community mental health training programmes initiated their own community mental health projects. These initiatives demonstrated both the need for research support to the developing NMHP (formulated in 1982) as well as the willingness of professionals to work as teams. The 1980s also saw the Council set up Advanced Centers for Research on Community Mental Health at Bangalore, Mental Health of Aged at Madurai, and Biological Psychiatry at Lucknow - all of which demonstrated how research support can help develop mental health services. The ICMR also supported research into the mental health aspects of disasters like the Bhopal Disaster in the 198Os, the Marathwada earthquake in the 1990s and the most recently Gujarat earthquake and the fire tragedy in Delhi. It is largely the result of these efforts.that following any disaster in India, psychosocial support is readily provided to the survivors along with other services. msc ii year

42. Mental health professionals • Against the above positive developments, the main challenges are the extremely limited number of mental health professionals (about 10,000 professionals of all categories for one billion population) and the very limited mental health service infrastructure (about 30,000 psychiatric beds for over a billion population); limited investment in health by the government (estimated public sector expenditure on health is only 17 % of total health expenditure) and problems of poverty (about 30% of population live below poverty line) and low literacy with associated stigma and discrimination for persons with mental disorders msc ii year

43. The scope of mental health in the new millennium • The scope of mental health in the new millennium should include care of the mentally ill persons, prevention of mental disorders and promotion of mental health as outlined by Dr Govindaswamy, the first Director of All India Institute of Mental Health (now NIMHANS), Bangalore22 over 50 yr back: "Mental health in India has three objectives. One of these has to do with mentally ill persons. For them the objective is the restoration of health. A second has to do with these people who are mentally healthy but who may become ill if they are not protected from conditions that are conducive to mental illness which however are not the same for every individual. The third objective has to do with the promotion of mental health with normal persons, quite apart from any question of disease or infirmity. This is positive mental health. It consists of the protection and development of all levels of human society of secure, affectionate and satisfying human relationships and in the reduction of hostile tensions in the community." msc ii year

44. Challenge for professionals • The challenge for professionals working in India is the competing demand to provide services to large numbers of persons with mental disorders and generation of new knowledge through research. The research agenda for the Council could have the goals of (i) reduction of the incidence, prevalence and burden of mental and behavioural disorders; (ii) develop and evaluate the mental health services so that they become available and accessible to the total population; (iii) enhance the positive mental health of the population; and (iv) create structures to promote long-term mental health research and dissemination of mental health information. msc ii year

45. ICMR • The following four strategies can be used by the ICMR to achieve the above goals: (i) provide research and evaluative foundation to the expanding national level mental health services, both as part of NMHP and in the private sector psychiatry; (ii) help generate new knowledge about the nature, course and outcome of mental disorders; (iii) develop measures for monitoring of the mental health of the community; and (iv) build capacity for mental health research and dissemination of mental health information among the public, policy makers and professionals. msc ii year

46. Research • Research in service development should focus as a priority, on areas like integration of mental health in primary care, early intervention in psychosis, use of family support, models of community long-term care, evaluation of suicide prevention initiatives and mental health in schools. The topics for generation of new knowledge could focus on course and outcome of different mental disorders; treatment by pharmacological and non-pharmacological methods of common mental disorders; mental health of women; .mental health of adolescents; disaster mental health; health and behaviour, development of culturally appropriate assessment tools; health system research; spirituality and health; and basic biological studies of mental disorders. The development of mental health indicators is an important strategy to give greater acceptance of mental health programmes. These indicators could be at the community level relating to services, studies of burden of mental disorders and the impact of alcohol and substance abuse. msc ii year

47. Capacity building • Capacity building through setting up of centres of excellence or advanced centres to support young professionals; regular compilation of psychiatric research data and periodic publications; greater use of information technology for dissemination of information is essential. • The last two decades of research efforts of the Council allow for focused national level workshops in the areas of disaster mental health, schizophrenia and organization of mental health care. Such workshops can not only allow consolidation of knowledge but greater dissemination of information. msc ii year

48. Conclusions • India is thus entering the new millennium with many challenges like promoting mental health of the population and developing mental services involving different social institutions. Professionals have been in the forefront to find solutions appropriate to the country and towards developing an Indian system of mental health care. There is need for a vision for the development of mental health that is broad-based, inclusive of all the needs of all the people, which is community based and community intensive. The ICMR and the mental health professionals in India have their roles clearly cut out. msc ii year

49. References • 1. Director General of Health Services (DGHS). National Mental Health Programme: The Research Agenda. New Delhi: DGHS. 24 March 2004. • 2. Dube KC. A study of prevalence and biosocial variables in mental illness in a rural and an urban community in Uttar Pradesh-India. Acta Psychiatr Scand 1970; 46 : 327-59. • 3. Collaborative study on severe mental morbidity. Report of an ICMR-DST Task force Study, ICMR and DST. New Delhi: Indian Council of Medical Research and Department of Science and Technology; 1987. msc ii year

50. News • KOZHIKODE: The Institute of Mental Health and Neurosciences (IMHANS), in Kozhikode, is all set to implement a community mental health programme for Kozhikode and Malappuram districts as part of the Arogya Keralam project. • Viswas Mehta, secretary to the Health and Family Welfare Department, and Dinesh Arora, Director, National Rural Health Mission (NRHM), who have taken a keen interest in the project have informed Imhans that an amount of Rs.50 lakh has been sanctioned for the projects. • Kozhikode and Malappuram districts will get Rs. 25 lakh each under the project. Imhans, Kozhikode, will be the implementing agency. Imhans director will be the project officer. • The program will be implemented in select primary health centres (PHC) and community health centres on the model of the District Mental Health Program as per the guidelines set by the Government of India. • About 15 to 20 centres will be identified for the programme msc ii year