Community

Mental
Current scenario
health
Dr. Manish Kumar

Community mental health

Providing

mental health care to people

in community ,at their door steps.

Sometimes

it simply means
deinstitutionalization

Background

Many cultures have viewed mental illness as a form of religious

punishment or demonic possession.
To remedy this, many individuals suffering from mental illness
were tortured in an attempt to drive out the demon, other
treatment like removing bad blood, ice bath, tranquilizing
chair, trephening
Later electric shock therapy, opium, cannabis and alcohol was
introduced as treatment
In the early 1930s the notorious lobotomy was introduced into
American medical culture

Phillipe Pinel(1793) is often credited as being the first in

Europe to introduce more humane methods into the
treatment of the mentally ill (which came to be known
asmoral treatment) as the superintendent of theBictre
Hospitalin Paris.
Removed restrained, open door treatment
Benjamin Rushof Philadelphia also promoted humane
treatment of the insane outside dungeons and without iron
restraints, as well as sought their reintegration into society

Problems surfaced, however, with patients becoming

unruly due to lack of restraints, and concern arose
with how patients were to occupy their time. To
combat these concerns, work programs and
recreational activities were devised for patients in
asylums,
Despite this number of asylum kept on increasing
with poor management

In the mid 1900s, when mental health treatment was

arguably at its worst, an apparent salvation emerged.
In the 1950s, the asylums reached its peak population.
The severe overcrowding led to a sharp decline in
patient care and once again, the revival of old
procedures and medical treatments, restraints returned.
Ice water baths were once again used along with shock
machines and electro- convulsive therapy were reintroduced.

Primarily, mental asylums were built to protect the

community from the insane and not to treat them as
normal individuals

Their function was more custodial and less curative.

Eugenics Movement

Compulsory sterilization of the "feeble-minded"

Theeugenicsmovement of the early 20th century led
to a number of countries enacting laws for the
compulsory sterilization of the "feeble minded", which
resulted in the forced sterilization of numerous
psychiatric inmates.As late as the 1950s, laws in
Japan allowed the forcible sterilization of patients with
psychiatric illnesses.

Germany and Occupied Europe: Nazi

Euthanasia Program

UnderNazi Germany, the euthanasiaprogram

resulted in the killings of thousands of the mentally ill
housed in state institutions. In 1939, the Nazis
secretly began to exterminate the mentally ill in a
euthanasia campaign. Around 6,000 disabled babies,
children and teenagers were murdered by starvation
or lethal injection

20th century
Mental Hospitals and
Deinstitutionalization

The movement for deinstitutionalization came to the fore

in various countries in the 1950s and 1960s
Several researchers agree that the introduction of new
health care policies and changes in the provision of public
welfare played at large role in deinstitutionalization
It was suggested that new psychiatric medications made
it more feasible to release people into the community.
Mental health acts promoted this system

Introduction to Rehabilitation

Psychiatric rehabilitation was started in the US through Boston

University's Rehabilitation Research and Training Center on Psychiatric
Rehabilitation led by Dr. William Anthony.
Rehabilitation can be described as consisting of eight main areas of
work: Psychiatric (symptom management); Social (relationships,
family, boundaries, communications & community integration);
Vocational and or Educational (coping skills,motivation); Basic Living
Skills (hygiene, meals, safety, planning, chores); Financial (budgets);
Community and or Legal (resources); Health and or Medical (maintain
consistency of care); and Housing (safe environments).

Another important innovation in the 1960s was the concept

of a day hospital, by which the patients resided in the
community with their families, yet enjoyed the therapeutic
and pharmacological benefits of hospitalization.
Overcrowding in custodial hospital was tackled by the
introduction of out-patient services and day hospitals.
Occupational therapy and recreational facilities were
introduced in a phased manner in many of the large
institutions.

Evolution

Vidyasagar in Amritsar (1950)

Based on this principle, family wards were established
in Bangalore mental hospital and CMC Vellore
In India, the early attempts to start psychiatric services
outside mental hospitals began with the initiative of
psychoanalysis pioneers. Dr Girindra Shekhar Bose, the
founder of the first psychoanalysis society in India,
started the first GHPU at R.G.Kar Medical College in
Kolkata in 1933.

General Hospital Psychiatry Unit (GHPU) is a broad term that

implies the existence of psychiatric service as one of the
many speciality services available in general hospitals
The real push came in the 1950s with the appearance of a
number of psychotropic drugs, which made it relatively easy
to treat a wide variety of psychiatric disorders in general
hospitals, both in out-patients clinics and in-patient wards.
Another psychoanalyst, Dr K. K. Masani opened a similar unit
in Mumbai in 1938 at J.J. Hospital. A little later in the 1940s,
Dr N. S. Vahia started a psychiatric unit at K.E. Medical
College in Mumbai
In the mid-1950s the movement rapidly spread to many
centres in India like New Delhi, Lucknow, Amritsar.

4 Important Movements in
Community Mental Health in India

Dr Vidya Sagar- Amritsar Mental Hospital and Deinstitutionalisation:General Hospitals psychiatric units:The NIMHANS Crash Programme:-It was at the initiative
of the director, Dr R.M.Varma and that of Dr Karan Singh,
Minister of Health, central government, that a crash
programme for community based mental health was
introduced at NIMHANS. A community psychiatry unit was
also started in October, 1975. This unit launched the
following experimental programmes:

i) Primary Health Centre (PHC) based

rural mental health programme:
ii) General Practitioner (GP) based
urban mental health programme
iii) School mental health programme
v) Psychiatric camps

The Chandigarh Experiment

Soon after the community psychiatry unit in NIMHANS
began, a rural mental health programme was started in
the Post Graduate Institute of Medical Education and
Research (PGIMER), Chandigarh, with the help of WHO.
After carrying out studies to estimate the prevalence of
mental disorders, the psychiatry department of PGIMER
developed manuals of training for the PHC personnel.
This programme too was a success.

Components

19

Major community mental

health initiatives in India
1946-BHORE committee found inadequate service provisions
recommended upgradation of mental hospitals & establishment
of new institutes.

1959- MUDALIAR committee assumed population of mental patients 2/1000

Shortage of mental health professionals
Recommended inclusion of preventive mental services as well
( school counselling , orientation of public professionals)
Recommended need for increased research.

20

Major community mental

health
initiatives in India
1974 Srivastava Committee : recommendation of Communiy

Health Volunteer (CHV), Group on Medical Education and Support

Manpower
1976 Program of Community Psychiatry launched at NIMHANS
1976-81 Raipur Rani project and sakalwara project as part of WHO
multi centric project on strategies for extending mental health care
Majority remained untreated inspite of being close to mental hospital.
First visit to traditional healing centers
Health care worker could easily identify and report cases
Limited number of drugs were effective in treatment
Most psychotic patients could be treated and successfully rehabilitated

 1982

: National Mental Health Program

( NMPHP)
1987-Mental Health Act
1995- Persons with disability act :
acknowledged mental disability
1996-97 DMHP launched in 4 districts of
the country

22

2010- Mental Health care bill drafting initiated

2011 Restructured NMPHP 11th five yr plan
65th world health assembly 2012 : approved &
adopted resolution WHA 65.4 envisages Coordinated response from health & social sectors at
the community level . India was one of the main
sponsors of this resolution .

NMHP-1982

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
: diffusion of mental health skills to the
periphery of the health service system
; appropriate appointment of tasks in
mental healthcare;
integration of basic mental healthcare
into general health services and linkage to
community development and mental
healthcare.
The service component will include three
sub-programmestreatment,
rehabilitation and prevention.

Advantages of Mental Health Care at

district
The district is an independent administrative unit with
district commissioner as the head
2. DHO (District Health Officer) has powers of
planning activities in the district
3. Monitoring of programmes occur at the district level
4. Inter-sectoral coordination is possible at the district
level

DMHP - (Bellary Project)

DMHP

was formally inaugurated at Bellary on

20th July 1985 with technical inputs from
NIMHANS

Covering

a population of 1.5 million distributed in

7 talukas at Bellary district, in Karnataka state

DMHP - (Bellary Project)

Objectives
To develop and implement a decentralized training
programme in mental health
To provide the minimum range of essential drug
To develop a system of simple recording and reporting
To monitor the effect of the service
To develop mechanisms of community participation

DMHP - (Bellary Project)

Components
Training of personnel
Provision of drugs
Simple recording system
District level programme officer & team
District Mental Health Clinic & Weekly mental health clinic in the
periphery
Review-cum training as part of visits to the periphery
Monthly reporting, monitoring and feedback
Field training for MH professionals

DMHP - (Bellary Project)

Results
During the first three years of the project (1985-1988),
1200 psychotics,
3525 epileptics,
750 neurotics and
380 mentally retarded persons were registered
Of the psychotics, 42% took treatment regularly and
showed improvement.

DMHP ---Launched at national level1996-97

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.

ixTH 5 YR PLAN
1997-5

districts
1998 ---5 districts
1999-2000- 6 districts - bankura

XTH and XI plan

Extended to 127 districts

Manpower development
Strengthening Medical colleges
Centre of excellences
Mental hospitals
IEC

Critique - Erwadi Tragedy

Erwadi- a small town in Ramanathapuram district ,

Tamil Nadu,famous for its 600 yr old Dargah
17 private asylums run by traditional healers
Treatment by restraint, bath in holy water & holy
oil in the lamp
Physical abuse has also been reported

The Badshah asylum had 43 patients including

schizophrenics, mentally retarded and epileptics
On August 6 2001 early hours, fire broke out in the
asylum
The patients who were chained could not escape but only
yell for help
The neighbours mistook the cry as the usual cry of
insane
25 inmates died immediately, 3 died later in hospital, the
other 15 were rescued

The Aftermath- Government Response

Closure of all illegal asylums in the district

571 patients recovered- 152 admitted in IMH, Chennai
;11 in local govt. Hospital: others returned home
Vow to implement NMHP
A Commission to review the mental health services in
the state
Poor implementation & deficiencies in the mental
health legislation

Critique
India

s mental health bureaucracy

Going

to the community
Local health center so near so far

Mana
Role

Symp

Administrative
Funds
Inter
Top

sectorial lack of coordination

down approach

41

Ground Reality

prevalence of mental disorders in India is 6-7% for common mental disorders

1-2% for severe mental disorders

Treatment gap for severe mental disorders is approximately 50%

Common Mental Disorders :over 90 %

current bed-population ratio for Government hospital beds

Urban areas (1.1 beds/1000 population)
Rural areas (0.2 beds/ 1000 population)

India spends less than 1% of its total health budget on mental health.
severe shortage of mental health professionals, with one psychiatrist for every 3.4 lakh people.

161 )

(Ministry of Health and Family Welfare, Annual Report 2012-13, p.

World Health Organization's Mental Health Atlasof 2011

 Absence
Political

of health culture in villages

and administrative will

Modified DMHP
Counseling
Work

stress management
Suicide prevention
Help of NGO
IEC
School mental health programmes

REHABILITATION
Mental

hospitals

Models

of rehabilitation

45

Evolution of National Mental Health Policy

April 2011 : GOI constituted policy group .

The policy group consisted of addl. Secretary of Mohfw as convenor

and member secretary

members from various fields such as faculties from NIMHANS ,LGB-IMH

Tezpur and indian law institute, Private psychiatrists, social organisations
and NGOs working in the field of mental health

The policy group also received technical Inputs from WHO.

Sub-groups were also formed to review DMHP for 12th five yr plan &
framing rules for mental health facilities for mental health care bill

MOHFW launched National Mental Health Policy 10th October 2014

46

Terminology

Mental Health : a state of well being in which the individuals

realize their own abilities , can cope with the normal stresses
of life, can work productively and fruitfully and are able to
make a positive contribution to their community

Mental health problems : conditions ranging from psychosocial distresses to mental illness and mental disability

Mental illness : refers to specific conditions such as

schizophrenia , Bipolar disorder, depression or OCD.

Persons with mental illness and persons with mental health

problems

47

Terminology
Mental

disability : refers to disability

associated with mental illness.

Persons

affected by mental illness

include persons with mental illness and
significant others such as family
members and care givers .

48

Vision

To promote mental health

To prevent mental illness

Enable recovery from mental illness

Promote destigmatization

Ensure socio-economic inclusion of persons affected with mental illness

providing accessible,affordable, quality health & social care

rights based framework

49

Goals and Objectives

Goals
To reduce distress, disability, exclusion, morbidity & premature
mortality associated with mental health problems across lifespan.
To
To

enhance understanding of mental health in country.

strengthen the leadership in mental health sector at national,

state and district levels.

50

OBJECTIVE

To

provide universal access & utilization of mental health care

To

increase access to services for vulnerable groups

To

reduce prevalence and impact of risk factors associated with mental

health problems
To

reduce risk and incidence of suicide & attempted suicide

To

ensure respect for rights and protection from harm.

51

Objective
To

reduce stigma associated with mental health problems

To

enhance availability and equitable distribution of skilled human

resources
To

progressively enhance financial allocation & improve utilization for

mental health promotion & care
To

identify & address the social, biological and psychological

determinants of mental health problems and to provide appropriate
interventions

52

Cross cutting Issues

Stigma

Rights based approach

Support for families

Inter-sectoral collaboration

Adequate funding

Provision of funds across related departments

Cross cutting Issues

53

Vulnerable populations : children, women, economically & socially

deprived , older persons and persons with physical disabilities

Conditions that increase vulnerability & need to be addressed :

Poverty
Homelessness
Persons inside custodial institutions
Orphaned persons with mental illness
Children of persons with mental health problems
Elderly care-givers
Internally displaced persons
Persons affected by disasters & emergencies

54

Cross cutting Issues

Institutional care : All in patient facilities must be linked to

community care for persons with continuing care or who are being
managed in community.

Promotion of mental health :

- predictable negative influences of socio-economic factors
- life stages unique challenges be recognized & addressed

55

Strategic directions and recommendations

Effective governance & accountability for mental health
Develop

relevant policies & regulations within all relevant sectors

Adequate

budgetary provision across sectors

Motivate

& engage stakeholders from relevant sectors in

development , implementation & evaluation of policies & services
Develop

& sustain technical capacity & suitable mechanism at all

levels to plan, monitor & evaluate implementation of policies &
programs

56

Strategic directions and recommendations

Promotion of mental health
Re-design

Anganwadi centres to cater to early child care, development

& emotional needs of children below 6 yrs with separate attention to
children under 3 years .
Introduce

mother-child sessions on parenting skills

Train

anganwadi workers & school teachers with knowledge & skill to

support parents & caregivers in understanding physical & emotional
needs of children
Life

skills education (LSE) program should be offered to school children

& college going young facilitated by skilled teachers & trainers

57

Strategic directions and recommendations

Promotion of mental health

Design appropriate curricula, teacher student relationship,

provision of suitable infrastructure in school system

Workplace policies to assist adults in handling of stressful life

circumstances

Mass media events, contact programs, counselling services,

help lines, websites

Increase awareness among policy makers & goverments to

reduce income disparities

58

Strategic directions and recommendations

Promotion of mental health

Encourage action to change poor living conditions

Implement programs to reduce risk factors for women

mental health

Gender sensitization programs for health system staff

Include Yoga & Avurveda practitioners as activists for

mental health promotion

59

Strategic directions and recommendations

Prevention of mental illness and reduction of suicide and
attempted suicide
Address
Enable

stigma, discrimination & exclusion

access to treatment & other care giving facilities

Encourage

PMHP to actively participate in socialeconomic activities

Mental

disability be treated on par with other disability

Scenario in west Bengal

Twenty beds are available in each district

Essential psychiatric drugs are available in mental hospitals even
at district level
PG seats have been increased to 18 in psychiatry
Eight institutions in west Bengal are offering MD psychiatry
courses
Institute of Psychiatry, Kolkata has been selected & declared as
Centre of Excellence &an amount of Rs. 30 crore already allotted
for urgent civil works.
De-addiction service is being provided by government medical
college and govt. mental hospital

conclusion

GHPU strenghthened

127

districts covered under DMHP

Psychotropic drugs are made available

Rehabilitation models lacking

Poor implementation of the available programmes

and legislations is a major cause for the Erwadi
tragedy
There is an urgent need to implement the existing
program before amending to prevent future tragedies

 Thank

you.