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
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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

Removed restrained. as well as sought their reintegration into society . open door treatment Benjamin Rush of Philadelphia also promoted humane treatment of the insane outside dungeons and without iron restraints.   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 as moral treatment) as the superintendent of the Bicêtre Hospital in Paris.

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

an apparent salvation emerged. Ice water baths were once again used along with shock machines and electro. The severe overcrowding led to a sharp decline in patient care and once again. the revival of old procedures and medical treatments.convulsive therapy were reintroduced. the asylums reached its peak population. . when mental health treatment was arguably at its worst. restraints returned. In the 1950s.   In the mid 1900s.

 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. .

 As late as the 1950s.Eugenics Movement  Compulsory sterilization of the "feeble-minded" The eugenics movement 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. . laws in Japan allowed the forcible sterilization of patients with psychiatric illnesses.

the euthanasia program resulted in the killings of thousands of the mentally ill housed in state institutions. children and teenagers were murdered by starvation or lethal injection .000 disabled babies.Germany and Occupied Europe: Nazi Euthanasia Program  Under Nazi Germany. the Nazis secretly began to exterminate the mentally ill in a euthanasia campaign. Around 6. In 1939.

Mental health acts promoted this system .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.

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

   Another important innovation in the 1960’s was the concept of a day hospital. . Occupational therapy and recreational facilities were introduced in a phased manner in many of the large institutions. 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. by which the patients resided in the community with their families.

Evolution    Vidyasagar in Amritsar (1950) Based on this principle. family wards were established in Bangalore mental hospital and CMC Vellore In India.G. the early attempts to start psychiatric services outside mental hospitals began with the initiative of psychoanalysis pioneers. . the founder of the first psychoanalysis society in India.Kar Medical College in Kolkata in 1933. Dr Girindra Shekhar Bose. started the first GHPU at R.

    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. Another psychoanalyst.J. Dr K. Dr N. K. Hospital.E. which made it relatively easy to treat a wide variety of psychiatric disorders in general hospitals. Amritsar. Vahia started a psychiatric unit at K. Masani opened a similar unit in Mumbai in 1938 at J. . A little later in the 1940s. Medical College in Mumbai In the mid-1950s the movement rapidly spread to many centres in India like New Delhi. both in out-patients clinics and in-patient wards. Lucknow. S.

1975. Dr R. that a crash programme for community based mental health was introduced at NIMHANS. Minister of Health.4 Important Movements in Community Mental Health in India    Dr Vidya Sagar. This unit launched the following experimental programmes: .Varma and that of Dr Karan Singh.Amritsar Mental Hospital and Deinstitutionalisation:General Hospitals psychiatric units:The NIMHANS Crash Programme:-It was at the initiative of the director. A community psychiatry unit was also started in October.M. central government.

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  .

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

Components .

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.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. .

“ 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 .20 Major community mental health initiatives in India 1974 Srivastava Committee : recommendation of Communiy         Health Volunteer (CHV).

 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 .

Mental Health care bill drafting initiated 2011 Restructured NMPHP – 11th five yr plan 65th world health assembly 2012 : approved & adopted resolution “WHA 65. . India was one of the main sponsors of this resolution .4” envisages Coordinated response from health & social sectors at the community level .22 2010.

. (b) to encourage the application of mental health knowledge in general healthcare and in social development.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. and (c) to promote community participation in the mental health service development and to stimulate efforts towards self-help in the community.

 integration of basic mental healthcare into general health services and linkage to community development and mental healthcare.Approaches to NMHP : diffusion of mental health skills to the periphery of the health service system  .  . rehabilitation and prevention.  The service component will include three sub-programmes—treatment. appropriate appointment of tasks in mental healthcare.

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

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 .

(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 .

DMHP . monitoring and feedback  Field training for MH professionals .(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.

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

2. . 3.DMHP ---Launched at national level1996-97       1. To take pressure off the mental hospitals. 5. To treat and rehabilitate mental patients discharged from the mental hospitals within the community.To provide sustainable basic mental health services to the community and to integrate these services with other health services.Early detection and treatment of patients within the community itself. To reduce the stigma attached towards mental illness through change of attitude and public education. 6. 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.

ixTH 5 YR PLAN  1997-5 districts  1998 ---5 districts  1999-2000.bankura .6 districts .

XTH and XI plan  Extended to 127 districts Manpower development  Strengthening Medical colleges  Centre of excellences  Mental hospitals  IEC  .

a small town in Ramanathapuram district .famous for its 600 yr old Dargah 17 private asylums run by “traditional healers” Treatment by restraint.Erwadi Tragedy     Erwadi. bath in “holy water” & “holy oil” in the lamp Physical abuse has also been reported . Tamil Nadu.Critique .

3 died later in hospital.     The Badshah asylum had 43 patients including schizophrenics. the other 15 were rescued . 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. mentally retarded and epileptics On August 6 2001 early hours.

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 . Chennai .11 in local govt.152 admitted in IMH.Government Response      Closure of all illegal asylums in the district 571 patients recovered.The Aftermath.

Critique  India s mental health bureaucracy  Going to the community  Local health center – so near so far .

Mana Role Symp .

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Administrative  Funds  Inter  Top sectorial lack of coordination down approach .

1 beds/1000 population) Rural areas (0. p. severe shortage of mental health professionals.  161 ) (Ministry of Health and Family Welfare.4 lakh people.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 (1.2 beds/ 1000 population)  India spends less than 1% of its total health budget on mental health. with one psychiatrist for every 3. World Health Organization's  Mental Health Atlas of 2011 . Annual Report 2012-13.

 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 .

social organisations and NGO’s working in the field of mental health   The policy group also received technical Inputs from WHO.  The policy group consisted of – addl. Secretary of Mohfw as convenor and member secretary  members from various fields such as – faculties from NIMHANS . 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 .45 Evolution of National Mental Health Policy  April 2011 : GOI constituted policy group .LGB-IMH Tezpur and indian law institute. Private psychiatrists.

46 Terminology  Mental Health : a state of well being in which the individuals realize their own abilities . depression or OCD.  Persons with mental illness and persons with mental health problems . 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 . can cope with the normal stresses of life. Bipolar disorder.

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 . .

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Vision
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To promote mental health

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To prevent mental illness

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Enable recovery from mental illness

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Promote destigmatization

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Ensure socio-economic inclusion of persons affected with mental illness

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providing accessible,affordable, quality health & social care
rights based framework

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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.

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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.

biological and psychological determinants of mental health problems and to provide appropriate interventions .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.

52 Cross – cutting Issues  Stigma  Rights based approach  Support for families  Inter-sectoral collaboration  Adequate funding  Provision of funds across related departments .

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 . economically & socially deprived .Cross – cutting Issues  53 Vulnerable populations : children. women.

life stages unique challenges be recognized & addressed .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 .

monitor & evaluate implementation of policies & programs . implementation & evaluation of policies & services Develop & sustain technical capacity & suitable mechanism at all levels to plan.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 .

56 Strategic directions and recommendations Promotion of mental health Re-design Anganwadi centres to cater to early child care. 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 . development & emotional needs of children below 6 yrs with separate attention to children under 3 years .

57 Strategic directions and recommendations Promotion of mental health  Design appropriate curricula. provision of suitable infrastructure in school system  Workplace policies to assist adults in handling of stressful life circumstances  Mass media events. teacher student relationship. help lines. websites  Increase awareness among policy makers & goverments to reduce income disparities . contact programs. counselling services.

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 .

Kolkata has been selected & declared as Centre of Excellence &an amount of Rs.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. 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……. .