Community Mental health Current scenario

Dr. Manish Kumar

Community mental healthProviding 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, trepheningLater electric shock therapy, opium, cannabis and alcohol was introduced as treatmentIn 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 treatmentBenjamin 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 re-introduced.

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 MovementCompulsory 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 ProgramUnderNazi 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 centuryMental Hospitals and DeinstitutionalizationThe movement for deinstitutionalization came to the fore in various countries in the 1950s and 1960sSeveral researchers agree that the introduction of new health care policies and changes in the provision of public welfare played at large role in deinstitutionalizationIt was suggested that new psychiatric medications made it more feasible to release people into the community. Mental health acts promoted this system

Introduction to RehabilitationPsychiatric 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 VelloreIn 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 hospitalsThe 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 MumbaiIn 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 IndiaDr Vidya Sagar- Amritsar Mental Hospital and De-institutionalisation:-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 ExperimentSoon 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

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 2/1000Shortage of mental health professionalsRecommended inclusion of preventive mental services as well ( school counselling , orientation of public professionals)Recommended need for increased research.*

Major community mental health initiatives in India 1974 Srivastava Committee : recommendation of Communiy Health Volunteer (CHV), Group on Medical Education and Support Manpower1976 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 careMajority remained untreated inspite of being close to mental hospital.First visit to traditional healing centersHealth care worker could easily identify and report casesLimited number of drugs were effective in treatmentMost psychotic patients could be treated and successfully rehabilitated

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1982 : National Mental Health Program ( NMPHP) 1987-Mental Health Act 1995- Persons with disability act : acknowledged mental disability1996-97 DMHP launched in 4 districts of the country

2010- Mental Health care bill drafting initiated 2011 Restructured NMPHP 11th five yr plan65th world health assembly 2012 : approved & adopted resolution WHA 65.4 envisages Co-ordinated response from health & social sectors at the community level . India was one of the main sponsors of this resolution .

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NMHP-1982The 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 head2. DHO (District Health Officer) has powers of planning activities in the district3. Monitoring of programmes occur at the district level4. 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)ObjectivesTo develop and implement a decentralized training programme in mental healthTo provide the minimum range of essential drugTo develop a system of simple recording and reportingTo monitor the effect of the serviceTo develop mechanisms of community participation

DMHP - (Bellary Project)ComponentsTraining of personnelProvision 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)ResultsDuring the first three years of the project (1985-1988), 1200 psychotics,3525 epileptics, 750 neurotics and 380 mentally retarded persons were registeredOf the psychotics, 42% took treatment regularly and showed improvement.

DMHP ---Launched at national level-1996-971.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 PLAN1997-5 districts1998 ---5 districts1999-2000- 6 districts - bankura

XTH and XI planExtended to 127 districts

Manpower development Strengthening Medical collegesCentre of excellences Mental hospitals IEC

Critique - Erwadi Tragedy Erwadi- a small town in Ramanathapuram district , Tamil Nadu,famous for its 600 yr old Dargah17 private asylums run by traditional healersTreatment by restraint, bath in holy water & holy oil in the lampPhysical abuse has also been reported

The Badshah asylum had 43 patients including schizophrenics, mentally retarded and epilepticsOn August 6 2001 early hours, fire broke out in the asylumThe patients who were chained could not escape but only yell for helpThe neighbours mistook the cry as the usual cry of insane25 inmates died immediately, 3 died later in hospital, the other 15 were rescued

The Aftermath- Government ResponseClosure of all illegal asylums in the district571 patients recovered- 152 admitted in IMH, Chennai ;11 in local govt. Hospital: others returned homeVow to implement NMHPA Commission to review the mental health services in the statePoor implementation & deficiencies in the mental health legislation

Critique

India s mental health bureaucracy

Going to the communityLocal health center so near so far

Administrative Funds

Inter sectorial lack of coordination

Top down approach

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.

(Ministry of Health and Family Welfare, Annual Report 2012-13, p. 161 ) World Health Organization's Mental Health Atlasof 2011

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Absence of health culture in villages

Political and administrative will

Modified DMHPCounseling Work stress managementSuicide prevention Help of NGO IECSchool mental health programmes

REHABILITATIONMental hospitals

Models of rehabilitation

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 *

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 psycho-social 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

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TerminologyMental 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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VisionTo 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*

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

To enhance understanding of mental health in country.

To strengthen the leadership in mental health sector at national, state and district levels.

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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.

*OBJECTIVE

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

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Cross cutting Issues Stigma

Rights based approach

Support for families

Inter-sectoral collaboration

Adequate funding

Provision of funds across related departments

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Cross cutting Issues Vulnerable populations : children, women, economically & socially deprived , older persons and persons with physical disabilities

Conditions that increase vulnerability & need to be addressed :

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

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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

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Strategic directions and recommendationsEffective 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

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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 & trainersStrategic directions and recommendations*

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

Strategic directions and recommendationsPromotion 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

Strategic directions and recommendationsPromotion of mental health *

Prevention of mental illness and reduction of suicide and attempted suicide

Address stigma, discrimination & exclusion

Enable access to treatment & other care giving facilities

Encourage PMHP to actively participate in social-economic activities

Mental disability be treated on par with other disabilityStrategic directions and recommendations*

Scenario in west BengalTwenty beds are available in each district Essential psychiatric drugs are available in mental hospitals even at district levelPG seats have been increased to 18 in psychiatryEight institutions in west Bengal are offering MD psychiatry coursesInstitute 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 availableRehabilitation models lacking

Poor implementation of the available programmes and legislations is a major cause for the Erwadi tragedyThere is an urgent need to implement the existing program before amending to prevent future tragedies

Thank you.

Instituonalization movement by pinel . Lead to birth of community treatment*These are two important models for community .have long lastingeffect.*