mental health in india

7/31/2019 Mental Health in India

1/12

24

District Mental Health

Programm e in India:A Case S tudy

Anant Kumar

Understanding the P roblem

Mental health is undeniably one of our most preciouspossessions, which needs to be nurtured, promoted, andpreserved as best as we can. It is the state of mind in which theindividual can experience sustained joy of life while working

prod uctively, interacting with others m eaningfully, and facingup adversities without loosing the capacity to functionphysically, psychologically and socially. It is undoubtedly avital resource for a nation's development, and its absencerepresents a great burden to the economic, political, and socialfunctioning of the nation.

T he World H ealth O rganisation (W HO ) d efines mental healthas a positive sense of well being encompassing the physical,mental, social, basic economic, and spiritual aspects of life; not

just the ab sence of disease. Mental health is a barometer of thesocial life of a population and the rising level of morbidity and

mor tality is a sign of social as well as individual malaise. T hescope of mental health is not only confined to the treatment of some seriously ill persons admitted to mental health cen tres,rather it is related to the whole range of health activities.

In the past, besides the various steps taken by the government,non-governmental organisations (NGOs) and other agenciesto improve mental health services, mental health d id not findits approp riate place in the national and State health p lanning.Since independ ence, the government recognised the need tobe proactive in its approach to promote good mental health of its citizens and to p rovide good quality care to those suffering

from mental disorders. But, unfortunately, these efforts areonly reflective and con fined to various recomm endations andmeetings, perhaps due to various reasons and the commonmisconception that prevalence of mental illness is low in India,par ticularly as compared to th e West. It is unfortun ate thatafter fifty years of independence, besides having a National

R E S E A R C H

Journal H & D Vol 1 No 1.qxd 5/9/05 2:20 PM Page 24


2/12

25Vol. 1 No. 1 January March 2005

Mental Health Programme (N MH P), we do not have any country-wideepidemiological data of m ental illnesses and there are on ly estimates, andthose estimates are based on the prevalence and incidence in other countries(Kumar 2002).

Although we do not have any epidemiological data, research studies fromdifferent parts of the countr y have shown that mental illness is as common inIndia as it is elsewhere and it is equally common in the ru ral and the urbanareas. Mental disorders cause an enormous burd en on affected individuals,their families and society, although this suffering m ay not be visible to oth ers.Over the years, mental illnesses have increased m anifold. Although there hasnot been any epidemiological study, psychiatrists estimate that about 2 p er centof Indians suffers from mental illnesses, i.e., a staggering 20 million p eople outof a population of one billion.

Rationale and Objective of the Study

With this background, a study was und ertaken to examine the state of mentalhealth services in India from a public health perspective, considering preventiveand prom otive aspects of mental health and recognising the socio-culturalfactors in mental health services.

T he objective of the stu dy was to review the development of mental healthservices in India and to analyse the imp lementation of the District M entalHealth Programme (D MH P) u nder the National Mental Health Programme(NMHP).

MethodologyT he study largely relied up on the various secondary sources (viz., governmentrepor ts, policy papers related to mental health pu blished by the Ministry of Health and Fam ily Welfare, Directorate G eneral of Health Services, PlanningCommission, and books and articles published in various Journ als) forliterature review and conceptual clarity on the subject of mental health. Bothprimary and secondary sources were used to gather information about theservices rendered. Initially, information was gathered throu gh the ministryabout the programm e and its objective. Further information was collected fromdifferent studies and research papers from various sources. Information wascollected from the field by administering case studies on selected nine patients

and informal interviews with local people, patients and their family members,and service providers (the doctor and social worker).

For the in-depth q ualitative insights, the study was undertaken usingobservation technique [at the Psychiatric OPD at Babu Jagjivan Ram MemorialHospital (BJRMH)] and in-depth case studies were conducted with ninepatients visiting the DMHP clinic at Jahangirpuri in Delhi during September-



3/12


D ecember 2000. In observation the emphasis was on service delivery, doctor-patient relationship, infrastructure availability, and prob lems in service deliveryin the background of D MH P guidelines and objectives of DM HP and N MH P.Informal interviews were also done with 25 p atients and 25 family members(care-givers) about the services available at Psychiatric Un it (D MHP,Jahangirpuri) and their understanding and perception of mental health andillness. Apart from these, secondary data was collected from various sourcesand in some cases informal unstructured interviews were also carried ou t.

Tools of Data Collection

Structured and unstructured interview schedule and observation techniquewere mainly used to collect information for the study. Apart from these,secondary data from various sources and in some cases informal unstructured

interview was also carried out.Observation Technique: T his technique was followed throughout the studyfrom the services point of view to see the services rendered by the O PDkeeping in background the D MH P guidelines, local needs, and infrastructureavailability. For the case studies, details regarding living conditions,demograp hic and socio cultural factors of the patients were collected.

Case study method : T his study is mainly based on the q ualitative data andcase studies on p atients. Within the case studies, quantitative information wasalso gathered, such as monthly income etc. In the case studies, the key areas of emphasis were personal information and demographic information of thefamilies, substance abuse, and the p atients perception of the problem.Emp hasis was also given on the perception of the p roblem/ illness among thepatients' family members/caregivers, the place of living, migration, majorstresses, information about the community outreach programme/DM HP, detailsof any previous medical interventions ( in the context of type of practitioners/cost/satisfaction) , need for mental health services, suggestions toimprove the existing facilities, prob lem with present facilities, and the patientsand family members p erception of services and m ental health and illnesses.

Interviews : Informal interviews were done with the patients and their familymembers while they waited for their turn at the psychiatric OPD about theservices, facilities available and their perception of mental health and the needfor services.

For interviewing service providers ( the doctor and social worker) same m ethodwas followed.

Both, the case studies and the informal interviews with the patients and th eirfamily members gave valuable insights about their perception of mental healthconditions and the services available.T he informal interviews helped in



4/12


exploring processes, relationships and its consequences in greater detail. Somekey results of the study are p resented here.

National Mental Health Programm e (NMHP )The Beginning

T he National Mental Health Programme (DG HS 1990), started in 1982 bythe governm ent, was the outcome of th e various initiatives taken to providemental health care through different methods as well as overall goals of healthcare in general. It aims at providing mental health care to the populationutilising the available resources.

T he Governm ent of India initiated the National Mental Health Programme in1982 with the objective of improving mental health services at all levels of health care (pr imary, secondary, and tertiary) for early recognition, adequatetreatment an d rehabilitation of the p atients with mental health p roblems withinthe community and in the hospitals. However, the programme did not m akemuch headway either in the Seventh or the Eighth Plan. Mental hospitals are inpoor shape. T he States have not p rovided sufficient fun ds for the mentally illrequiring inpatient treatment despite the Supreme Court having directed theCentre and the States to m ake necessary provision for these hospitals so thatthe inmates do get humane and appropriate care (Ninth Five-Year Plan,Government of Ind ia).

T he C entral Council of Health and Family Welfare recommended th at mentalhealth must form an integral part of the total health programme and should beincluded in all national policies and program mes in th e field of education andsocial welfare and th e impor tance of mental health m ust be raised in thecourses/curricula for various levels of h ealth p rofessionals. A comm ittee underthe chairmanship of G.N. Narayana Reddy, Director, NIMH ANS, Bangaloresubmitted a plan for the implementation of the NM HP. T he salient features of the plan were:

1. Programme of commun ity mental health at primary health care level inStates/union territories;

2. Setting up of regional centres for community mental health;3. Formation of a national advisory group on mental health;4. Setting up of a task force on mental health;5. Prevention of mental illness and promotion of mental health;

6. Integration of multipurpose training schools in N MH P;7. Involvement of voluntary agencies in mental health;8. Mental health education for the undergraduates;9. Evaluation of community mental health programmes;10. Preparation of manuals and records; and11. Training programmes for m ental hospital staffs;



5/12


An outcome of these recommendations was the order of 22 September 1987issued by the government, which outlined the pattern of assistance for NM HPduring the Seventh Five Year Plan to the States.

NMHP : The Objectives and Approaches

T he key objectives of NM HP (G overnm ent of India 1982) are:

a) To ensure the availability and accessibility of minimum m ental health care forall in the foreseeable future, par ticularly the most vulnerable and un privilegedsections of the population;

b) To encourage the application of mental health knowledge in general healthcare and social development; and

c) To promote community participation in developing mental health services,and to stimulate efforts towards self help in the comm unity.

T he specific approaches suggested for the implementation of NM HP are:

a) D iffusion of mental health skills to the periphery of the health servicesystem;

b) Appropriate appointment of tasks in mental health care;

c) Equitable and balanced territorial distribution of resources;

d) Integration of basic mental health care within general health services; and

e) Linkages to community development.

T he C entral Cou ncil of Health and Family Welfare has recommen ded th atmental health should form an integral part of the total health programme and

should be included in all national policies and program mes on health,education, and social welfare. T he Centr al C ouncil of Health and Fam ilyWelfare reviewed the progress and resolved that the National Mental HealthProgram me should b e accorded d ue p riority and full-scale operationalsupport, (including social, political, professional, administrative, and financialback up) are provided.

During the Eighth Plan, National Institute of Mental Health and Neurosciences(NIMHANS) developed a district mental health care model in Bellary districtof Karnataka (Isaac 1988). It is proposed that during the N inth Plan p eriod theexperience gained in implementing mental health care, both in the central andState sectors, will be u tilised to p rovide sustainable mental health services at

primary and secondary care levels and to build up community support fordomiciliary care. Information, education, and communication (IEC) on mentalhealth, especially prevention of stress-related disorders th rough p romotion of healthy lifestyle and operational research studies for effective implementation of preventive, prom otive, and curative program mes in mental health throughexisting health infrastructure will receive due attention.



6/12


As decided in the meeting of the Central Council of Health in 1995 and asrecommended by the workshop of all the health administrators of the countryheld in Febru ary, 1996, the District Mental Health P rogramme was launchedin 199697 in four districts, one each in Andhra Pradesh, Assam, Rajasthan,and Tamil Nadu with a grant assistance of Rs. 22.5 lakhs each. A budgetaryallocation of Rs. 28 crore has been made during the Ninth P lan for theNational Mental health programme.

T he programme envisages a community based app roach to the problem, whichincludes:

(i) training of the mental health team at the identified nodal institute within aState;

(ii) increasing awareness about mental health prob lems;

(iii) providing services for early detection and treatment of mental illness in th ecommunity itself with both OPD and indoor treatment and follow-up of discharge cases; and

(iv) provide valuable data and experience at the level of community in the Stateand C entre for future planning, improvement in services, and research.N IMH ANS, Bangalore is providing the training to the trainers at the Statelevel regularly under the National Mental health Programme.

T he D istrict M ental Health Programme (D MH P) was extended to sevendistricts in 199798, five more districts in 1998, and six more districts in19992000. T hus this programme is being implemented in 22 districtscovering 20 States.

DMHP The B eginningDistrict Mental health Programme (Under the National Mental HealthProgram me 199697) was successfully developed by National Institute of Mental Health and Neuro Sciences (NIM HANS) , Bangalore in the Bellarydistrict of Karnataka, and it is conceived as a model and adop ted by all Statesfor implementation.

D MHP The Objectives

T he objectives of the programm e are:

a) To provide sustainable basic mental health services to the community and tointegrate these services with other health services;

b) Early detection and treatment of patients within the community itself;c) To ensure that patients and their relatives do not have to travel long distances

to go to hospitals or nursing home in cities;d) To take the pressure off from mental hospitals;e) To reduce the stigma attached towards mental illness through change of

attitude and public education; and



7/12


f) To treat and rehabilitate mental patients discharged from the mental hospitalwithin th e comm unity.

DMHPKey Features

1. T he States will set in m otion the process of finding suitable personnel formann ing the D MH P teams. T hey can take in service candidates who arewilling to serve in this pilot project and provide them the necessarytraining in the identified institution.

2. T he patients will be from the district itself and the adjoining areas.3. D istrict M ental Health Team will be expected to provide service to the

needy m entally ill patients and their families, such asdaily out-patientservice, ten bedded in-service facilities, referral service and liaison withthe primary health centres, follow up service, awareness programmes, andalso community survey if feasible.

D MHPThe Jahangirpuri Experience

T he District Mental Health Program me is being implemented as a pilotproject, in Ch hatarpur d istrict of D elhi.T he allocation grant by the centralgovernment for the programm e is Rs. 1.5 crore for five years. T his coverstraining, recruitment of staff, provision of medicines and IEC activities. T henodal agency is the Institute of H uman Behaviour and Allied Sciences,Shahadara, N ew Delhi. In place of Chhatarpur D istrict the programme wasimplemented in Jahangirpu ri, at Babu Jagjiwan Ram Mem orial Hosp ital,because the Pradhan of Chhatarpur district was not ready for suchprogrammes. Although from December 2001, DM HP also began its operations

at Chhatarp ur, the present study covers only Jahangirpu ri area.Profile of Jahangirpuri Resettlement Colony

Jahangirpu ri presents a mix of Slum characteristics and refugee resettlementpattern. T he colony was earlier meant for resettlement of the refugees fromPakistan and P unjab. T here are 11 blocks in the colony with plotted housingscheme, which are interspersed with jhuggi-jhopri clusters. With the passage of time, many of these plots have been sold to migrant workers, mostly dailywagers or p etty traders.

T he colony is overcrowded and the p opulation density is quite high where fiveto six people are living in one room of 10x12 ft size.T he basic amenities are

inadequate. T here are common toilets for both males and females. T his createsprob lem of availability and become unsafe for human habitation. In add ition,overcrowded p ublic utilities often face the p roblem of maintenance andsustenance of public utility.

In Jahangirpu ri, the squatter ( Jhuggis ) settlement over-crowded. Dwellings aresmallon an average about 2.5m wide and about 3m long. A few people have



8/12


a second floor, usually reached by a ladder. T he streets are irregular in width.Most are just wide enough for a rickshaw to pass through. T here are somesmall open spaces on the streetsusually at the end of culs-de-sacbut thereare a few more formal community spaces, such as temple courtyards. D rainageis a problem. T he site is relatively flat and is at the edge of a swamp. Many of the open d rains are blocked. T hey are cleaned twice a week, but mostly remainfull with h ousehold wastes. In som e places streets have been p aved with br icks,which have raised their level above the floor level of the houses, with obviousconsequences during heavy rain.

Occupational S tructure

T he occupational structure is quite diverse. T here are people working ingovernment service, private service, sales, production, labour, self-employment,

and petty business. Basically the population is involved in the informal sectorfor bare sur vival. A large num ber of them b elong to categories such as dr iver,mechanic, safai, brush maker, factory worker, rickshaw puller, constructionworker, or house maid etc.

Income

T he qualitative data based on the case studies shows that due to a large numberof informal sectors, there is a great variation in the level of income. Level of income as economic stratification has been playing pivotal role in determiningthe issue of access to basic amenities and health services.

Status of DMHP in Jahangirpuri: A Preliminary Report

T he study in Jahangirpu ri was und ertaken with an ob jective to und erstandthe d evelopm ent of m ental health services in In dia and to see theimplementation of District Mental Health Programme under the NationalMental Health Programme (1982) as a decentralised model of mental healthcare in Ind ia.

In this study, a modest attempt is made to examine the implementation of DMH P, its shortcom ings and other associated factors. T he findings of thestudy, which are based on inter views, give preliminary insights into thefunctioning of DMHP.

T he psychiatric OPD is situated at Babu Jagjiwan Ram Mem orial Hosp ital in a

single room in the general ward of the hospital. T here is no signboard wherethe service is presently given. T his leads to a lot of runn ing around for theilliterate population in trying to locate the doctor or the room where the serviceis given. T he room allotted for the purpose is very small. However, the room isused for the treatment of patients as well as for distribution of medicine by thesocial worker.T he resident doctor com ing from IHBAS to assist the main



9/12


doctor also uses the same room. With so many officials operating from thesame room and the presence of waiting patients in the room, the patients find itdifficult to share their p roblems with the doctor.

Presently the service is available once a week on Wednesdays, between 10 a.m .and 2 p.m whereas the programm e specifies daily OP D service. Consequently,there is a lot of overcrowding on Wednesdays. T his affects the quality of treatment, as the doctor is not able to allocate adequate time to each and everypatient. Even the doctor corroborated the facts and felt constrained andsuggested the extension of the OP D service on a daily basis. Due to the non-availability of daily OP D services, the programm e is not accessible to m ajorityof the working population. As has been mentioned earlier, most of theinhabitants of the area are engaged in p etty activities like vending, rickshawpulling, masonar y, daily wage labour, or government servants. It is difficult formost of them to m iss out their daily labour. People expressed the need to makethe service available either in the evening or on Sundays. T he present emphasisof service is only curative, whereas the patients also need gu idance andcoun selling to adjust with families and other rehabilitative measures. T his ispresently not possible due to crowding and it is practically impossible for thedoctor to give enough time to each patient.

Although from the beginning there is emphasis on comprehensive approachand teamwork in the field of mental health including professionals like clinicalpsychologist, physician and other p rofessionals, whereas the services availableare run on ly by a psychiatrist and a social worker. Even at the p rogramm e level,

the psychiatrist and social worker give only curative services against thebroader ob jective of the DMH P. T he social worker is supposed to take care of the social aspects of mental health p roblems, which include prep aration of casehistory, giving insight into the sociological causes of a patient's problem to thepsychiatrist, visiting patients at home, rehabilitative measures, and follow up atthe community level. It is his duty to arrange and organise the communitymental health awareness programmes along with other measures, which willenhance the coping mechanism of the commun ity. But unfortu nately, the socialworker is doing the work of distributing medicines, thereby not utilising thecreative space, which is given to him.

T he sole objective of providing a social worker is to develop a comm unity

based approach towards the problem. T he social worker is supposed to look into the social aspects of the p roblems through counselling and regularinteraction. He is also supposed to look into the social problems which caneither create conditions leading to mental problems or help in accentuatingthem. A proper study of these could also be beneficial to the doctor indiagnosing the patient better and such valuable data and experience can also



10/12


help the government and policy makers in the future planning andimprovement in services and reach. T he social worker is supp osed to be theformal as well as informal link with the community. Contrar y to the roleexpected of him, the social worker here ( Jahangirpu ri) was mostly engaged inthe distribution of medicines. T here was no effort to build a community basedapproach to the p roblem, nor was there any effort to educate the communityabout the various aspects of prevention from mental health problems.

It is evident from the case studies that at p resent there is no emphasis onawareness program mes, which is not difficult keeping in mind the area coveredby the programme. In the case studies and interviews, it was repeatedly stressedthat most of the patients came to know about the services through neighbours,fellow patients, or family members of the patients. Most of the patients are notaware of the DMHP but a large number of them have an idea that thispsychiatric un it is a par t of Babu Jagjiwan R am M emorial Hospital.

Other form s of Coping Mechanism s

It was found in the case studies that there is a substantial section of thepopulation, which visits various spiritual healers, pr iests, and mystics forsolutions to their prob lems. It is quite evident from case studies that patientsare taking treatment at psychiatric OPD and simultaneously they are under thetreatment of spiritual healers. Even in the case studies, one patient reported thather epilepsy is under con trol due to the medicine that she is taking prescribedby psychiatrist and other p roblems like of Devi Aana are un der con trol due to

spiritual healing of Usha Mata. On the basis of this study, it can be reasonablyestablished that since its inception, the DMHP has not been sensitive to thesecultural needs and intricacies.

Another significant finding that came out in the case studies is the doctor'srefusal to take into cognisance these coping mechanisms such as visiting theshamans, pr iests and other indigenous practitioners. Preference for thesepractitioners has its roots in diverse social factors which affect the generalbeing of the patient and his family. Whereas the case history taken by thedoctor does not record this fact and, as a consequence, the whole focus isnarrowed down to a techno-centric (read curative) approach to the problemof mental health. T hus, the much rhetorical emphasis on the issues of

awareness, prevention and other supp ortive mechanisms professed in theprogram me is structu rally excluded while imp lementing the program me. T hismay not be entirely intentional; rather it may be an outcome of the scantresource allocation, which derails the whole program me. T he policymakersand planners should take these shortcomings into account and an appropriatemethodology can be evolved.



11/12


Some Problems in the Implementation of Programme

Some of the salient observations based on the case studies, and in-depthinterviews are as follows:

1. T here is no provision for guidance and counselling. It is found that at timespatients and family members need guidance and counselling to cope withillness.

2. T he service available is run by a psychiatrist and a social worker.T here is nocomprehensive approach and teamwork with the inclusion of professionalslike clinical psychologist and physician.

3. D ue to crowding, the doctor is not able to give adequate time to each patient.4. T here is no coordination between the facilities and various agencies,

especially the NGOs working in the area.5. T here is no integration of mental health care with primary health care.6. N o attempt is made to include the commun ity leaders, workers at the grass

root level such as ANM's, anganwadi workers, and the local NG Os in trainingprogrammes organised by the nodal institute.

7. T here is no provision for early detection and treatment of patients within thecommunity. Presently services are available to those visiting psychiatric OPDthemselves.

8. T here is no awareness programme to reduce the stigma attached to mentalillness through change of attitude and public education.

9. T here is no p rovision to treat and rehabilitate mentally ill patients dischargedfrom the men tal hospitals within th e comm unity.

10. T here is no effort to under take commu nity surveys on mental illnesses andother associated factors, although it is feasible.

11. At times some med icines are not available and patients have to buy themfrom market and there is no provision for reimbursement.

Concluding Observations

T he development of mental health p rogramm es in Ind ia is still at an embryonicstage. Perhaps th is is an advantage for the developm ent of mental healthprogramme as it is occurring at a time when the emphasis is on communitycare and u tilisation of commu nity resources. T his could help u s avoid theprob lems of too much institutionalisation in the field.

T he above discussion clearly signifies that mental health is an impor tantcomponent of health and development of the human society. D espite various

recommendations and p olicies, the development of mental health services hasbeen uneven. Since Indep endence various committees have recommendedpolicies to conduct epidemiological survey to generate base-lineepidemiological data and information system for the developm ent of mentalhealth services. But till date we are dependent on estimates that vary regionallyand are mostly generated on th e basis of hospital admissions and d ischarge. A



12/12


similar lag has been noticed in the implementation of the Mental Health Act,which in sp ite of having been accepted by the parliament in 1987 becomeoperational only in Apr il 1993.

It is necessary on the part of public health personnel to conduct research inbringing out the epidemiological basis of such programmes. Responsibilities alsolie with the social scientists to influence the government and public health workersin order to have a broader view and better understanding for the problems relatedto mental health. In the Indian context, no proper research has been done to seethe ways in which culture and religion influence mental illnesses and health. It isalso clear that mental illness is a significant cause of disability in India, which hasbeen largely ignored in health related developm ent activities.T he impact of economic structural adjustment in impoverishing people, the breakdown of traditional community and family relationships caused by urban migration, andthe myriad adverse effects of newer diseases like AIDS are likely to cause a greaterimpact on peoples psycho-social health. In addition, these programmes do notincorporate proper preventive measures and even curative and rehabilitativeservices provided are inadequate in terms of the estimated needs.

T he case studies of the DMH P at Jahangirpu ri in D elhi show that thedevelopment of support materials and models at the district level facility forinitiating and coordinating the large-scale expansion of the mental healthproblem is a serious problem. T hese programmes lack in-built evaluationmechanisms and have no space for continuous research and communityparticipation at the functional level.

T here are a number of new issues that have come up in the countr y withimplications for m ental health. T he most notable are alcohol policies, violencein society, the growing pop ulation of elderly persons, urbanisation, mentalhealth of women, disaster care, migrants and refugees, street children, andstress at the work place. T hese new problems p ose serious challenges to existingmental health services and infrastructure. It is also doubtfu l, given the status of DMHP, whether the existing programme can take care of such a complexmental health scenario.

ReferenceKumar, Anant. 2002. Mental Health in India: Issues and Concerns, Journal of M ental

Health and Ageing , 8(3), Fall.

Director General of Health Services (DG HS) . 1990. N ational M ental Health Programme:AProgress Report (19821990) , New Delhi: DGHS.

Government of India. 1982. N ational M ental Health Programme for India . New Delhi:Ministry of Health and Family Welfare, Government of India.

Isaac, M.K . 1988. Bellary District Mental Health Programm e, Community M ental Health N ews , 11 & 12, ICMR-CAR on Community Mental Health, NIMHANS, Bangalore.


mental health in india

Documents