Community Mental Health in India

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  • 1. Community Mental Health in India
  • 2. Community Mental Health in India Editors BS Chavan Professor and Head Department of Psychiatry Government Medical College and Hospital Chandigarh, India Priti Arun Professor Department of Psychiatry Government Medical College and Hospital Chandigarh, India Nitin Gupta honorary senior lecturer Staffordshire University Formerly Consultant Psychiatrist South Staffordshire and Shropshire NHS ­ oundation Trust F United Kingdom Sushrut Jadhav Senior Lecturer in Cross-cultural Psychiatry UCL Mental Health Sciences Unit University College London Consultant Psychiatrist Camden and Islington Mental Health Foundation Trust London, United Kingdom Ajeet Sidana Assistant Professor Department of Psychiatry Government Medical College and Hospital Chandigarh, India ® Jaypee Brothers Medical Publishers (P) Ltd New Delhi • Panama City • London • Dhaka • Kathmandu
  • 3. ®   Jaypee Brothers Medical Publishers (P) Ltd. Headquarters Jaypee Brothers Medical Publishers (P) Ltd 4838/24, Ansari Road, Daryaganj New Delhi 110 002, India Phone: +91-11-43574357 Fax: +91-11-43574314 Email: Overseas Offices J.P. Medical Ltd. Jaypee-Highlights medical publishers Inc. 83, Victoria Street, London City of Knowledge, Bld. 237, Clayton SW1H 0HW (UK) Panama City, Panama Phone: +44-2031708910 Phone: + 507-301-0496 Fax: + 507-301-0499 Fax: +02-03-0086180 Email: Email: Jaypee Brothers Medical Publishers (P) Ltd 17/1-B Babar Road, Block-B, Shaymali Mohammadpur, Dhaka-1207 Bangladesh Mobile: +08801912003485 Email: Jaypee Brothers Medical Publishers (P) Ltd Shorakhute, Kathmandu Nepal Phone: +00977-9841528578 Email: Website: Website: © 2012, Jaypee Brothers Medical Publishers All rights reserved. No part of this book may be reproduced in any form or by any means without the prior permission of the publisher. Inquiries for bulk sales may be solicited at: This book has been published in good faith that the contents provided by the contributors contained herein are original, and is intended for educational purposes only. While every effort is made to ensure accuracy of information, the publisher and the editors specifically disclaim any damage, liability, or loss incurred, directly or indirectly, from the use or application of any of the contents of this work. If not specifically stated, all figures and tables are courtesy of the contributors. Where appropriate, the readers should consult with a specialist or contact the manufacturer of the drug or device. Community Mental Health in India First Edition: 2012 ISBN 978-93-5025-805-7 Printed at
  • 4. About the Editors BS Chavan is presently Professor and Head, Department of Psychiatry at Government Medical College and Hospital, Chandigarh, India. He additionally holds the positions of Joint Director, Regional Institute for Mentally Handicapped; Head, Human Genetic Centre; Member-Secretary of Chandigarh Mental Health Authority and Mental Health Institute; Head, Centre of Excellence (COE) for Manpower Production in Mental Health; and the Nodal Officer, National Trust, Ministry of Social Justice and Empowerment, Government of India. Earlier, after doing his MBBS from Pt Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences, Rohtak, Haryana and MD Psychiatry from Postgraduate Institute of Medical Education and Research, Chandigarh, India, he served in All India Institute of Medical Sciences (AIIMS), New Delhi, India as Senior Faculty (1988-1996). He is holding the charges of Secretary General, Indian Association for Social Psychiatry (2011-2015), Zonal Representative to Indian Psychiatry Society (2009-2012), Member, Board of Trustees for State Institute for Training and Rehabilitation of Mentally Challenged Children, Rohtak, Haryana, India and Member, WPA Section on Public Policy and Psychiatry, WHO Fellow, Member Central Working Committee of Indian Medical Association (IMA). He is a member of National Academy of Medical Sciences, Fellow of International Academy of Medical Sciences and has completed Diploma in Hospital Administration from NIHFW, New Delhi, India. In addition to receiving Dr Vimla Virmani National Award by National Academy of Medical Sciences, Buckshey Award, AK Kala Award, GC Boral Award, BB Sethi Award, and Dr VK Varma Award, he is the recipient of the Presidential Award. In Chandigarh, he is pioneer in setting up Suicide Prevention Helpline, Crisis Intervention Team, Half Way Home and Community-based Clinics, Camp Based Detoxification, Umeed—an NGO for Social and Vocational Rehabilitation of Mentally Challenged Children and Prayatan—an NGO for the Rehabilitation of Mentally Ill Persons. His areas of interest include community psychiatry, social and vocational rehabilitation of mentally challenged and mentally ill persons, alcohol and substance abuse disorders, suicide prevention and sexual disorders. Nitin Gupta underwent his basic and higher specialist (Junior and Senior Residency) training from the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India; and thereafter, he served as a Faculty member from 2000 to 2003. He subsequently relocated to United Kingdom where he worked as a Consultant Psychiatrist in South Staffordshire and Shropshire Healthcare NHS Foundation Trust from December 2003 to February 2012. He is currently an Honorary Visiting Clinical Lecturer at the Center of Mental Health and Ageing, Staffordshire University, United Kingdom. He was awarded the Kataria Memorial Gold medal for the best postgraduate student of PGIMER (1996-1997). He has also won numerous awards in Psychiatry and Mental Health at zonal and national levels (of various professional associations, including the Indian Psychiatric Society) in India. He has a keen interest in transcultural psychiatry and clinical application of psychotherapeutic techniques. His main research and clinical interests are liaison psychiatry, community psychiatry, seasonal affective disorder, early and acute psychosis, and clinical psychopharmacology. He has over 130 research publications (including coauthoring of three books), with more than 50 papers presented at various conferences. Of the major professional organizational responsibilities, he has been a member of the Executive Council of the Indian Association of Social Psychiatry (2001-2003), and member of World Psychiatric Association–Young Psychiatrists Council (2003-2005). He served as Expert Member (and later briefly as Vice-Chair) of the Local Research Ethics Committee, South Staffordshire, UK from 2005-2010. Priti Arun is currently working as Professor, Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India. Her undergraduate and postgraduate trainings are from Sawai Man Singh Medical College, Jaipur, Rajasthan, India. She has worked in Postgraduate Institute of Medical Education and Research, Chandigarh, India, as Senior Resident and Research Associate. She had joined the Department of Psychiatry, Government Medical College and Hospital in 1996, where initially she was in-charge of community services. Later, she developed the Child Guidance Clinic and is running it since 1997.
  • 5. vi  Community Mental Health in India She has participated in 5 workshops on development of Clinical Practice Guidelines of Indian Psychiatric Society. She has about 50 national and international publications and two books’ chapters. She has won awards at zonal level and in national conferences (Indian Association of Social Psychiatry). Her areas of research and interest are Community Psychiatry, Childhood Disorders, Dyslexia and Autism. She has been Assistant Secretary-General of Indian Association of Child and Adolescent Mental Health (1994-1995), and Executive Council Member from 1995-1997 and 2001-2003. She is convener of Website Committee of Indian Psychiatric Society (2012-2013). She was an Editor of Journal of Mental Health and Human Behavior, official publication of Indian Psychiatric Society, North Zone, from 2005 to 2010. Ajeet Sidana is working as Assistant Professor, Department of Psychiatry, Government Medical College and Hospital, Chandigarh, India since 2001. He is Consultant in-charge of Community Outreach Services, De-addiction Services and Consultation–Liaison Psychiatry. He did his MBBS from Sardar Patel Medical College, Bikaner, Rajasthan, India and MD from Sawai Man Singh (SMS) Medical College, Jaipur, Rajasthan, India. He completed his Senior Residency from Institute of Human Behavior and Allied Sciences (IHBAS), Delhi, India. He has presented various papers in the national and international conferences and won awards at zonal levels. He participated in various workshops, symposia related to community psychiatry. He is a co-supervisor of many MD thesis work. His main areas of interest are de-addiction services and community de-addiction camps. He is the Fellow of Indian Psychiatric Society, Assistant Secretary-General of Indian Association for Social Psychiatry and Treasurer of Indian Psychiatric Society-North Zone. Sushrut Jadhav is a Senior Lecturer in Cross-cultural Psychiatry at University College London (UCL). He is Consultant Psychiatrist, Archway Community Mental Health Team, and Lead Clinician for Camden Homeless Services, Camden and Islington NHS Foundation Trust, London, UK; and Co-Director, UCL Cultural Consultation Service for Staff and Students. He is the Founding Editor of the international journal, Anthropology and Medicine (Taylor and Francis), and continues as the E ­ ditor of the journal. He graduated from Grant Medical College, Mumbai, Maharashtra and completed his MD in Psychiatry at the National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India. He subsequently obtained his PhD in Cultural Psychiatry at UCL researching White British natives of London. He has been a visiting professor to various external Universities (Toronto, Copenhagen, Oslo, Ghent) and external examiner to the MSc/MPhil in Medical Anthropology, University of Oxford. His current research areas include: (1) Development of Cultural Formulation to engage with mentally unwell patients; (2) Mental health dimensions of marginal groups with a focus on India; (3) Examining the cultural premise of Western psychiatry; (4) Stigmatization of mental illness across cultures; (5) Traditional healing in India; (6) Caste, conversion and stigma; (7) Overseas health professionals in the UK; and (8) Ethnographic investigation into exclusion from Supplementary Nutrition Programme in Gujarat, India (with PHFI, India). He has been Chair, University College London Masters in Culture and Health. He currently supervises doctoral and postdoctoral scholars conducting medical anthropological research on: (1) Cultural Appropriateness of Community Psychiatric Services in Uttar Pradesh, India; (2) Suicide amongst cotton farmers in Andhra Pradesh, India; (3) Anthropology of Health Tourism in Brazil; (4) Agriculture and Community Mental Health in Tanzania; and (5) Rehabilitation of Child Soldiers in Nepal. He is Co-Director of the UCL-BALM/Banyan Research Unit, Chennai, Tamil Nadu, India, where he also directs an annual course on Medical Anthropology and Cultural Psychiatry. He is an advisor, DSM 5 Task Force on Cultural Formulation.
  • 6. Contributors Munish Aggarwal Senior Resident Department of Psychiatry Postgraduate Institute of Medical Education and Research Chandigarh, India Email: Niraj Ahuja Consultant and Adult Psychiatrist Northumberland Tyne and Wear NHS Foundation Trust Honorary Clinical Lecturer, Newcastle University Deputy Training Programme Director Northern Core Training Scheme United Kingdom Email: Jasmin Arneja Junior Resident Department of Psychiatry Government Medical College and Hospital Chandigarh, India Email: Priti Arun Professor Department of Psychiatry Government Medical College and Hospital Chandigarh, India Email: Dinesh K Arya Clinical Lead, Innovation and Reform Program Hunter New England Area Health Service Director, Hunter New England Mental Health Service Adjunct Professor in Project Management University of Sydney, Australia Conjoint Associate Professor Faculty of Medicine University of Newcastle, Australia Email: Ajit Avasthi Professor Department of Psychiatry Postgraduate Institute of Medical Education and Research Chandigarh, India Email: Vikas Bhatia Associate Professor Department of Community Medicine Government Medical College and Hospital Chandigarh, India Email: Maan Barua* Dibrugarh University Dibrugarh Assam, India Manik C Bhise Assistant Professor Department of Psychiatry Mahatma Gandhi’s Mission Medical College and Consultant Psychiatrist Medical Center and Research institute (MCRI) Aurangabad Maharashtra, India Email: Debasish Basu Professor Drug De-addiction and Treatment Center Department of Psychiatry Postgraduate Institute of Medical Education and Research Chandigarh, India Email: Prakash B Behere Director Research and Development Professor and Head Department of Psychiatry and Drug De-addiction Centre Jawahar Lal Nehru Medical College Datta Meghe Institute of Medical Sciences (Deemed University) Sawangi (Meghe), Wardha Maharashtra, India Email: Rachna Bhargava Assistant Professor Department of Psychology Delhi University, North Campus New Delhi, India Email: Rakesh K Chadda Professor Department of Psychiatry All India Institute of Medical Sciences New Delhi, India Email: Ajita Chakraborty* University of Calcutta Kolkata, West Bengal, India CR Chandrashekar* Lecturer Department of Psychiatry NIMHANS National Institute of Mental Health and Neuro Sciences (NIMHANS) Bengaluru, Karnataka, India Late Haroon Rashid Chaudhry Professor of Psychiatry Fatima Jinnah Medical College Sir Ganga Ram Hospital Lahore, Pakistan
  • 7. viii  Community Mental Health in India BS Chavan Professor and Head Department of Psychiatry Government Medical College and Hospital Joint Director Regional Institute for Mentally Handicapped Chandigarh, India Email: Samir Dalwai Developmental and Behavioral Pediatrician Consultant, LD Clinic Lokmanya Tilak Municipal General (Sion) Hospital and Medical College Mumbai, Maharashtra Director, New Horizons Child Development Center Mumbai, Maharashtra, India Email: Lee Cheng Senior Consultant and Chief Department of Community Psychiatry Institute of Mental Health Woodbridge Hospital Buangkok Green Medical Park 10 Buangkok View Singapore E-mail: Bhargavi V Davar Center for Advocacy in Mental Health A 4-38, Ujwal Park Housing Society NIBM Road, Kondhwa Khurd Pune, Maharashtra, India Email: Arabinda N Chowdhury Consultant Community Psychiatrist Northamptonshire NHS Foundation Trust, UK Ex-Professor and Head Department of Psychiatry Institute of Postgraduate Medical Education and Research Kolkata, West Bengal, India Email: Cheah Yee Chuang Senior Consultant Psychiatrist (Community and Rehabilitation) Hospital Bahagia Ulu Kinta Tanjung Rambutan 31250 Perak Darul Ridzuan, Malaysia Email: Andrew Cole Consultant Adult Psychiatrist Northumberland Tyne and Wear NHS Foundation Trust Honorary Clinical Lecturer Newcastle University Assistant Medical Director North Tyneside United Kingdom Koushik Sinha Deb Senior Research Officer Department of Psychiatry All India Institute of Medical Sciences New Delhi, India Email: Anju Dhawan Additional Professor National Drug Dependence Treatment Centre And Department of Psychiatry All India Institute of Medical Sciences New Delhi, India Email: Mirjam Dijkxhoorn Deputy Director The Banyan Academy of Leadership in Mental Health (BALM) 6th Main Road ERI Scheme, Mogappair West, Chennai Tamil Nadu, India Email: Abhiruchi Galhotra Assistant Professor Department of Community Medicine Government Medical College and Hospital Chandigarh, India Email: BN Gangadhar Professor Department of Psychiatry National Institute of Mental Health and Neurosciences Bengaluru, Karnataka, India Email: Rohit Garg Senior Research Associate Department of Psychiatry Government Medical College and Hospital Chandigarh, India Email: Veena Garyali Private Practice of Psychiatry Elmira, New York, USA Navendu Gaur Chief Psychiatrist Gaur Mental Health Clinic Consultant Psychiatrist St Francis Hospital Ajmer, Rajasthan, India Email:  Vandana Gopikumar The Banyan Academy of Leadership in Mental Health (BALM) 6th Main Road ERI Scheme Mogappair West Chennai, Tamil Nadu, India Email: Arunima Gupta Associate Professor Department of Psychology Maharshi Dayanand University Rohtak, Haryana, India. Email: Divya Gupta National Advocacy and Campaign Analyst United Nations Millennium Campaign New Delhi, India Email:
  • 8. Contributors  Nitin Gupta honorary senior lecturer Staffordshire University Formerly Consultant Psychiatrist South Staffordshire and Shropshire NHS F ­ oundation Trust United Kingdom Email: Rajiv Gupta Senior Professor and Head Department of Psychiatry Pt Bhagwat Dayal Sharma Postgraduate Institute of Medical Sciences CEO State Institute of Mental Health Rohtak, Haryana, India Email: Swapnil Gupta Resident Department of Psychiatry State University of New York Downstate Medical Center Brooklyn, New York United States of America TW Harding* World Health Organization Geneva, Switzerland Mohan Isaac Professor of Psychiatry School of Psychiatry and Clinical Neurosciences The University of Western Australia, Perth Consultant Psychiatrist Fremantle Hospital and Health Service Fremantle, Australia Email: Sushrut Jadhav Senior Lecturer in Cross-Cultural Psychiatry UCL Mental Health Sciences Unit University College London Consultant Psychiatrist Camden and Islington Mental Health Foundation Trust London, United Kingdom Email: Sumeet Jain Lecturer in Social Work School of Social and Political Science University of Edinburgh Chrystal Macmillan Building 15A George Square Edinburgh, United Kingdom Email: RC Jiloha Director Professor and Head Department of Psychiatry Maulana Azad Medical College And GB Pant Hospital Faculty of Medical Sciences University of Delhi New Delhi, India Email: Leong Jern-Yi, Joseph Consultant Psychiatrist Department of Community Psychiatry Institute of Mental Health Woodbridge Hospital Buangkok Green Medical Park 10 Buangkok View, Singapore Email: Anirudh Kala Clinical Director Mind Plus Clinic Ludhiana, Punjab, India Email: ix Malavika Kapur* Department of Clinical Psychology National Institute of Mental Health and Neurosciences Bengaluru Karnataka, India RL Kapur* Ex-Professor and Head Department of Psychiatry National Institute of Mental Health and Neurosciences Bengaluru Karnataka, India Nilamadhab Kar Consultant Psychiatrist and College Tutor Black Country Partnership NHS Foundation Trust, Steps to Health Wolverhampton United Kingdom Email: Mohammad Zia Ul Haq Katshu PhD Student School of Psychology and Wolfson Centre for Cognitive Neurosciences University of Wales Bangor United Kingdom Email: Kunal Kala Consultant Psychiatrist Mind Plus Clinic Ludhiana, Punjab, India Email: Jagdish Kaur Chief Medical Officer Directorate General of Health Services Ministry of Health and Family Welfare Government of India, Nirman Bhawan New Delhi India Email: Roy Abraham Kallivayalil Professor and Head Department of Psychiatry Pushpagiri Institute of Medical Sciences Tiruvalla, Kerala, India Email: Paramleen Kaur Ex-Assistant Professor Department of Psychiatry Government Medical College and Hospital Chandigarh India Email:
  • 9. x  Community Mental Health in India Brian Kelly Professor of Psychiatry Faculty of Medicine University of Newcastle Australia Email: Hemant Singh Keshwal Course Coordinator and Member Expert Committee RCI Regional Institute for Mentally Handicapped Chandigarh India Email: Raumish Masud Khan Assistant Professor Department of Applied Psychology Kinnaird College for Women Lahore Pakistan Emai: Sudhir Kumar Khandelwal Professor Department of Psychiatry All India Institute of Medical Sciences New Delhi India Email: Nishant Kumar Chief Resident Academic, Research and Administrative Psychiatry Department of Psychiatry and Behavioral Neurosciences Cedars-Sinai Medical Center Los Angeles, California, USA Rajesh Kumar Professor and Head School of Public Health Postgraduate Institute of Medical Education and Research Chandigarh, India Email: Sunder Lall Professor Department of Community Medicine Adesh Institute of Medical Sciences and Research Bathinda, Punjab, India Email: Roland Littlewood* Department of Anthropology and Psychiatry University College London London, United Kingdom KV Kishorekumar Senior Psychiatrist Department of Psychiatry National Institute of Mental Health and Neurosciences Bengaluru Karnataka, India Santosh Loganathan Associate Professor Department of Psychiatry Vydehi Institute of Medical Sciences and Research Center Nallurahalli, Whitefield Bengaluru, Karnataka, India Email: Dinesh Kumar Assistant Professor Department of Community Medicine Dr Rajendera Prasad Government Medical College Kangra Himachal Pradesh, India E-mail: Savita Malhotra Professor and Head Department of Psychiatry and Drug De-addiction and Treatment Center Postgraduate Institute of Medical Education and Research Chandigarh, India Email: Jayan Mendis Director and Consultant Psychiatrist National Institute of Mental Health (NIMH) Sri Lanka Email: Keerti Menon Principal and Clinical Psychologist Community Health Team-Psychological Therapies Hertfordshire Partnership Foundation NHS Trust Watford, United Kingdom Email: Sukriti Mittal Geriatric Psychiatry Fellow Department of Psychiatry Weill Cornell Medical Center Westchester, New York, USA R Srinivasa Murthy Professor (Retd) Department of Psychiatry The Association for the Mentally Challenged Hosur Road (Near Kidwai Hospital) Dharmaram College PO Bengaluru Karnataka, India Email: Naresh Nebhinani Senior Resident Department of Psychiatry Postgraduate Institute of Medical Education and Research Chandigarh, India Email: Elizabeth Negi Independent Consultant and Social Scientist Guindy, Chennai Tamil Nadu, India Email:
  • 10. Contributors  S Haque Nizamie Professor Department of Psychiatry Director, Central Institute of Psychiatry Ranchi, Jharkhand, India Email: Antti Pakaslahti Adjunct Professor of Transcultural Psychiatry School of Health Sciences University of Tampere Finland Email: Rajeev Panguluri Assistant Professor of Psychiatry University of Mississippi Medical Center and Staff Psychiatrist GV Montgomery VA Medical Center Jackson, Mississippi, USA R Pathasarathy* Department of Social Work National Institute of Mental Health and Neurosciences Bengaluru, Karnataka, India Soumitra Pathare Coordinator Centre for Mental Health Law and Policy and Consultant Psychiatrist Indian Law Society ILS Law College Campus Pune, Maharashtra, India Email: Suravi Patra Senior Resident Department of Psychiatry Government Medical College and Hospital Chandigarh, India Email: Raman Deep Pattanayak Senior Research Associate Department of Psychiatry All India Institute of Medical Sciences New Delhi, India Email: Reeta Peshawaria Lead Consultant and Clinical Psychologist Tertiary Assessment and Treatment Unit and Specialist Residential Services Harperbury Hospital Hertfordshire United Kingdom Email: Samir Kumar Praharaj Assistant Professor Department of Psychiatry Kasturba Medical College Manipal, Karnataka, India Email: Chhaya Sambharya Prasad Developmental Pediatrician Regional Institute for Mentally Handicapped Chandigarh, India Email: Shanker Prinja Assistant Professor Department of Community Medicine Postgraduate Institute of Medical Education and Research Chandigarh, India R Raguram* Department of Psychiatry National Institute of Mental Health and Neurosciences Bengaluru, Karnataka India Lok Raj Consultant Psychiatrist Community Health Services Milton Keynes Primary Care Trust Milton Keynes, United Kingdom Email: Sneha Rajaram Freelance Writer Pune, Maharashtra India Email: xi Abhijit Rozatkar Ex Senior Resident Department of Psychiatry Government Medical College and Hospital Chandigarh, India Email: Andrew G Ryder* Department of Psychology Concordia University Montreal, Canada Rahul Saha Ex-Resident Department of Psychiatry CSM Medical University Erstwhile KG Medical University Lucknow, Uttar Pradesh, India Email: Bhagirathy Sahasranaman Medical Director Henderson Behavioral Health Fort Lauderdale, Florida Clinical Assistant Professor of Psychiatry NSU College of Osteopathic Medicine United States of America Saji PG Assistant Professor Department of Psychiatry Government Medical College Kottayam, Kerala, India Email: Alok Sarin Senior Fellow Nehru Memorial Museum and Library Senior Consultant and Psychiatrist Sitaram Bhartia Institute New Delhi, India Email: Somnath Sengupta Consultant General Psychiatry Institute of Mental Health/Woodbridge Hospital Buangkok Green Medical Park Buangkok view, Singapore Email:
  • 11. xii  Community Mental Health in India Ammara Shabbir Research Associate Fountain House Lahore, Pakistan Dr Sood Former President Prayatan Chandigarh, India Email: KS Shaji Professor and Head Department of Psychiatry Government Medical College Thrissur, Kerala, India Email: Jagannathan Srinivasaraghavan Professor Emeritus Department of Psychiatry Southern Illinois University School of Medicine Consultant Psychiatrist Veterans Affairs Medical Center Marion, Illinois, USA Email: Pratap Sharan Professor Department of Psychiatry All India Institute of Medical Sciences New Delhi, India Email: Lokesh S Shekhawat Senior Resident Department of Psychiatry GB Pant Hospital New Delhi, India Ajeet Sidana Assistant Professor Department of Psychiatry Government Medical College and Hospital Chandigarh, India Email: Dato’ Suarn Singh Senior Consultant Forensic Psychiatrist Ministry of Health Malaysia Hospital Bahagia Ulu Kinta Perak Darul Ridzuan, Malaysia Email: Suman K Sinha Assistant Professor Department of Psychiatry Lady Hardinge Medical College   New Delhi, India Email: A Shyam Sundar Assistant Professor Department of Psychiatry National Institute of Mental Health and Neurosciences Bengaluru, Karnataka, India Email: Siva Kumar Thanapal Department of Psychiatry All India Institute of Medical Sciences New Delhi, India R Thara Director Schizophrenia Research Foundation Chennai, Tamil Nadu, India Email: Hema Tharoor Consultant Psychiatrist Schizophrenia Research Foundation Chennai, Tamil Nadu, India JK Trivedi Professor Department of Psychiatry CSM Medical University (Erstwhile K Medical University) Lucknow, Uttar Pradesh, India Email: Umamaheswari V Junior Resident Department of Psychiatry Postgraduate Institute of Medical Education and Research Chandigarh India Email: Vijoy K Varma Clinical Professor of Psychiatry Indiana University School of Medicine Indianapolis, USA Retired Professor and Head Postgraduate Institute of Medical Education and Research Chandigarh India Email: Penelope Vounatsou Department of Public Health and Epidemiology Swiss Tropical Institute and University of Basel Switzerland Mitchell G Weiss* Department of Public Health and Epidemiology Swiss Tropical Institute and University of Basel Switzerland NN Wig Professor Emeritus Psychiatry Postgraduate Institute of Medical Education and Research Chandigarh India Email: NB : Names marked with an asterisk (*) indicate affiliation of author at the time when the paper was originally published, and may not necessarily reflect the current affiliation and/or address.
  • 12. Foreword Traveller, there is no path; paths are made by walking (An Australian Aboriginal Saying). The progress of psychiatry in India since Independence in 1947 is a remarkable story of development of mental health services from very inadequate, largely custodial care centers to a robust network of mental health facilities now available through governmental, private and voluntary sectors spread through most of the cities, towns and even reaching to some of the rural areas in a few states. It has been achieved with many innovative approaches, taking up paths that were never traveled before. Recalling some of the significant developments which took place in the last sixty years, one can first think of opening up of a number of training centers for mental health professionals (starting with Institute of Mental Health in Bengaluru) in 1950s and opening of a large number of General Hospital Psychiatric Units, first in the government hospitals and then in private sector during 1960s. It rapidly changed the psychiatric scene with easy availability of mental health services in the community and acceptability of modern psychiatric treatment by general public. The decade of 1970s saw another major innovation when attempts were made to integrate mental health services with primary care services in the rural areas (early experiments at Sakalvada near Bengaluru and then at Raipur Rani near Chandigarh). The decade of 1980s saw a major breakthrough when the National Mental Health Programme was officially adopted by Government of India. The same decade also saw a rapid rise in the private sector of psychiatry and easy availability of many psychopharmacological drugs now being produced in India locally. The decade of 1990s will be remembered for many judicial interventions for safe-guarding the human rights of mentally ill, and rise of voluntary sectors, with many NGO groups getting active in various mental health issues like drug addiction, suicide prevention, rehabilitation of mentally ill, etc. The main theme, which emerges in this brief review of last 60 years, is that Psychiatry which was a minor and neglected area of health has come to the center stage as a major specialty of medicine. Furthermore, an important shift is continually taking place; psychiatry no more remains only a “clinical specialty” confined to hospital wards and OPDs, but it is quickly becoming a public health discipline with focus shifting from the individual to the community. The new wave of psychiatry in India is not only bringing psychiatry to the community but also trying to empower the patient and the family to make the best use of available resources. In this context, I feel it is the right time that the Editors (Professor Chavan and colleagues) have taken the decision to bring out the book Community Mental Health in India, putting down in one place the available knowledge as well as to outline areas for further development. One of the problems in developing mental health services in India, and perhaps in other developing countries in Asia and Africa, has been the heavy load of the Western model of psychiatric care, which we have inherited. For a long time after independence, our thinking was pre-occupied with hospital-based care and planning in terms of numbers of hospital beds, doctors, other staff and so on, not realizing that this model is largely inappropriate for our needs because neither we have financial and manpower resources to run such hospital-based services, nor can we reach vast rural areas of our country where majority of our population lives by this model. On the other hand, our own rich resources like the family support system, cultural traditions and newly emerging network of primary care centers remained largely unused, till recently, in our mental health planning. It is good to see that new models of community-based mental health services are now emerging, which are more appropriate for our needs. We are also fortunate that though we were left behind in the Industrial Revolution of Europe and America in the 18th and 19th centuries, we are already in the forefront of the Information Technology Revolution over the last forty years. India is now considered as a leader in computer software technology, and we have one of the largest number of mobile phone sets and other types of telecommunication facilities, which can be readily put to use for our community mental health programmes (Telepsychiatry being one such example). Not too long back, a very important book Turning the World Upside Down: The Search for Global Health in 21st Century by Sir Nigel Crisp was published. Sir Nigel Crisp was the Chief of National Health Service (NHS) in the UK and later became member of the House of Lords. He has extensive experience of not only running the NHS, but also of providing aid for health care in developing countries. His book had been reviewed in the BMJ by its former editor Richard Smith (BMJ 27 Feb, 2010). His conclusions were that the present health care system that evolved in rich Western countries has outlived its utility and something different is needed now in the 21st century. Poor countries do not need just a diluted version of what rich countries have now. In fact, poor may have more to teach the rich, than the other way around.
  • 13. xiv  Community Mental Health in India I have gone through the contents of Community Mental Health in India and I am very impressed to note how the editors have covered a wide range of issues related to community psychiatry including historical background, legislative aspects, different models of community-based care that are currently available, roles of governmental, private and voluntary sectors, experiences of community psychiatry movements and services in other parts of the world, relationship with other psychiatric subspecialties, etc. It is indeed pleasing to see that cultural anthropology has been included as a section and contributions from carers, media, social activists, etc. also form an important part of the book. In brief, I feel it is a landmark book, a monumental effort to put the current available knowledge on the subject in one volume. It will be a very valuable document for all categories of mental health professionals in India and abroad. NN Wig Professor Emeritus Psychiatry Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
  • 14. Foreword One in four people will at some time in his life requires mental health care. Only two percent of the government health budget goes into mental health services. A vast majority of the available mental health budget is spent on mental hospitals that often provide only custodial care. Between 76 and 85 percent of people with serious mental disorders do not even receive the most basic services in low and middle income countries. Persons with mental disorders and their families are commonly subjected to denial of basic human rights and equal opportunities. The situation of mental health services in low and middle income countries is indeed alarming. The World Health Organization (WHO) made a clear and unequivocal recommendation for all mental health care to be provided in communitybased facilities in its World Health Report-2001. However, the progress towards community care in most parts of the world has been slow and uneven. The WHO’s Mental Health Atlas 2011 clearly shows that the world is moving too slowly towards community mental health care. Atlas data demonstrate that two-thirds of the mental health budget is still assigned to mental hospitals and inpatient beds in mental hospitals are still five times the number of beds in general hospitals. India has seen, simultaneously, some of the most successful experiences of implementing community psychiatry programs in the world but also some of the most stigmatizing mental hospitals. What will hasten the progress towards community mental health care in India? One of the critical steps is developing, distilling and disseminating knowledge around the theory and practice of community mental health care. I am very pleased to see that the book Community Mental Health in India edited by Drs BS Chavan, Nitin Gupta, Priti Arun, Ajeet Sidana and Sushrut Jadhav does an admirable job in fulfilling this need. The book is authored not only by the researchers and mental professionals but also has seminal contribution by carers, media and the NGO/Self Help Groups of mentally ill patients. They have contributed from their rich experience of working with persons with mental health problems. Thus, the book provides rich and unique perspectives on the overall area of community mental health. The result is an unusually rich tapestry of colors, patterns and designs—all woven neatly into delivering a powerful message on community mental health care. Though the title of the book contextualizes it to India, the contents relate to and are relevant to many other countries, cultural settings and health care situations. I hope and wish that the book will further catalyze thinking, learning and most importantly—the practice of community mental health care not only in India but also in many other low and middle income countries. The result will be more effective and more humane care to those who need it the most. Shekhar Saxena Director Department of Mental Health and Substance Abuse World Health Organization Geneva, Switzerland
  • 15. Preface THE ROAD LESS TRAVELED To date, an Indian book written by scholars in the field of contemporary community mental health in India, is surprisingly absent. This is the first such venture. It is multidisciplinary both in content and authorship. It is, therefore, both unique and timely. Our target readership includes mental health trainees and professionals working in both rural and urban Indian settings, social scientists engaged with public health, and health policy professionals in India. In attempting to edit this book, the editors have traveled from differing directions to meet within the space of this text. The content and layout of this book reflect their individual journeys and indeed their differing epistemological positions. As the editors, we wish to share with the reader, an account of our individual paths and passions that have shaped the rationale and contents of the book. The Journey During our training days, one key aspect of learning, and considered as an essential topic for the postgraduate examination, was related to the Raipur Rani and Bellary projects; projects that were implemented under the rubric of ‘Community Psychiatric Services’ in the 1970s. This remained etched in our minds, though each one of us got involved in ‘Community Psychiatry’ at different stages of our careers and in differing settings. BS Chavan (BSC), decided to travel on this unchartered road of delivering services in the community, by starting from scratch in 1996, when he joined the Department of Psychiatry, Government Medical College and Hospital-32 (GMCH-32), Chandigarh, India. In this endeavor, Priti Arun (PA) and other colleagues (who have subsequently moved onto other places) aided him. Ajeet Sidana (AS) became an integral part of this team from 2004 onwards. These services included community outreach clinics, community-based camps, community day care centers, half-way home, suicide prevention helpline and crisis intervention services (discussed in detail in Chapters 25 and 26). The trio of BSC, PA and AS made further efforts by conducting a National Workshop on Community Psychiatry in 2006; wherein eminent psychiatrists from across India deliberated for two days. Unfortunately, those deliberations did not translate into publications or proceedings. However, this workshop provided some valuable insights. One amongst these was that Community Psychiatry was still alive and being practiced in different forms in various parts of India. Not long after, BSC and Nitin Gupta (NG) met at the Silver Jubilee Conference of the Indian Association of Social Psychiatry in November, 2009. NG was working in the United Kingdom as a Consultant Psychiatrist in the National Health Service (NHS) delivering community-based services to people with mental illnesses. The theme for this conference was “Mental Health: Prioritizing Social Psychiatry”; and that probably helped in initiating a conversation related to the advent of biological psychiatry and the associated neglect of social and community psychiatry. Soon into the conversation, cognitions and emotions got intertwined and took on a passionate flavor. Numerous reasons were discussed; most of these are outlined later in some detail. To cut a long story short, both BSC and NG, with their varied experiences in community psychiatry, felt the need to pool together information relevant to community psychiatry under one roof. This was in order to make this easily accessible as a ready resource for any mental health professional, and also to ensure its utility in postgraduate and possibly undergraduate academic settings in India. Such was the enthusiasm in both BSC and NG, that a couple of hours were spent during the conference in initiating a discussion around the actual logistics of the project. However, both appreciated that such a task would require a larger team, and for that they did not have to look far. What better than to have colleagues with a vast expertise and experience in the setting up, running of and delivering community-based interventions for people suffering with mental disorders and substance use disorders? Hence, PA and AS were approached and requested, and the editorial team of BSC, NG, PA and AS was created. The team discussed on the brass-tacks and logistics. An outline was framed in terms of contents and chapters. There was consensus that the book needed to be not only comprehensive in its coverage of content but also have inputs from other relevant disciplines. It was also felt that although ‘mental illness’ may be a psychiatrist’s business, ‘mental health and related suffering’ is everyone’s business. Hence, contributions were solicited from eminent researchers and clinicians who
  • 16. xviii  Community Mental Health in India were experts in the field of community mental health, preventive and social medicine, psychology, and pediatrics. Additionally, contributions were requested from non-professionals who have had some experience with people with mental illnesses. Work continued into 2010 at varying pace; sometimes frenetic, sometimes lethargic due to a multitude of factors. Then, under serendipitous circumstances, in September 2010, Sushrut Jadhav (SJ) joined the then existing team of editors. One may argue, “Too many cooks spoil the broth”, but in this case, “Collective Wisdom” was the outcome. May be, we were out to prove Rudyard Kipling wrong! A fresh debate, and revisit of logistics, led to a further expansion of the book; both in terms of contents and concepts. New chapters were solicited and new sections incorporated. SJ was keen that the book both addressed and reflected the vital gap between social sciences and mental health, and between etic and emic perspectives in community mental health in India. SJ’s journey into community mental health took a different route. Trained as a psychiatrist and medical anthropologist, his early experiences led him to specialize in the area of marginality and mental health. His desire for India’s mental health professionals to reflect upon their own personal and professional values in order to generate a degree of self-reflectivity, led to his enthusiasm for this venture. Like any journey through unchartered waters, our editorial ship had its ‘ups’ and ‘downs’; but it weathered the vagaries of human nature encountered at various times. It was an ongoing learning experience; including numerous revisits, by the editorial team, to the formulation of the sections and their themes. This was also necessitated by our ‘pleasant discovery’ about the wealth of information on community mental health that seemed to have been lying untapped and/or incorporated within the expertise of the contributors (without being available to the wider scientific community). In fact, the title and outline of the finished product is a far cry from the original concept. Indeed, the editors of this book have individually, on occasions, agreed to disagree during discussion around the contents and directions of several chapters. The chapters that follow, therefore, reveal contradictions and incongruity within the field of mental health. We sincerely hope that the readers will not be confused with the conceptual layout of the textbook. New thoughts brought new challenges; though none that were insurmountable. Deadlines were made; some achieved, some not. And this brings us back to Rudyard Kipling’s famous opening lines (from his poem, The Ballad of East and West, 1889): “Oh East is East, and West is West, and never the twain shall meet”. But the editorial team, based on East and West (across two different continents; with dissimilar cultural and conceptual practices and approaches) met successfully, and the proof for this assertion lies in the presence of this book in the reader’s hands. For our readers, this book offers a rich brew of concepts, practices, and policies in the field. The readers may wonder why we chose to provide such a detailed account of our journey! This has been done to provide an ethnographic feel for the readers regarding the editorial team and its work; an approach reflected in many parts of this book. The Rationale The germination of the idea for this book and its culmination into the current product is a combination of various factors and needs identified by us; some initially, some during various stages of its development. They are enumerated below: The need of a book on Community Mental Health was felt because; in India the emphasis is shifting from institutionalbased care to community-based care. However, the community-based services are not only limited but also localized only to certain pockets. Majority of these experiences have remained undocumented, and therefore, been out of reach of students and teachers alike. Also, eminent and senior psychiatrists (and teachers for many of us) had been providing consistent words of encouragement and motivation for BSC (under whose tutelage, the Department of Psychiatry, Chandigarh, India had been conducting workshops, seminars, camps, etc. at various points in the last decade) to write-up one’s experiences for sharing, debating, and discussing with the wider scientific community. Thus, the foremost aim was to capture various developments in the field of community mental health in India and to highlight the same from other countries. Another contributing factor for this book came from the insights and experiences gained by BSC in his various capacities of holding administrative positions in national professional bodies (Indian Psychiatric Society, Indian Association for Social Psychiatry). The opportunity to organize special seminars, workshops and CME programs in the field of community psychiatry paved the way for the realization that very little work had been carried out in this area. In fact, whatever small work had been done, very little of it was known to the wider scientific community. Most of the discussions in these programs focused on theoretical frameworks, and there was a general impression that the field of community psychiatry was
  • 17. Preface  xix growing sporadically, probably being more individual-driven than system-driven. Thus, the book is an attempt to present, to the scientific community, these small developments for replication and refinement, thereby enhancing their applicability and generalizability. The field of Mental Health in India gained considerable boost in the 11th and 12th five-year plans. In addition to earmarking large amounts of money for mental health, the government initiated new programs in the area of mental health. These included—launch of the District Mental Health Programme (DMHP), strengthening of Departments of Psychiatry in various medical colleges, setting up of Centers of Excellence (COE) for increasing manpower in the field of mental health, drafting a consumer-friendly new Mental Care Act, implementation of UNCRPD, search for country specific community mental health models, etc. These government-driven projects need to be evaluated by clinicians and researchers to document their feasibility and cost-effectiveness. This book is an attempt to bring together all the recent developments that have taken place at the level of policy planners in the field of mental health, along with a critical appraisal of these new initiatives. The de-institutionalization movement gained public support on the presumption that it will result in enhanced quality of care and a better standard of living in the community. It was based on the following assumptions: (a) the newer drugs (especially antipsychotics) will be able to control most of the symptoms thereby allowing patients to return to a normal life in the community with better insight into their illness, (b) the community will show increasing acceptance and tolerance to mentally ill persons and their related behavior, (c) adequate accommodation will be available in the community and (d) availability of effective community services will reduce the need of hospitalization. Unfortunately, the mental health professionals and caregivers of mentally ill persons are now experiencing a reality, which is far removed from these assumptions. In our view, all these real-life experiences need to be acknowledged and addressed to, while designing, developing and refining newer components of care. This book attempts to bring these issues out in open for better public awareness, thereby re-focusing on the importance of social and cultural factors in the area of mental health. Disability due to mental disorders leads to a huge burden on the patient, their families, and the community they live in. It is well established that despite efforts, there is a big treatment gap and a large number of untreated mentally ill patients live in the community. The caregivers and/or relatives of these patients, nongovernmental organizations, voluntary and religious bodies have attempted, in their own ways, to address the issue of restoration of positive mental health for persons with mental illness living in the community. The alternative systems of medicine and traditional methods of healing (yoga, meditation, lifestyle changes) have their own roles to play in ensuring the same. In recent times, the media has played its role in reduction of stigma and highlighting the human rights violation of the mentally ill. The National Human Rights Commission has actively stepped in to ensure a minimum standard of care at places where persons with severe and enduring mental illnesses are treated. The judiciary has played a crucial role through landmark judgments on important issues relating to mental health. Our vision was to be able to try and capture all such varied yet crucial developments in the field of community mental health. It has been satisfying to realize that advancements in psychiatry, especially biological psychiatry and psychopharmacology, over the last two decades or so, have helped in a better understanding of the etiology and treatment of numerous mental disorders and thereby demystifying psychiatry as a specialty. However, with rapid advances in the field of psychopharmacology, most of the researches in psychiatry is funded by the pharmaceutical industry. Unfortunately, this has led onto a shift of focus from sociocultural basis to a rather skewed biological basis of mental disorders and generated a false sense of security and promise that the panacea for cure are medications. This paradigm shift has hampered, and even made us neglect, the growth and effective utilization of non-pharmacological methods of treatments. Not only have these paradigm changes affected our qualified practicing psychiatric brethren but also they have had an even more far-reaching and worrisome deleterious effect on both undergraduate and postgraduate training in psychiatry. Increasingly, trainees are being deprived of learning and practicing skills to carry out psychotherapy and other psychosocial interventions. This is further compounded by the fact that both students and faculties alike feel frustrated at the lack of scientific literature on recent developments in the field of community psychiatry. The lack of robust literature precludes application of evidence-based practice, with its own ramifications. This book has been envisaged as an important resource tool and guide to the faculty and students in the field of mental health; in fact, to any one who is interested in mental health. Equally significant and crucial is the absence of any serious engagement between mental health and social science disciplines in India. Like the advances in biological sciences discussed earlier, social sciences, most notably anthropology and sociology, have made significant contributions to mental health in India. Scholars in medical anthropology in particular, have
  • 18. xx  Community Mental Health in India contributed to both national and international literature in advancing our understanding of a range of topics. Significant areas include nuanced histories of colonial psychiatry in India, lay illness experiences, critiques of existing biomedical theory and interventions including psychopharmaceuticals, gender and caste as contributors towards social suffering, pluralism in help to seeking, and social analyzes of existing policies and their failures. Tragically, this rich literature remains inaccessible to most graduate and postgraduate mental health trainees and practicing professionals. This has not been a one-way process either. Social scientists in India have equally been unsuccessful in establishing an academic dialogue with mental health professionals. This failure to establish linkages between mental health and social sciences in India has negatively and deeply impacted patients and their families. By incorporating a section on community psychiatry and clinically applied anthropology, this book hopes to engage the readers by drawing them into a field that addresses varied and diverse themes. These include critiques of a universal validity of mental illness, social context of suffering and healing including help seeking and stigma, and the cultural construction of mental health professionals themselves. The Contents As had been mentioned earlier in the section “The Journey….”, the evolution of the book has been an extremely dynamic process. We, as editors, were pleasantly surprised (even astonished) at the amount of work that has been carried out in the field of community psychiatry. We hope that after going through the contents, the reader shall agree with our perception. An attempt has been also made to keep the book contemporary in terms of recent trends across the world, wherein there is an increasing trend for (a) stakeholders from a non-mental health professional background being involved and having a say, and (b) conceptual shift from ‘mental illness’ to ‘positive mental health’. The focus in the book has, therefore, been on ‘Community Mental Health’ and not specifically restricted to ‘Community Psychiatry’; thereby broadening the scope of readership and hopefully generating greater involvement and interest for people from a non-mental health professional background, social activists, media, and the service users and carers. Additionally, we, as psychiatrists, have traditionally followed the ‘etic’ approach. This has apparently contributed to the lack of efficacy of various community-based initiatives and approaches. For quite some time, and increasingly so, it has been recognized that alternative approaches (ethnographic, ‘emic’) are equally crucial. This includes the deployment of both qualitative and mixed methodologies in designing and developing research approaches and instruments. This book has similarly aimed to capture the experience and work in the field of ‘Community mental health’ by adopting a ‘mixed’ approach. In the era of political correctness, it may have been more appropriate for us to follow the same paradigm. However, we have restrained ourselves from going down that path. The esteemed contributors, due to their expertise and vast experience, have been given the opportunity for expressing their views in as unfettered a manner as possible. Readers may find, in various chapters, topics, issues, concepts, explanations that are interesting and thought provoking, if not necessarily provocative, contradictory, and contentious. Viewed in totality, the contributions in this book may be viewed as a kaleidoscopic collection of views, thoughts, experiences, and research evidence; each chapter differing from one another in intensity, quality and quantity across a spectrum rather than a dimension. Indeed, rather than making any effort to ideologically homogenize the text, the editors have deliberately allowed multiple ‘voices’ to be heard. The book, therefore, truly reflects the contradiction inherent to the discipline of community mental health in India and elsewhere. Rather than establishing newer cannons, or reproducing and perpetuating received ‘wisdom’ within our discipline, we would instead urge our readers to approach this book with a healthy skepticism. Another glaringly obvious aspect of the contents of the book is that at numerous places, the reader may find things to be repetitious. However, this can best be termed as a ‘necessary evil’ in order to ensure continuity and retain the original (undiluted and untampered) uniqueness of the contributors. A little more about the contents At the cost of making this piece seemingly long-winded, it may be helpful to share with the readers our thought process surrounding individual sections and specific chapters. In order to give a structure to the book, sections were conceptualized. Section I (Chapter 1) was solicited as a ‘critical overview’ based upon evidence, facts, and personal experiences. This served as a ‘rudder’, so as to speak. It is said that in order to understand and put in perspective the present, an understanding of the past is necessary. This prompted Section II (Historical Concepts…) and its contents. This section comprises of five chapters (Nos 2-6) wherein the ‘roadmap’ to the development of community psychiatry is outlined. Though we felt that there was considerable overlap across various chapters in this section; especially related to National Mental Health Programme (NMHP)
  • 19. Preface  xxi and District Mental Health Programme (DMHP), we did recognize that this was a ‘necessary evil’ as these two programs form the backbone of community mental health in India (as reflected in their oft appearance across various chapters of the book). A closer look at Section II will reveal that the contributors were a near equal mix from specialties of psychiatry and preventive and social medicine (PSM). As historically, there had been very minimal dialogue and/or liaison of PSM with Psychiatry, we anticipated that the conceptualization, views and suggestions for a way forward, would be ‘reasonably dissimilar’ if not ‘radically different’. After reading Section II and also some other chapters (e.g. No 29), it was a pleasant surprise to be proven wrong. But this did make us wonder as to why over the last 30 years, these specialties have not joined hands, as has been the case of PSM working closely with other medical specialties and delivering high quality, result-oriented programmes of care (e.g. ICDS, Anti-TB, etc.). Is it to do with policies or politics? May be some of the readers will have the answers… Not just restricted to Community Mental Health, but as such in the field of Psychiatry, there are certain key dimensions that tend to influence the development and perpetuation of illness, formulation of a management and/or policy framework, and hinder or facilitate implementation at the grass-root level. These include issues like family, stigma, disability, etc., and have been addressed in Section III. An attempt has been made to add a ‘unique’ flavor to this section by the addition of topics not so commonly discussed (in our opinion) addressing areas of homelessness, gender, and NGOs. One may wonder why so much of a hullabaloo! This is because the contributors are from different backgrounds, with different approaches, and providing different perspectives. It is well established that mental health in the West has come quite a long way as regards governance and legislation. The Indian scenario is gradually picking up. Section IV addresses the same. A not-so-dispassionate discussion around the revision of the Mental Health Act (1987) and the current Mental Health Care Bill provides us with a glimpse of the intricacies related to its drafting and consensus. Tensions between various stakeholders and various principles are probably a reflection of not only the issues being addressed in the proposed new Act but also due to the relevance and importance of certain dimensions/factors culturally relevant to India (i.e. family, homelessness). These are detailed in Chapter 13. An equally important and relevant issue is the ever-growing recognition in India of ‘individual rights of the common man’; duly addressed in Chapter 16. Super-specialization in psychiatry is a common enough paradigm; more so in the West. Though formal training programs for higher/super-specialization are still in their rudimentary stage of development in India, yet super-specialization through the avenue of experience gained out of clinical practice (arising out of the ‘forced’ necessity of delivering quality care to the relevant masses) made us formulate a separate section (Section V) on ‘psychiatric specialties’. With the general trend and emphasis on shifting towards community-based mental health care, it was felt imperative to review and capture the current state of play regarding interface and availability of super-specialty services like child, substance misuse, geriatric, and learning disability in the community. We found this a useful exercise but it was not very heartening to learn that considerable lacunae exist and the integration of psychiatric super-specialty care still needs considerable work (to paraphrase, in keeping with the theme of this editorial: “a considerable amount of traveling before thinking of rest”). Nevertheless, we feel that this information should serve as a benchmark for the future. Emergencies are part and parcel of any branch of medicine, and psychiatry is no different. All psychiatric emergencies may not occur in the community setting. Nevertheless, certain emergencies occur predominantly (e.g. ‘natural disasters’), whereas other emergencies (e.g. acts of harm to self and others) are reasonably common enough phenomena, in the community settings. Some of these aspects are dealt with in Section VI. Chapter 21 (on ‘farmers suicides’) was initially not a solicited chapter but we were convinced soon enough to include it in the book. Suicide as a problem is something which India (and probably every nation) is grappling and trying to come to terms with. It is indeed surprising, if not shocking, that very little is happening regarding formulation of some specific strategy/policy/plan for suicide prevention (and/or reduction of suicides as a goal) by the concerned/relevant stakeholders in India. Many countries have been able to successfully reduce suicide rates; a prime example being the United Kingdom where they have used the National Service Framework (NSF), National Confidential Enquiry into Suicide and Homicide by people with Mental Illness (http://www.medicine.manchester., and NICE Guidance. The issue of suicide has been dealt passionately by the authors (Chapters 21 and 22). Violence is gradually increasing phenomenon in the Indian society, and it was felt only appropriate to delve into this issue (Chapter 23). India is very prone to disasters (especially natural disasters, e.g. the Latur earthquake, Dabwali fire, Tsunami, etc). Disasters are associated with mental health consequences, and the role of mental health professionals has been revisited. An evidence-based conclusion is the lack of strong disaster response systems in India (Chapter 24), which should be the focus of both mental health professionals and policymakers alike in the time to come.
  • 20. xxii  Community Mental Health in India It was clearly felt by us that we cannot talk about the mantra of ‘delivering mental health care in the community’ if we are unable to demonstrate that there exist ‘alternatives to hospitalization’. What exists in the community which can act as a valuable resource for management? How best to utilize it? How can it be best integrated with mental health services? These aspects are addressed in Section VII. A whole chapter on ‘Complementary (Alternative/Indigenous) Therapies’ highlights relevant issues and proposed measures to address the same (Chapter 28). Use of such therapies in the field of mental health is still potentially contentious, and can still generate passionate discussions/debates amongst a reasonable proportion of our psychiatric colleagues. However, these therapies are widely utilized by patients with mental illnesses and are too important to be ignored. Hence, this chapter! Another nugget of inside information for the reader: this chapter generated considerable debate within the editorial team; disclaimer- SJ does not endorse the views expressed by the authors at certain places in Chapter 28. Section VII has a chapter on ‘models of community mental health care’ (Chapter 25). It seemed but natural for the editorial team to conceptualize a section on ‘Models and Strategies for Management’ (Section VIII). Chapter 29 can be taken as an expansion and/or extension of the thoughts on ‘integration of mental health with general health care’ expressed in Chapter 4. Similar would be the case for Chapter 31 being an extension of discussion initiated in Chapter 8. We would suggest the reader to view Chapters 12 and 34 as ‘two sides of the same coin’. Section VIII focuses in detail on various non-pharmacological modes of management; both individual (Chapter 35) and in groups (Chapter 33); at secondary and tertiary levels of prevention (Chapter 36); and highlights the importance of simple yet extremely effective tools readily available in the community, i.e. ‘psychoeducation’ and ‘counseling’ (Chapters 30, 31, 35). At face value, the reader will probably find Chapter 32 to be more of a specialty chapter (dealing with ‘intellectual disability-ID’). But a closer read will reveal that it talks about the replication and application of ‘lessons from dealing with ID’ demonstrating the axiom that ‘simple can be effective’! To be able to develop, deliver, and maintain any clinical service; the operational key factors tend to be centered on a framework whose three pillars are: research, governance (audit), and administrative-cum-service evaluation. Section IX looks at these aspects, and is probably one of the cornerstone sections of the book. Various aspects of the framework are discussed in Chapters 39 and 40. The role of major stakeholders, i.e. professional bodies (Chapter 37) and government (Chapter 38) are outlined. It would serve the reader best to read these in conjunction with Chapters 12, 41, 57, and 59 in order to gain a coherent insight and formulation into the system and movement of ‘community mental health’ in India; its past, present, and future! Any service, model or concept is as good or bad as itself if one is unable to make a comparison! Additionally, cultural influences have a significant bearing on the field of mental health (and related sciences). Hence, the focus on Indian Community Mental Health would have been incomplete without this important section (Section X) in this book. Historically, the world has been split into developed versus developing countries, first-world versus third-world countries, West versus East, etc. Therefore, chapters were commissioned from various parts of the world to gather a snapshot of the system and practice of community mental health in these countries. Chapter 42 was an eye-opener as it made us aware regarding considerable variation of community mental health across states in USA. It was interesting and enlightening to learn that some of the contributors from the ‘developed nations’ in this section felt that it was extremely difficult or nigh possible to adapt their model to the Indian scene (Chapters 43, 45), whereas others did not comment (Chapters 44, 46). But, may be that is what should have been the expected viewpoint, as it highlights the unique role played by culture in the manifestation and management of mental illnesses. On reading about the scenario in Sri Lanka (Chapter 47), one is struck by the relative greater degree of development in services. On the other hand, in Pakistan, the scenario seems to be the closest to what one would encounter in India (Chapter 48). Overall, Section X provides a feel of the inherent contradictions and idiosyncrasies that exist in community mental health across the world. Section XI introduces both theory and clinical application of concepts from medical anthropology to community mental health in India. Although medicine has always been a rich mixture of knowledge that has crossed borders across the globe, there are serious conceptual and practical challenges that arise when Western models of mental health and illness are uncritically applied to Indian settings. Cultural Psychiatry has for long argued that both experience–‘near emic concepts’ and experience distant–‘etic professional theory’ need to be differentially valued without scaling one against the other. Chapter 49 demonstrates, with the help of an example, conceptual and indeed ethical problems that ensue when received (western) wisdom is uncritically accepted, internalized, and applied to the Indian clinic setting. Chapters 50 outlines a cultural history of community mental health in post-independent India to reveal how we may have arrived at current mental health program and policies that continue to fail the majority of the Indian population who place their trust in biomedical health
  • 21. Preface  xxiii professionals. Evidence to back, this is detailed through a sustained clinical ethnography in a north Indian rural mental health programme in Chapter 51. This ethnography demonstrates how well-meaning policies and interventions fail at the point of delivery, and how the culture of community mental health professionals shape such failures. Chapter 52 is a bold and admirable attempt to challenge a landscape that generates mental health suffering. It includes both an exhaustive literature review as well as a case study to illustrate how theory and concepts of cultural psychiatry can be applied in practice. The fact that a counter-therapeutic landscape can be transformed into a therapeutic one, by deploying existing community resources is both inspiring and sets an example that can be adapted in other parts of the country. The subsequent chapters (53 and 54) illustrate how ethnographic instruments could be developed for research, and yield valuable insights that generate future research questions for national and cross-national comparison on stigmatization of severe mental illness, and its outcome across cultures. In response to the challenges outlined in Chapters 50 and 51, the authors of chapter 55 demonstrate the value of capturing local distress through the use of a cultural formulation approach that could be deployed in rural settings. This section concludes with a meticulous chapter which both describes and demonstrates the role and efficacy of traditional healing at a specified North Indian traditional healing temple. Although traditional healing is an extensive and integral part of Indian society that is patronized by the rich and poor, the term evokes sentiments that range from naive romanticism to debunking such institutions as predicated upon superstition. Like biomedicine, traditional healing is a plural concept. Yet, mental health professionals are seldom taught about such healing systems and their mode of operation in a manner that can be understood in secular terms. There is a great deal of opacity between the boundaries of existing mental health theory, policy, and practice that separate modern psychiatry from traditional healing. This boundary needs to be rendered porous. Chapter 56 does precisely that. It is only in recent times that mental health professionals and the government alike have become more active in involving lay persons, service users, carers, etc. in policy-related decisions surrounding mental health. Earlier in the preface, we have talked about the ‘emic’ approach; and in keeping with that assertion Section XII was conceptualized. Empathic narratives have been provided by a carer-parent (Chapter 57), a professional carer (Chapter 58), and a journalist (Chapter 59). An important take-home message from these narratives is that there is considerable human suffering from mental illnesses; the resources so available are not necessarily the best or sufficient; but it is not impossible to be able to achieve a ‘good outcome’ especially once all relevant stakeholders are involved in the care of the individual at any given point in time. This section provides a good ‘emic’ perspective to issues highlighted in earlier sections, e.g. stigma (Chapters 8, 31), family (Chapter 7), disability (Chapters 9, 32), rehabilitation (Chapters 9, 36), alternative treatments (Chapter 28), etc. The chapters in the book, taken together, provide a spatial collection of information and experience. But, we felt that the reader would be able to develop a better and more comprehensive understanding if the linear, historical perspective was also available. Hence, Section XIII was envisaged. It comprises reprints of key historical papers related to the development and journey of the Indian Community Psychiatry movement (Chapters 60–62). Readers may differ in their opinion about these being ‘key papers’ or ‘papers of immense historical importance’, but that is a moot point. For the editorial team, this section is ‘icing on the cake’. Whether the reader will agree with us or not, is left to the crystal ball! To Conclude Community Psychiatry, more specifically—Community Mental Health, is a “road less traveled” as compared to other specialties of Psychiatry. The book has helped the editorial team to travel a fair bit in this relatively unchartered territory, and we are much wiser than was the case before. We hope that the readers will experience the same feeling after reading the book. It is our belief that though the road may be more traveled now, but the journey has only just started. To quote: A journey of a thousand miles must begin with a single step Lao Tzu in ‘Tao Te Ching’ (The Book of the Way, 600–531 BC) BS Chavan Nitin Gupta Priti Arun Ajeet Sidana Sushrut Jadhav
  • 22. Acknowledgments Acknowledging the people and forces behind this book is an onerous yet pleasant task, as there have been contributions by a large number of people in some way or the other. First and foremost, we are extremely thankful to our patients whose sufferings persuaded us to reach out to them through community-based intervention strategies. The urge to match their unmet needs was the guiding force to design and try newer methods of community-based care and this book is a collection of these initiatives. This book is expected to provide further direction to our small attempts in trying to reach out to our patients in the community. We are equally grateful to our teachers and senior colleagues who constantly encouraged our efforts and guided us in our journey. Our heartfelt thanks to the contributors who put up with our demands at various time-frames during the completion of the book. Our initial ideas have been converted into this voluminous book with their excellent contributions. A special tribute for the Late Professor Haroon Rashid Choudhury, a passionate community psychiatrist from Pakistan, whose untimely death robbed us of being able to share this joy with him. We would also like to express our gratitude to Professor NN Wig (Emeritus Professor of Psychiatry, PGIMER, Chandigarh, India), Professor Shekhar Saxena (Director, Mental Health and Substance Abuse, WHO) and Professor Mohan Issac (Professor of Psychiatry, School of Psychiatry and Clinical Neurosciences, The University of Western Australia, Fremantle, Australia), who have not only appreciated our work but agreed to write the Forewords and Introduction for the book. Their association with the book itself is a reflection of seriousness of our work. This section would be incomplete without thanking Professor R Srinivasa Murthy. His valuable guidance during the various stages of this project; intuitive observations; helpful tips and troubleshooting skills (including agreeing to contribute from his rich experience of working in the community) were invaluable, to say the least. Words cannot express our gratitude towards his ‘personalized touch’. We would also like to thank the Editor, Indian Journal of Psychiatry; Director, General, Indian Council of Medical Research (ICMR) and the Head, Non Communicable Disease Division, ICMR; Editor, Tehelka Weekly News Magazine; AMB Publishers; John Wiley & Sons; Baywood Publishers; Sage Publishers; and Taylor & Francis Ltd, for providing permission to reprint articles/book chapters relevant to the field of Community Mental Health. We are indebted to Shri Jitendar P Vij (Chairman and Managing Director), Mr Tarun Duneja (Director-Publishing), Ms Samina Khan (PA to Director-Publishing), Mr KK Raman (Production Manager), Mr Sunil Dogra (Production Executive), Neelambar Pant (Production Coordinator), Mr Subrato Adhikary, Mr Akhilesh Kumar Dubey, Mr Chaman Lal, Mr Sudhir Babu and all other support staff at Jaypee Brothers Medical Publishers (P) Ltd, New Delhi, India, who worked tirelessly in an extremely professional and cooperative manner to achieve this outcome. We are thankful to all the people from the Department of Psychiatry, Government medical college and Hospital, Chandigarh, India, for their support at different stages. We would especially like to acknowledge the inputs by Dr Abhijit Rozatkar, Dr Rohit Garg, Mr Sunil Kumar Saini, Mrs Meenakshi Pahuja, Mr Vinod Kumar Maurya, and Mr Prashant Kumar. A special thanks for our commissioned copyeditors, Ms Supriya Guha (Basel, Switzerland) and Ms Kaushiki Bose (Kolkata, India), who worked tirelessly and under pressure, and provided the polishing touches to this ‘rough, uncut diamond’. Thank you, R Sivapriya and Madhu Reddy, for putting us in touch with them. Finally, we would like to thank the unflinching support, commitment and confidence shown in us by our individual families. Without them, the initiation, progress and culmination of this massive project was untenable. Simple words cannot express our gratitude…!
  • 23. xxvi  Community Mental Health in India Acknowledgments for reprints Chapter 49 The authors gratefully acknowledge permission to reprint this chapter that appeared in: Essays for an anthropologist. Edited by Van der Geest, Sjaak & Marian Tankink. Diemen, Uitgeverij AMB, 2010. pp. 92-96. Chapter 50 The authors gratefully acknowledge permission to reprint this chapter that was published earlier as a paper in: Jain S, Jadhav S: Cultural history of community psychiatry in India. International Journal of Health Services 2008;38(3): 561-584. Baywood Publishers. Chapter 51 The authors gratefully acknowledge permission to reprint this chapter that was published earlier as a paper in: Jain S, Jadhav S: Pills that swallow policy: Clinical ethnography of a community mental health programme in India. Transcultural Psychiatry 2009;46(1):60-85. Sage Publishers. Chapter 53 The authors gratefully acknowledge permission to reprint this chapter that was published earlier as a paper in: Jadhav S, Littlewood R, Ryder A, Chakraborty A, Jain S, Barua M: Stigmatization of severe mental illness in India: against the simple industrialization hypothesis. Indian Journal of Psychiatry 2007;49(3):189-194. Chapter 54 The authors gratefully acknowledge permission to reprint this chapter that was published earlier as a paper in: Weiss M, Jadhav S, Raguram R, Littlewood R: Psychiatric stigma across cultures: local validation in Bangalore and London. Anthropology & Medicine, special issue on ‘Cultural Epidemiology’ 2001;8(1):71-87. Taylor & Francis Publishers, UK Chapter 56 The authors gratefully acknowledge permission to reprint this chapter that appeared in: Health-Seeking Behavior for Psychiatric Disorders in North India: An Exploration of Medical Pluralism. Chapter in Psychiatrists and Traditional Healers. Edited by Incayawar M, Wintrob R, Bouchard L, John Wiley & Sons, Ltd., 2009. Chapter 59 The editors gratefully acknowledge permission to reprint this article that appeared earlier in: Gupta D: Mind Snare. Tehelka Magazine, 15(9), 15 May 2010. pp. 28-43. Chapter 60 The editors gratefully acknowledge permission to reprint this chapter that was published earlier as a paper in: Wig NN, Srinivasa Murthy R, Harding TW: A model for rural psychiatric services-Raipur Rani experience. Indian Journal of Psychiatry 1981;23:275-290. Chapter 61 The editors gratefully acknowledge permission to reprint this chapter that was published earlier as a paper in: Issac MK, Kapur RL, Chandrasekar CR, Kapur M, P Pathasarathy R: Mental Health Delivery through Rural Primary Care— Development and Evaluation of a Training Programme. Indian Journal of Psychiatry 1982;24:131-138. Chapter 62 The editors gratefully acknowledge permission to reprint this chapter that was published earlier as: ICMR-DST: Collaborative Study on Severe Mental Morbidity. Indian Council of Medical Research-Department of Science and Technology, New Delhi, 1987.
  • 24. Contents Section I: An Introduction to Community Mental Health 1. The Relevance of Community Psychiatry in India...................................................................................................................3 Srinivasa Murthy R • Challenging Mental Health Situation in India 3 • International Development of Mental Health Services 7 • Development of Mental Health Services in Low and Middle Income Countries 8 • Development of Mental Health Services in India 9 • Community Mental Health Initiatives in India 9 • International Developments 16 • Personal Reflections of Last Six Decades 16 • Future of Community Psychiatry in India 17 Section II: Historical Concepts and Evolution 2. Psychiatry in India: A Historical Perspective..........................................................................................................................25 Haque Nizamie, Mohammad Zia Ul Haq Katshu, Samir Kumar Praharaj S • History of World Psychiatry 25 • Psychiatry in Ancient Vedic India 26 • Psychiatry in Medieval India 27 • Psychiatry in Colonial India 27 • Psychiatry in Postindependence India—The Colonial Hangover and Development of Modern Psychiatry 32 • How Far We Have Come? 36 3. General Hospital Psychiatry......................................................................................................................................................39 Prakash B Behere, Manik C Bhise • The Concept of General Hospital Psychiatry Units 39 • History 40 • Integrating Psychiatry with General Health Care System in India 40 • Roles of General Hospital Psychiatry Units in India 41 • Inter Relationship between Psychiatry and other Specialties 43 • Future of Ghpus in India 49 4. Towards Community Mental Health Care: Primary Health Care Model...........................................................................53 Sunder Lall, Shanker Prinja • Village Level 53 • System of Sub-health Centers 53 • System of Primary Health Centers 54 • System of Community Health Centers 54 • Moving away from Mental Institutions—Towards Community Mental Health Care 55 5. National Mental Health Programme........................................................................................................................................58 Rajesh Kumar, Dinesh Kumar National Mental Health Programme 58 • Evolution of District Mental Health Programme 59 • National mental health programme in Eleventh five-year Plan (2007–12) 61 • District Mental Health Programme and national rural health mission 62 6. District Mental Health Programme..........................................................................................................................................65 Gangadhar, KV Kishorekumar BN • The Magnitude of Mental Health Problems: The Need for Decentralized Mental Health Care 65 • The Burden of Mental Disorders 66 • Current Resources for Mental Health Care 66 • Capacity-building for Primary Care Personnel to Deliver Mental Health Care 66 • The Advantages of Planning Mental Health Care at the District Level 67 • Aims and Objectives of the Dmhp 67 • The Process of Implementation of the Dmhp in the District 67 • Mid-Course Evaluation of the Dmhps 69 • Findings and the Recommendations of the Evaluation of the Functioning of Dmhp in India: Evaluation by the Ministry of Health and Family Welfare, Govt of India, 2009 69 • Key Issues for Effective Implemen­ation of the Dmhp in India 71 t Section III: Dimensions of Community Psychiatry 7. Family and Mental Health in India .........................................................................................................................................77 Vikas Bhatia, Rohit Garg, Abhiruchi Galhotra • Changing Concepts Over the Role of Family in Mental Illness 77 • The Indian Family 78 • Historical Aspects of the Role of the Family in Mental Illness in India 80 • Impact of Mental Illness on the Families 80 • Therapeutic Role of
  • 25. xxviii  Community Mental Health in India Family in Management of Psychiatric Illnesses 82 • Changes in Traditional Indian Family and Implications for Mental Health 82 • Role of Family Self-help Groups and Nongovernmental Organization in Mental Health in India 84 • Early Warning Signs of Psychiatric Illnesses: Can Family Prevent Psychiatric Illness? 85 8. Stigma of Mental Illness............................................................................................................................................................89 Santosh Loganathan, R Srinivasa Murthy • Historical Perspectives 89 • Stigma: Concepts and Terminologies 91 • Consequences of Stigma 92 • Stigma Research: Instruments and Methods 94 • Research from India 96 • Research Among Low and Middle-income Countries 99 • Research Studies from Western Countries 100 • Anti-stigma Campaigns 102 • An Agenda for Action—What can be done by the Following Stakeholders? 103 9. Disability and Functioning...................................................................................................................................................... 112 R Thara, Hema Tharoor • Definitions 112 • Areas Affected 112 • Impact of Disability 113 • International Classification of Disabilities 113 • Relevance of Icf to Rehabilitation 114 • Measurement of Disabilities 114 • Indian Disability Evaluation and Assessment Scale 114 • Why Measure Disability? 115 • International Study 115 • Indian Research on Disability 116 • Cross-cultural Issues and ­ isability 116 • The Interplay of Disability and its Impact on Practice of Community D Psychiatry 117 • Conclusion and the Way Ahead 117 10. Homelessness and Mental Illness............................................................................................................................................ 119 RC Jiloha, Lokesh S Shekhawat • Definitions and Concepts 119 • Prevalence 120 • Homelessness and Mental Illness 120 • Pathways to Homelessness for the Mentally Ill 121 • Homelessness and Individual Psychiatric Disorders 123 • Legal Issues Related to Homeless Mentally Ill 123 • Negative Effects of being Homeless 124 • Community Mental Health Programs and the Homeless Mentally Ill in India 124 • Government and Nongovernment Organizations Working for Homeless Mentally Ill 124 • Management 125 • Principles of Management 127 • Early Intervention 127 • Housing Programs 128 • Outreach Services 128 • Assertive Community Treatment 128 • Service Integration 129 • Motivational Interventions/Stages of Change 129 • Modified Therapeutic Communities 129 • Self-help Programs 129 • Involvement of Consumers and Recovering Persons 130 • Psychiatric Rehabilitation 130 • Training and Employment 130 • Crisis Care Services 130 • Teaching and Training 130 11. Gender and Community Mental Health: Sharing Experiences from our Service Program...........................................136 Bhargavi V Davar • Contested Concepts of ‘Mental Illness’ 136 • Mental Health Empowerment as the Basis for (Urban) Community Mental Health Policies 138 • Nuancing Gender in the Context of Development, Urbanization and Mental Health 143 • Designing a Gender Sensitive Urban Community Mental Health Program 144 12. The Role of Non-Governmental Organizations in Community Mental Health Care.......................................................148 Vandana Gopikumar, Elizabeth Negi, Mirjam Dijkxhoorn • Case Study 1 148 • Mental Health Sector—An Overview 149 • Ngo Sector in India 150 • Working with Divergent Mental Health and Well-being Needs of People from Lower Socioeconomic and Vulnerable Groups 151 • Case Study 2 152 • Working with Tribal Communities 154 • Working with Self-help Groups 154 • Focus on a Rights Framework 154 • Caregiver and User Driven Programs 155 • Focus on Research 156 • Working with Traditional Systems of Healing 156 • Community Fostering 156 • Challenges Faced by Ngos in the Mental Health Sector 156 • Positive Trends in Community Mental Health Care in the Ngo Space 157 Section IV: Legislative Aspects 13. Contemporary Debates about Mental Health Legislation: A Summer and a Winter of Discontent............................. 161 Anirudh kala • United Nations Convention Rights of Persons with Disabilities (UNCRPD) and Mental Health Act 163 • Towards a New Mental Health Act 165 • Concerns about the Proposed New Act 167 14. Persons with Disability Act ....................................................................................................................................................169 Rachna Bhargava, Siva Kumar Thanapal, Abhijit Rozatkar • What is Disability? 169 • Change in Perspective of Viewing Disability 169 • Epidemiology of Disability 169 • Policies for Disability in India 170 • Salient Features of the Pwd Act, 1995 170 • Inclusion of Mental Illness in Pwd Act, 1995 170 • Criticism of Pwd Act 172 • General Policy Issues 172 • Sectoral Policy Issues 173
  • 26. Contents  xxix • Implementation of the Act 173 • Awareness of the Act 174 • Certification of Disability 174 • United Nations Convention on the Rights of Persons with Disabilities 174 • Right to Persons with Disabilities Act, 2010: Working Draft 174 • Notable Advances in the New Act 175 • Disability Rights Authority 175 15. Narcotic Drugs and Psychotropic Substances Act ...............................................................................................................176 Debasish Basu, Munish Aggarwal, Umamaheswari V • Historical Background 176 • The Narcotic Drugs and Psychotropic Substances Act 177 • Amendments 180 • Community and the Narcotic Drugs and Psychotropic Substances Act 180 16. Human Rights and Law ..........................................................................................................................................................184 Soumitra Pathare, Kunal Kala, Alok Sarin • Interaction between Human Rights and Mental Health 184 • International Human Rights Systems 185 • The Indian Scenario 188 • Necessity of Mental Health Legislation—Protecting, Promoting and Improving Rights through Legislation 188 • Substantive Content of Mental Health and Related Legislation 189 • Interface between Policy and Legislation 191 Section V: Community Mental Health and Psychiatric Specialties 17. Community Based Addiction Psychiatry ..............................................................................................................................195 Anju Dhawan, Raman Deep Pattanayak • Background and Rationale 195 • Concept 195 • Principles and Practices 196 • Range of Community Based Services 196 • Advantages 197 • International Perspectives 197 • Community based Approaches in India 198 • Sector-based Interventions (Workplace, Schools) 201 • Cost-effectiveness 202 18. Community Based Geriatric Psychiatry................................................................................................................................205 Shaji KS • Care of older People 205 • Disability/Dependence 205 • Caregiver Issues 206 • Geriatric Psychiatric Disorders 206 • Treatment Gap 208 • Integration with other Services 208 • Peoples’ Participation in Mental Health Care for Older People 209 • Lessons from Palliative Care 209 • Development of Community based Dementia Care 210 • Schemes and Policies 210 • Welfare Associations for Elderly 211 • Future Directions 211 19. Community Child and Adolescent Psychiatry .....................................................................................................................213 Savita Malhotra, Navendu Gaur • Historical Account 213 • Introduction 213 • Principles and Goals of Community Child and Adolescent Psychiatry (CCAP) 214 • Therapeutic Foster Care (TFC) Model 215 • Chandigarh’s Child Protection Programme: A Community Initiative 217 • Inter-sectoral Interface 217 • School Mental Health 218 • Conclusion 221 20. Learning Disabilities: Community Based Approaches and Initiatives ..............................................................................222 Chhaya Sambharya Prasad, Samir Dalwai, Hemant Singh Keshwal Background 222 • Diagnosis 224 • Issues to be Addressed 227 Section VI: Emergencies in the Community 21. Farmers’ Suicides in Central Rural India ............................................................................................................................231 Prakash B Behere, Manik C Bhise • Definition of Various Terms 231 • Magnitude of Problem 231 • Epidemiology 232 • State wise Prevalence in India 233 • Etiology 233 • Survivors of Farmer Suicide 235 • Prevention of Farmer Suicides 236 • Role of Psychiatrists 238 • Role of other Allied Professionals 238 • Role of Community-based Psychiatry in Prevention 238 22. Suicidal Behavior and Suicide Prevention.............................................................................................................................241. Roy Abraham Kallivayalil, PG Saji • myths about Suicide 241 • Definition and Terms 242 • Epidemiology 242 • Suicidal Behavior as a Public Health Problem 242 • Associated Factors in Suicide 243 • Causes of Suicidal Behavior 243 • Psychiatric Disorders and Suicide 244 • Survivor Guilt in Suicide 245 • Copycat Suicide and Media 246 • Society and Suicide 246 • Religion, Culture and Suicide 247 • Economic Situation and Suicide 247 • Suicide by Farmers 247 • ‘What’ after Assessment 247 • General Approaches in Suicide ­ revention 248 • The Kerala Experience 249 P 23. Crisis and Violence Intervention.............................................................................................................................................251. Rajiv Gupta, Arunima Gupta • Crisis: Concept and Definition 251 • Violence Potential and Crisis Intervention 251 • Management 253 • Crisis Intervention 253 • Violent Behavior 254
  • 27. xxx  Community Mental Health in India 24. Disaster Management: Mental Health Perspective .............................................................................................................257 Nilamadhab Kar Post-disaster Mental Health Sequelae 257 • Vulnerability Factors 260 • Post-disaster Interventions 261 • Types of • Psychological Intervention 262 • Psychopharmacological Intervention 263 • Role of Mental Health Professionals in Disaster Management 263 Section VII: Alternatives to Hospitalization 25. Models of Community Mental Health Care..........................................................................................................................269. BS Chavan, Abhijit Rozatkar, Ajeet Sidana • What is Required? 269 • Evolution of Community Mental Health 269 • Component of Community Mental Health Model 270 • Are Western Models Appropriate for Developing Countries? 270 • Various Community Models 271 • Future Models for Community Psychiatry 279 26. Camp Approach........................................................................................................................................................................281 Chavan, Ajeet Sidana, Abhijit Rozatkar BS • Introduction • Why do We Need the Camp Approach? 281 • Camp Approach in Psychiatry 281 • The Camp Approach in Substance ­ ependence 282 • History of the Camp Approach for ­ ubstance Dependence 282 • Organizing a Camp 283 D S • The Camp Experience 284 • Current Status of Camp Approach 286 27. Primary Prevention of Psychiatric Disorders ......................................................................................................................288 Chavan, Nitin Gupta, Jasmin Arneja BS • Definition of Prevention 288 • Mental Health Promotion 288 • Risk and Protective Factors 289 • Altering Environmental Settings 289 • Prevention in Relation to Prenatal Period and Infancy 290 • Preventing Specific Disorders 291 • Problems Encountered in Primary Prevention Research 294 28. Alternative/Indigenous Therapies ..........................................................................................................................................296 Rakesh K Chadda, Koushik Sinha Deb • Defining Indigenous and Alternative Medicine 296 • Classifying Indigenous and Alternative Therapies 296 • How Many People Actually Seek Alternative Medicine Treatment before coming to Modern Treatment Centers? 297 • Why do Patients Turn to Indigenous and Alternative Medicine in the Present-day Context? 298 • A Brief Overview of the Various Types of Alternative Medicine 298 • Efficacy of Alternative Treatment/Indigenous Therapies 304 Section VIII: Models and Strategies for Management 29. Integration of Mental Health Services with General Health Care..................................................................................... 311 Srinivasa Murthy R • Historical Aspects 313 • Magnitude of Mental Disorders in Primary Health Care 314 • Integration of Mental Health Care with Primary Health Care 314 • General Practitioners Training 318 • Training Resources for Integration of Mental Health Care 319 • Current Status of Integration of Mental Health with General Health Services 319 • Future Needs 320 30. Public Mental Health Education.............................................................................................................................................324 Srinivasa Murthy R • Existing Beliefs and Practices 324 • Mental Health Educational Activities in the Country 326 • Evaluation of the Public Mental Health Education Activities 329 • International Experiences 331 • Guidelines for Preparing Mental Health Education Programs 331 31. Fight Against Stigma................................................................................................................................................................334 Sudhir Kumar Khandelwal, Raman Deep Pattanayak • Concept and Consequences 334 • Strategies and Interventions to Fight Stigma 334 • Health-related Stigma: What has Worked Elsewhere? 337 • Action Against Stigma 338 • Global Program Against Stigma: ‘Open the Doors’ 339 • Stigma Reduction: Asian Perspective 339 • Stigma Reduction: Indian Perspective 340 • Addressing the Stigma Associated with Psychiatry 340 • Addressing the Stigma in Media 341 • Need to Address the Stigma in Special Populations 341 • Future Directions 341 32. Social Inclusion and Mental Health: Some Experiences with Intellectual Disability.......................................................345 Keerti Menon, Reeta Peshawaria • Initiatives and their Applicability 345 • Summary and Conclusions 348
  • 28. Contents  xxxi 33. Role of Self-Help Groups.........................................................................................................................................................350 Raj Lok • Definition 350 • Classification 350 • What helps in Self-help Groups? 351 • How Effective are Self-help Groups? 352 • Recovery International Experience 353 • Indian Perspective 354 • Challenges and Way Forward 355 34. Voluntary Sector and NGOs................................................................................................................................................... 357 Arun, Suravi Patra, Nitin Gupta Priti • History and Present Scenario of Ngos in India 357 • Role of Voluntary Sector in Health 358 • Need of Voluntary Sector in Mental Health 358 • Areas addressed by Ngos 358 • Research Evidence 360 • Future Directions 361 35. Role of Psychotherapy and Counselling................................................................................................................................362 Vijoy K Varma, Nitin Gupta • What is Psychotherapy? 362 • Why Consider Psychotherapy? 362 • Western Model of Psychotherapy 362 • Eastern Traditional Model of Psychotherapy 363 • Types of Psychotherapy 364 • Pragmatics Related to the Process of Psychotherapy 364 • How Psychotherapy Heals? 365 • Adapting Psychotherapy for India 365 • Manpower Constraints 365 • Practical Aspects 366 • Role of Health Professionals in India at the Community Level 366 • Principles and Practice of Psychotherapy at the Community Level 366 • Psychotherapy in Specific Situations 367 36. Psychosocial Rehabilitation in Psychiatry.............................................................................................................................369 Paramleen Kaur, Abhijit Rozatkar • Introducing Disability in Mental Illness 369 • Nosological Status of Disability 369 • Disability, Functioning and Rehabilitation 369 • What is Psychiatric Rehabilitation? 370 • Assessment of Psychiatric Disability and Rehabilitation Needs 370 • Interventions in Rehabilitation 371 • Planning Rehabilitation Needs of Patient 373 • Residential Continuum 374 • Rehabilitation in Mental Retardation 374 • Psychosocial Rehabilitation in Developing World Versus Developed World 375 • Psychosocial Rehabilitation in India 376 Section IX: Administrative, Governance and Research 37. Contributions of Major Professional Bodies.........................................................................................................................383 Trivedi, Rahul Saha JK • Beginning of Ips and Ijp: Aims and Objectives and Postindependence Scenario 384 • Major Contributions and Impact 386 • Other Professional Bodies 387 • How are Professional bodies and Community Psychiatry Interlinked? 389 • Possible Goals for Future 390 38. Community Mental Health Initiatives by the Government: Past, Present and Future...................................................393 Jagdish Kaur, Suman K Sinha • Burden of Mental Disorders 393 • Role of the Government in Mental Health Care Delivery in India 393 • National Mental Health Programme 394 • Mental Health Act and other Supportive Legislations 395 • National Health Policy Supporting Community Mental Health 396 • District Mental Health Programme 396 • Gaps Identified in Effective Implementation of DMHP during the ninth Plan Period 396 • Restrategized Nmhp in the tenth Plan Period 396 • Expansion of District Mental Health Programme 396 • Achievements of Nmhp during the tenth Plan Period 397 • Revised Strategy of Nmhp in the eleventh five year Plan Period 397 • Revised Implementation Plan for Dmhp 397 • DMHP-Team 397 • Integration of Nmhp with Nrhm 399 • International Cooperation in Community Mental Health 399 39. Community Psychiatry: Cost-Effectiveness and Monitoring..............................................................................................402 Pratap Sharan, A Shyam Sundar • Cost Effectiveness 402 • Who Choice 403 • Monitoring of Community Psychiatric Services 407 40. Models for Research in the Community................................................................................................................................413 Avasthi, Naresh Nebhinani Ajit • Research in Community Psychiatry 414 • The Principal Methods used in ­ ommunity Research 414 • Models of C Community Mental Health Care 415 • Indian Research 417 • Ethical Issues in Community Research 417 • Monitoring and Auditing in ­ ommunity Research 417 • Importance of Community Based ­ esearch 418 • Conclusion 418 • Future C R Directions 418 41. Appropriate Resource Management: Administrative and Political Initiatives.................................................................421 Chavan BS • Availability of Manpower in Mental Health 421 • Human Resources Management 424 • Use of Nonprofessionals for Mental Health Care 426
  • 29. xxxii  Community Mental Health in India Section X: Community Mental Health: International Perspectives 42. Community Psychiatry in United States of America .........................................................................................................431 Jagannathan Srinivasaraghavan, Sukriti Mittal, Nishant Kumar, Bhagirathy Sahasranaman, Veena Garyali, Swapnil Gupta, Rajeev Panguluri • History of Community Psychiatry 431 • Community Psychiatry in California 434 • Community Psychiatry in Florida 435 • Community Psychiatry in Illinois 437 • Community Psychiatry in New York 438 • Community Psychiatry in Mississippi 439 • Conclusion 440 43. Community Psychiatry in United Kingdom.........................................................................................................................442 Niraj Ahuja, Andrew Cole • Historical Aspects and Evolution 443 • Deinstitutionalization, Community Psychiatry and General Hospital Psychiatry 443 • Tiers: Primary, Secondary and Tertiary Care (Stepped Care Model) 445 • Community Mental Health Teams 445 • National Service Framework for Mental Health 446 • Functional or Specialist Teams 446 • Multidisciplinary Teams: The Evidence 447 • Funding, Tariffs and Payment by Results 447 • New Horizons 447 • Mental Health Act 448 • Relevance and Suggestions towards Adaptation to the Indian Setting 448 44. Community Mental Health Services in Australia and New Zealand................................................................................451 Dinesh K Arya, Brian Kelly • Structure of Services 451 • Community Psychiatry—It is Important to Define its Scope 452 • Community Psychiatry in India, Australia and New Zealand—Similarity in Trends 452 • Growth of Community Psychiatry 456 • Some Myths about Community Psychiatry 457 45. Community Psychiatry in Singapore.....................................................................................................................................460 Somnath Sengupta, Leong Jern-Yi, Joseph, Lee Cheng • Factors that Influence the Effectiveness of a Community Mental Health Program 460 • Community Mental Health Program (Cmhp) in Singapore 462 • Summary of Community Psychiatric Services in Singapore 466 • Is Cmhp Singapore Applicable to India? 466 • Community Mental Health Program of Singapore Applied to the Realities of India 468 46. Community Psychiatry in Malaysia.......................................................................................................................................470 Dato’ Suarn Singh, Cheah Yee Chuang • Prevalence of Mental Disorders and an Overview of Mental Health Services 470 • Historical Background 470 • Important Milestones in the Development of Community Psychiatry in Malaysia 471 • Family Support Groups 473 • Strategies to Strengthen and Enhance Community Mental Health Services 474 • Interface between Primary and Secondary Care 475 • Training and Human Resources 475 • In Service Training 475 • Clinical Practice Guidelines 476 • National Mental Health Registry 476 • Clinical Audit Indicators for Quality Management 476 • Future Direction 476 47. Community Psychiatry in Sri Lanka....................................................................................................................................478 Jayan Mendis • History of Community Psychiatry in Sri Lanka 478 • The Present State of Community Psychiatry in Sri Lanka 479 • The Community Health Care Program of Sri Lanka 479 • Non-Governmental Organizations in the Provision of Community Psychiatry 482 • Community Mental Health Care in the Gampaha District 482 • Strengths of the Existing Community Mental Health Services 483 • Weaknesses of the Existing Community Mental Health Services 483 • The Future of Community Psychiatry in Sri Lanka 483 48. Community Psychiatry in Pakistan.......................................................................................................................................485 Haroon Rashid Chaudhry, Raumish Masud Khan, Ammara Shabbir Late • Historical Perspective of Community Psychiatry in Pakistan 485 • Current Mental Health Scenario 485 • Existing Manpower Resources and Infrastructure 486 • Existing Training and Research Facilities and Initiatives 487 • Existing Models of Delivery of Care 488 • Role of Ngos 489 • Mental Health Legislation 489 • Mental Health Policy 489 • Current Scenario 489 • Suggestions and Future Directions 490 Section XI: Community Psychiatry and Clinically Applied Anthropology 49. What is Cultural Validity and why is it Ignored? The Case of Expressed Emotions Research in South Asia..................................................................................................................................................................................493 Sushrut Jadhav • What is Cultural Validity? 493 • Validity of Expressed Emotions Research in South Asia 493 • Why is Cultural Validity Ignored? 494
  • 30. Contents  xxxiii 50. A Cultural Critique of Community Psychiatry in India......................................................................................................496 Sumeet Jain, Sushrut Jadhav • What Ails Community Psychiatry in India? Three Vignettes 496 • Brief Cultural History of Community Psychiatry in India 498 • Critical Issues and Future Directions 504 51. Pills that Swallow Policy: Clinical Ethnography of a Community Mental Health Programme in Northern India..........................................................................................................................................................................509 Sumeet Jain, Sushrut Jadhav • the ‘Policy’ Pill 510 • Compliance with Medication: The Pill as a Boundary Marker 511 • ‘Sarkari Davai’ (Government Medicine): Community Reactions to Government Services 515 • Discussion 515 52. Eco-psychiatry: Culture, Mental Health and Ecology with Special Reference to India..................................................522 Arabinda N Chowdhury, Sushrut Jadhav • Concepts Relevant to Ecopsychiatry 522 • Development of the Concept of Ecopsychiatry 523 • Ecopsychiatric Issues—Ecology and Mental Health 523 • Ecosystem Services and Human Health 524 • Social Change and Ecology 524 • Disasters 525 • Urbanization, City Ecology and Mental Health 525 • High-rise and Metro-Rail 526 • Deforestation 527 • Development-induced Population Displacement 529 • Climate Change 530 • Environmental Degradation 532 • Eco-specificity and Mental Health: A Case Study from Sundarban, West Bengal, india 533 • Some Practical Steps in Clinical Community Psychiatry 533 53. Stigmatization of Severe Mental Illness in India: Against the Simple Industrialization Hypothesis.............................543 Sushrut Jadhav, Roland Littlewood, Andrew G Ryder, Ajita Chakraborty, Sumeet Jain, Maan Barua • Materials and Methods 543 • Results 544 • Discussion 545 • Appendix: Stigmatization ­ uestionnaire 548 Q 54. Psychiatric Stigma Across Cultures: Local Validation in Bangalore and London...........................................................550 Mitchell G Weiss, Sushrut Jadhav, R Raguram, Penelope Vounatsou, Roland Littlewood • Methods 551 • Results 552 • Discussion 557 55. Clinical Appeal of Cultural Formulations in Rural Mental Health: A Manual................................................................560 Sushrut Jadhav, Sumeet Jain • What is Culture? 560 • Discussion 563 • Summary 565 56. Cultural Dimensions of Health-Seeking Behavior for Psychiatric Disorders in North India: An Exploration of Medical Pluralism....................................................................................................................................566 Antti Pakaslahti • Orientation to the Temples and the Healing Tradition 567 • The Network of Healers in Balaji 568 • Background and Help-seeking Pathways of Patients 569 • on Symptoms and Diagnoses of ­ atients from two Perspectives 571 P • Three Accounts of Help-seeking 572 • Summing up for Future Research 574 Section XII: Personal and Popular Narratives of Suffering 57. Experiences and Reflections from the Parent of a Schizophrenic Daughter ....................................................................581 Sood Dr • Onset of the Problem 581 • Handling of a Schizophrenic at Home 582 • Society and Stigma 582 • Great Relief to the Patient and the Parents 583 58. Gopalan .....................................................................................................................................................................................584 Sneha Rajaram 59. Mind Snare................................................................................................................................................................................591 Divya Gupta • Millions of Families are Struggling with Psychiatric Illnesses with ­ lmost no Support: Divya Gupta ­ urveys a A S Landscape of Intense ­ espair—and Hope 591 D Section XIII: Appendix (Reprints of Historical Papers) 60. A Model for Rural Psychiatric Services—Raipur Rani Experience...................................................................................605 Wig, R Srinivasa Murthy, TW Harding NN • Mental Illness at the Village Level 605 • Issues 606 • the Study Area 606 • Progress and Observation 607 • Health Staff Interview 607 • Screening of the General Health Clinic Population (Adults) 608 • Screening of the General Health Clinic Population (Children) 608 • Community Attitude to Mental Disorders 609 • Priority Selection 609 • Rural Psychiatric
  • 31. xxxiv  Community Mental Health in India Clinics 609 • Training of the Health Personnel 610 • Training Manual 611 • Training Programs 611 • Supervision and Support of the Health Personnel 611 • Decentralization of Services 611 • Observation during Supervision of Health Personnel 613 • Administrative 613 • Community Involvement and Health Education Activity 615 • Implications 616 61. Mental Health Delivery Through Rural Primary Care—Development and Evaluation of a Training Programme................................................................................................................................................................617 Mohan K Isaac, RL Kapur, CR Chandrashekar, Malavika Kapur, R Pathasarathy • Context 618 • Objectives 618 • Trainee Characteristics 618 • Resources 619 • Process 619 • Effects 619 • Discussion 619 • Appendix 621 62. ICMR-DST: Collaborative Study on Severe Mental Morbidity.........................................................................................623 Indian Council of Medical Research and Department of Science and Technology • Introduction 623 • Review of Literature 623 • The Present Study 628 • Phase I: Development, Modification and Translation of Research Instruments 635 • Phase II: Training of Centre Personnel and Intervention by Trained Personnel 637 • Phase Ii: Field Survey 645 • Discussion 646 • Issues Emerging Out of the Study 649 • Epilogue 651 Index.................................................................................................................................................................655
  • 32. Introduction Mohan Isaac Wow! A book on Community Mental Health in India! That too authored and edited by mostly Indian mental health professionals based on their experiences in attempting to provide meaningful mental health services to over a billion populations. When the editors invited me to contribute an introduction to this book, I was indeed delighted. I was naturally reminded of my own entry to the field of community mental health in India almost 35 years ago, during the second half of 1976. The first and only specially designated community mental health unit in the country was set up at the National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru and the late Professor Ravi Kapur was appointed to the first Chair of Community Psychiatry in India at NIMHANS. The main goal of this unit was to develop methods of taking mental health care out of the psychiatric institutions to the large sections of unserved and underserved populations, particularly in the rural areas. Those were the days when Milton Greenblat had famously termed ‘psychiatry’ the ‘cinderella of medicine’ in the New England Journal of Medicine and Fuller Torrey had predicted the “death of psychiatry”. Specialization in psychiatry by young medical graduates was not considered very commendable. After my initial years of postgraduate training in psychiatry, my decision to join the newly formed community mental health unit at NIMHANS as one of its few earliest staff members (against the possibility of working as a junior consultant in the hospital setting) and carry out my doctoral thesis related work in the villages around the Sakalawara Rural Community Mental Health Center was frowned upon by many around me. However, the quick acceptance with minimal changes and publication of my thesis related work on detection of psychosis and epilepsy in the community by multipurpose health workers of rural primary health centers in journals such as The Lancet and the British Journal of Psychiatry convinced me that we were in the right direction. I was also convinced that the only way mental health care could be delivered to the unreached populations in the country was by big development of community mental health. I continued to be attached to the community mental health unit at NIMHANS for nearly the next 30 years. During this period, I also had the privilege of personally knowing the work in the field of community mental health of most of the authors of this textbook. Subsequently, after I moved to the University of Western Australia where I continue to be attached to a community, culture and mental health unit, I learned on the first hand basis how very different is the delivery of community based mental health services in a resource rich developed setting and a developing country. What follows in this introduction is my personal perception of issues in community mental health in western and nonwestern settings such as India. Community mental health Community mental health, in very broad and simple terms, refers to care of and services provided to persons with mental health problems and their families in community settings. In developing countries such as India, community settings would include a person’s home, large joint family setting, a general practitioner’s clinic, a government run primary health center (PHC), community health centre (CHC) or a district hospital, a non-hospital residential facility such as a half-way home or hostel run by non-governmental organizations, a private psychiatrist’s office/clinic, a counseling center or a rehabilitation center in a community location running day programs and providing a range of other community based services. Such care or services may be provided by; besides trained mental health professionals (psychiatrists, clinical psychologists, psychiatric social workers, and psychiatric nurses), trained general practitioners, primary health center doctors and multipurpose health workers, counselors, rehabilitation workers and family members and other carers under the overall supervision of mental health professionals. The broad range of services can include early identification
  • 33. xxxvi  Community Mental Health in India and prompt treatment of both common and severe mental disorders, management of persons with chronic mental disorders in the community, referral to secondary and tertiary mental health services as well as other social welfare services, attention to the mental health needs of persons with various physical health problems, and interventions aimed at mental health promotion and mental health prevention in community organizations such as schools, anganwadis (pre-school institution), industries and in the larger community itself. The goals and principles of community mental health ideally are decentralization, comprehensiveness of care, accessibility of appropriate, affordable and equitable basic mental health care to all, multidisciplinary and multisector (including private sector) involvement, community participation and inter-sectoral collaboration. Community mental health in the West In the rich and developed countries of Western Europe, Scandinavia, and North America and in Australia and New Zealand, community mental health care really began only during the second half of the twentieth century. Up until the 1950s, care for persons with severe mental disorders in these countries was provided only in large stand-alone institutions called asylums (mental hospitals). Such institutions steadily grew in number, size and occupancy in most of these countries during the previous two centuries. However, beginning in the early part of twentieth century, due to a variety of factors such as overcrowding, poor living conditions, declining financial resources, unmotivated staff, growing public and professional discontent, etc. The mental hospitals progressively started declining in their therapeutic role and functions. The serendipitous discovery of the first effective antipsychotic medication, chlorpromazine in 1952 and its subsequent widespread use triggered a process which was later referred to as deinstitutionalization. Deinstitutionalization was not preconceived and has been variously defined. Mental health historians are divided about whether to call it a ‘policy’, ‘concept’, ‘movement’, ‘protest movement’ or just an ‘era’. Some critics of deinstitutionalization have referred to the phenomenon as a ‘factoid’. Deinstitutionalization essentially meant moving severely mentally ill people out of large institutions—mental hospitals and shifting their care and support to community based settings and later closing part or all of the institution. For example, the total number of severely mentally ill inpatients in all mental hospitals in the United Sates of America which was 558,329 in 1955 came down to 71, 619 in 1994 (US population in 1955 was 164 million and in 1994, 260 million). In USA, the growth of community mental health was accelerated by numerous factors including the final report of the Joint Commission on Mental Illness and Health (appointed by President Eisenhower in 1955) titled “Action for Mental Health” submitted in 1961. President John Kennedy called for the closure of large stand alone psychiatric institutions and their replacement by home and community care services. The enactment of the Community Mental Health Centres Act (signed by President Kennedy in 1963, three weeks prior to his assassination) paved the way for the creation of community mental health centers in USA. During the succeeding years, similar events occurred in most rich and developed countries. Care of persons with severe mental disorders moved out of the mental hospitals and into the community. The process of deinstitutionalization and the creation of various alternatives to mental hospitals occurred at varying pace in different countries. Factors which determined the pace of reforms included changes to mental health legislation, financial resources and funding arrangements, availability of trained human resources, social acceptance, political will and administrative commitment. For example, in Italy a new mental health law, called the “Law 180” was enacted in 1978. The law aimed to change mental health services radically. It had four main components namely: (1) Phase out mental hospitals and cease all new admissions, (2) Establish general hospital psychiatry wards (maximum 15 beds), (3) Restrict compulsory admissions and (4) Set up community mental health centers. The mental health care scenario changed dramatically following the enactment of the legislation. The development of the type of community based services varied internationally. Non-hospital residential facilities such as half way houses and hostels and different forms of supported accommodation in the community were established. Catchment area teams and multidisciplinary community mental health teams were created to deliver different types of services for the persons discharged from mental hospitals. A form of intervention consisting of initial engagement with patients, assessment of their needs, individualized care planning, environmental interventions, regular monitoring and review and patient advocacy referred to as ‘case management’ was developed. Different forms of case management including a particular form of intensive care called ‘assertive community treatment’ (ACT) became the predominant mode of community based care in all resource rich settings. The current form of mental health services in the West is a pragmatic balance of community and hospital based care, referred to as “balanced care” wherein treatment and a variety of community based services are provided either at home or close to home, coordinated by mental health
  • 34. Introduction  professionals and agencies. Such care also includes short-term hospitalization when needed, invariably in a general hospital based psychiatry unit. In many western countries, mental health reform is still an ongoing process (Burns, 2007; Fagin, 1985; Fakhoury and Priebe, 2002; Isaac, 2007; Thornicroft and Tansella, 2004). Community mental health in developing countries such as India In most Asian and Latin American countries with very modest financial and trained human resources mental health services continue to be provided largely through mental hospitals or stand alone psychiatric institution. The mental health reform process has barely begun only during the past decade in most countries. In Japan, the number of institutionalized mentally ill increased over the years. In many countries of Africa, formal mental health services are rudimentary. The story of community mental health in India is very different from the West. Persons with mental disorders traditionally have always been treated within the community. Such persons were generally taken care of by the family, the larger community and traditional healers. Asylums which later became mental hospitals were opened in India, initially by the British East India Company and later by the country’s colonial rulers, primarily for British soldiers and British nationals who suffered from mental disorders. For a large country with a huge and growing population, the total number of mental hospital beds available was always very small. At the time of India’s independence in 1947, the country had just 17 psychiatric institutions and about ten thousand mental hospital beds. Since the mental health care facilities were so inadequate, some more mental hospitals were built in the country during the first two decades after independence. However, more than fifty years later, when the country’s National Human Rights Commission (NHRC) surveyed all the then existing mental hospitals (total of 37, most of them funded by various state governments), and other mental health care institutions in the country, the total number of hospital/institutional beds for persons with mental disorders was still less than twenty thousand. Bold reforms involving the family members of those admitted to the hospital were initiated as early as the mid 1950s and 60s in the mental hospitals at Amritsar and Agra and certain centers such as Vellore. Strength of institutions such as the joint family, marriage, the close knit community, greater tolerance of deviant behaviour not only within families but also in the larger community, lower expectations from persons with mental disorders, religion and faith based coping as well as healing strategies, all contributed to large numbers of persons with various mental disorders being taken xxxvii care of in the community. Many years later, the 2 years, 5 years and 25 years follow-up of persons with schizophrenia studied on a long-term basis by the World Health Organization’s Division of Mental Health at Agra, Chandigarh and Chennai centers showed that such patients, in general had relatively a much better outcome in India than in many other developed countries in the world. Around this time, a steadily increasing number of mental health units in the general hospital and medical college based teaching hospital settings were set up in the bigger cities in the country. General hospital psychiatric care meant shorter periods of hospitalization and greater involvement of family members in the care of person with mental disorder. More and more persons with various less severe forms of mental disorders too sought help in general hospital psychiatry units. All over the country, almost every person with any mental disorder was initially treated/managed primarily by traditional healers of various types including healers and priests who worked from within religious institutions such as temples. One of the consequences of the grossly limited modern facilities for care of mental disorders was that many mentally ill persons became “wandering and homeless mentally ill” across the country. Widespread misconceptions about causation of mental disorders, all pervasive stigma, and lack of community demand for modern mental health care services, grossly inadequate budgetary inputs for mental health in the midst of competing needs for infectious and communicable disorders and nutritional disorders, severe shortage of trained mental health professionals, all contributed to neglect of mental health care. Health planners, administrators and even other medical specialists and general practitioners were unaware of the wide prevalence and suffering caused by mental disorders. Unlike most other newly independent developing countries of Asia, Africa and Latin America and despite the above mentioned problems, psychiatry grew in India slowly and steadily, but definitely. Amongst several developments which took place in the country during the initial post-independence decades which contributed to not only the growth of psychiatry but also the starting of pilot community mental health projects, three are worth mentioning. These three important developments were: (i) Starting of the Indian Psychiatric Society (IPS) – the professional body of psychiatrists in India, with a membership of 42 in 1947. First annual conference of the Indian Psychiatric Society was held in Patna in January 1948. Not many years later, in 1958, the IPS began publishing its academic journal – Indian Journal of Psychiatry (or the IJP, as it is popularly referred to in India), currently in its 53rd Volume. (ii) Conduct of some very good epidemiological surveys of mental disorders in the community during the late fifties and early sixties, in places such as Bengaluru and Agra.
  • 35. xxxviii  Community Mental Health in India Agra later was chosen as one of the nine centers in the World Health Organization International Pilot Study of Schizophrenia (IPSS) – one of the only two centers in the developing world, the other was Ibadan, Nigeria. (iii) Perhaps the most important development was the starting of an institution for training and research in the field of mental health – the All India Institute of Mental Health (AIIMH) in Bengaluru in 1954. It is interesting to note that such an institute for training mental health professionals (psychiatrists, clinical psychologists, psychiatric nurses and psychiatric social workers) was opened even before the starting of other major training and research institutions in the overall field of medicine such as the All India Institute of Medical Sciences (AIIMS) in New Delhi and the Post Graduate Institute of Medical Education and research (PGIMER) in Chandigarh. It is also interesting that the All India Institute of Mental Health in Bengaluru had full fledged departments of Neurology, Neurosurgery and allied basic sciences departments such as Neurophysiology, Neuropathology and Biophysics right from its early days – the realization of the close links between mental health and neurosciences, “brain and mind”, the concept of clinical neurosciences in action, well ahead of such developments taking place much later in developed countries of the West. To convey the true nature of the institution more appropriately, AIIMH became the National Institute of Mental Health and Neurosciences (NIMHANS) in 1974, now arguably one of the most productive and prestigious research and training institutions in the fields of mental health and neurosciences in the whole of the developing world. Realizing the need to develop and evaluate meaningful and feasible alternate approaches/strategies to mental health care delivery in the country, NIMHANS created a Chair of Community Psychiatry and started a specially designated Community Psychiatry unit in 1975, much before positions and units for developing community psychiatry became fashionable elsewhere in the world. During the late 1970s and 80s, the Community Mental Health unit at NIMHANS developed an approach and a strategy for integrating basic mental health care with the existing general health care services in India. This approach involved decentralized training in basic mental health care for primary health center doctors and multipurpose health workers, making essential psychotropic medications easily available at all peripheral primary health care institutions and providing continued on-the-job training, support and supervision for the trained primary health center staff to carry out simple mental health care services under the overall supervision of a mental health professional at the district head quarters level. This approach was initially tried in various primary health centers (PHCs) in Karnataka State which those days covered a population of hundred thousand. Later, it was expanded to a whole district (i.e. all the peripheral health care institution in a district), in Bellary district of Karnataka State. The overall strategy which evolved after 5 years of trial in Bellary came to be known as the “Bellary model” of District Mental Health Programme (DMHP) and was adopted by the Ministry of Health and Family Welfare, Government of India for staggered country wide implementation as a fully centrally (federally) funded programme (Isaac, 2011; Srinivasa Murthy, 2011). It is interesting to note that nearly three decades later, an international consortium of 422 researchers, advocates and clinicians working in more than 60 countries have identified “integration of screening and core packages of services into routine primary health care”, “reducing the cost and improving the supply of effective medications”, “providing effective and affordable community based care and rehabilitation” and “strengthening the mental health training of all health care personnel” as some of the top “grand challenges in global mental health” (Collins et al., 2011). In 1982, India was one of the first countries in the developing world to formulate a National Mental Health Programme (NMHP). But budgetary allocation for the implementation of the NMHP was made only since 199697, during the ninth (1997-02), tenth (2002-07) and the eleventh (2007-12) Five Year Plans by the Government of India. Recently, several authors have critically looked at the successes and failures in the implementation of the NMHP and its main component namely the District Mental Health Programme (DMHP) and have offered numerous corrective suggestions (Goel, 2011; Isaac, 2011; Jacob, 2011; Patel, 2011; Srinivasa Murthy, 2011). Most experts believe that the DMHP has failed to “integrate mental health care delivery into primary care” due to a wide variety of administrative, managerial and technical reasons. However, experts observe “… the programme has ensured wider availability of essential psychotropic medication…” (Jacob, 2010), the DMHP is “essentially a psychiatrist led out-patient clinic in district hospitals” (Patel, 2011) and “major gains have been made…. The NMHP is now accepted as a relative low-cost, high-yield public health intervention which is doable, as shown in states such as Kerala and Gujarat” (Goel, 2011). The country can soon expect a “radical revision and re-haul of the dysfunctional NMHP” and a “re-written” DMHP for the 12th Five year plan (2012-2017) in independent India’s first mental health policy as in early 2011 the Ministry of Health and Family Welfare, Government of India constituted a Mental health policy group comprising diverse stakeholders (Patel, 2011). The country is also on the threshold of seeing a new
  • 36. Introduction  National Mental Health Care Plan with specific reference to the NMHP and DMHP, with specific strategies and activities to implement the priority areas of action identified in the National Mental Health Care Policy and an estimate of financial resources required to implement the Plan by April 2012, according to the ‘  erms of Reference’ of the Policy T Group (GOI-MOHFW, 2011). A Book of Community Mental Health for Non-Western Settings This multiauthored book of Community Mental Health largely follows a ‘mental health systems’ approach to deal with various topics. The term mental health system includes (i) mental health policies, plans, programmes (ii) legislations and regulations governing mental health service organization and practice (iii) organization of service programes for detection and treatment of mental disorders including reliable supply of psychotropic medicines and rehabilitation services (iv) programmes that are devoted to mental health promotion (v) social arrangements that promote social participation including work and income support for persons with mental illness and (vi) the political, socio cultural and economic environment in which all the above occurs, besides other topics (Minas and Cohen, 2007). The book begins with an introductory chapter on the needs, relevance, growth and current status of community mental health in India (Section I). The historical evolution of mental hospitals as an institution in India, growth of general hospital psychiatry units and the genesis of the national mental health programme and its flagship programme, the district mental health programme are described in Section II. Integrating mental health into primary care in developing countries is different from such integration in developed countries because the primary care network itself is very differently organized due to a variety of factors such as limited trained personnel and poor financial resources. Chapter 29 describes the challenges in the integration of mental health into general health services. Innovative approaches such as mental health camps and extension clinics in smaller towns and big villages have been developed to reach the vast unreached populations in rural areas. Various such models of community mental health care are described in Chapters 25 and 26. It is well known that almost all people who need mental health care in developing countries often seek such care and help from traditional and indigenous healers. Chapter 28 reviews the role and significance of alternative therapies in mental health care. When support for research is limited, the area which is often forgotten is community mental health. There is a need to build research capacity in community mental health in developing countries. Models xxxix of research in community mental health are explained in Chapter 40. There are comprehensive chapters on community based services for special populations such as the elderly, children and adolescents, children with learning disabilities and those suffering from substance use related problems (Section V). Issues of specific relevance to developing countries such as India including steadily increasing suicides in the country and farmer’s suicides (Chapters 21 and 22), continuing difficulties related to stigma (Chapters 8, 31, 53 and 54), homelessness of the mentally ill with special problems relevant to developing country settings (Chapter 10), mental health aspects of manmade and natural disasters which are endemic in India (Chapter 24), and the role of gender in community mental health (Chapter 11) are included. Contributions to the development of community mental health by professional organizations such as the Indian Psychiatric Society are reviewed in Chapter 37.The section on legislation (Section IV) also includes a chapter on the Narcotics and Psychotropic Substances Act of India. The authors who are predominantly Indian and who come from multiple backgrounds – well known academicians, researchers and teachers, clinicians from the governmental as well as private sectors, health administrators from the government in charge of mental health program, practitioners and activists from the non-governmental sector, care providers and a media person who writes about mental health issues in the popular print media (Chapter 59) – add to the richness and variety of the contents and coverage in this text book. The continuing role of the federal government in supporting community mental health is discussed in Chapter 38 by senior officers who were in charge of the mental health program at the time when the chapter was commissioned (and subsequently submitted for the book). The role of non-governmental sector in various mental health programs is being increasingly recognized in India. There are a growing number of such organizations carrying out different types of community based activities all over the country. The relevance of the voluntary non-governmental sector is well described in Chapters 12 and 34. Carer and consumer participation in mental health programs have only begun in a small way in India. Carer and consumer advocacy organizations are very few unlike western settings. Chapters 57 and 58 provide caregiver perspectives from the caregivers as well as the professionals points of view. A fairly large section on community mental health in some South and East Asian countries such as Sri Lanka, Pakistan, Malaysia and Singapore and developed countries such as the USA, UK, Australia and New Zealand (Section X) will give the reader an opportunity to compare and contrast issues across the world. The fact that the authors
  • 37. xl  Community Mental Health in India of chapters about community mental health in developed countries have had training and first hand experience of situation in non-western settings adds value to their chapters. The community mental health professionals’ understanding of the relevance of clinically applied anthropology in their work is very limited. An entire section (Section XI) is devoted to cultural critique of community mental health in India and related issues including what cultural validity is and why it is often ignored. Editors have chosen to include few papers not very easily accessible such as the ICMR-DST Collaborative Study on Severe Mental Morbidity and some of the initial papers describing work done in Raipur Rani near Chandigarh and Sakalawara near Bangalore which describe the early phase of developments in community mental health in India as appendices (Section XIII). Most psychiatry postgraduate training centers in India do not provide any organized and structured training or exposure to community mental health related topics. This book can immensely contribute to filling up the lacunae in community mental health training of not only psychiatrists but other mental health professionals as well. Although, the issues are largely based on the authors work and expertise in India, the book will be valuable to any mental health professional working in non-western settings. Published literature in peer reviewed journals on issues related to community mental health in developing countries including India is very limited. The authors have reviewed the grey literature consisting of various documents, papers in non peer-reviewed and non-academic publications and the lay print media. There are numerous contradictions and puzzles yet to be clarified and answered as far as mental disorders in developing countries such as India are concerned. One such puzzle is raised by Sartorius (2011), an internationally recognized leader in mental health, a distinguished past President of the World Psychiatric association and for over 25 years the Head of the World Health Organization’s mental health division and under whom I had the privilege to work for a number of years. He has visited all the mental hospitals and a variety of other institutions in India. He raises a question “simple to ask” but “without a satisfactory answer”. “How was it possible that India had in all approximately 20,000 beds in mental hospitals and psychiatry departments in general hospitals when by conservative estimates in India there were at least 10 million seriously mentally ill people who need in-patient care for at least 2 weeks a year?” He goes on to observe that “Some patients were probably living as vagrants or beggars and others were undoubtedly in prisons. Still, with all these calculations – and taking into account that the incidence of severe mental illness such as schizophrenia in India did not differ from that in other countries and that there must have been more people with various forms of brain damage due, for example to poor perinatal care, infectious diseases and malnutrition in childhood than in Europe – it was not clear what was happening with the millions of people who were acutely ill and who needed help and more millions whom mental illness left impaired and unable to look after themselves”. “The extended family system might explain part of the puzzle – but not all of it: in surveys families did not have as many mentally ill people in their midst as could be expected if most of the mentally ill were cared for in this way”. The various chapters in this book on Community Mental Health describing largely the current situation in India may provide at least part of the answer to this puzzle. Conclusion During the past 35 years, after the starting of the community mental health unit at NIMHANS, many things have changed in the field of mental health care all over the world. Significant developments have occurred in community based mental health care in India too, most of which are well described in this book. However, as a series of comprehensive and authoritative reviews of the situation of mental health in low and middle income countries, including India published recently in journals such as The Lancet have shown, the treatment gap in mental health continues to be quite wide and much needs to be done to fill this gap. It is interesting to note that the broad principles of community mental health in developing countries have changed very little over the years as indicated by the recent mental health gap action programme of the World Health Organization (mhGAP) and similar programmes elsewhere (Jacob, 2011) and some of the top “grand challenges in global mental health” (Collins et al., 2011) as identified by more than 400 experts in the field of mental health from all over the world. Meaningful partnerships and collaboration between diverse stakeholders are urgently required for progress in community mental health in India. True innovation and leadership are needed, more than ever before. Bibliography 1. Burns T. Community Mental Health Teams. Psychiatry 2007;6:325328. 2. Collins PY, Patel V, Joestl SS. Grand challenges in global mental health. Nature 2011;475:27-30. 3. Fagin L. Deinstitutionalisation in the USA. Psychiatric Bulletin 1985;9:112-114. 4. Fakhoury W, Priebe S. The process of deinstitutionalisation: an international overview. Current Opinion in Psychiatry 2002;15:187-192.
  • 38. Introduction  5. Goel DS. Why mental health services in low and middle income countries are under-resourced, under-performing: An Indian perspective. The National Medical Journal of India 2011;24:94-97. 6. Government of India Ministry of Health and Family Welfare (GOI-MOHFW). Constitution of a policy Group to frame a Mental Health policy for India, No. V.15016/49/2009-PH-I dated 15th April 2011. 7. Isaac M. Provision for the long term discharged patient. Psychiatry 2007;6:317-320. 8. Isaac M. The National Mental Health programme: Time for reappraisal. in Themes and Issues in Contemporary Indian Psychiatry. Edited by Kulhara P et al. New Delhi, Indian Psychiatric Society, 2011. 9. Jacob KS. Repackaging mental health programmes. The Hindu, 2010, Opinion, 4th November 2010. xli 10. Jacob KS. Repackaging mental health programmes in low and middle income countries, Indian Journal of Psychiatry 2011;53:195198. 11. Minas H, Cohen A. Why focus on mental health systems? International Journal of Mental Health Systems 2007;1:1-4. 12. Patel V. The great push for mental health: why it matters for India. Indian Journal of Medical Research 2011;134:407-409. 13. Sartorius N. Notes of a traveller. Acta Psychiatrica Scandinavica 2011;123:239-246. 14. Srinivasa Murthy R. Mental health initiatives in India (1947 – 2010) The National Medical Journal of India 2011;24:26-35. 15. Thornicroft G, Tansella M. Components of a modern mental health service: a pragmatic balance of community and hospital care: Overview of systematic evidence. British Journal of Psychiatry 2004;185:289-290.
  • 39. Section I An Introduction to Community Mental Health
  • 40. 1 The Relevance of Community Psychiatry in India R Srinivasa Murthy INTRODUCTION Community psychiatry, is an important approach to the organization of mental health care in both economically rich and low and middle income (LAMI) countries. The growth of community psychiatry movement, all over the world, is part of a series of phases of development of mental health care over the last two to three centuries, starting from setting up of special institutions for the care of the persons with mental disorders (asylums), the humane treatment of such persons, deinstitutionalization when required and the recognition of the rights of these afflicted people (WHO, 2001). Community psychiatry in India is nearly six decades old. (Agarwaal et al., 2004; Srinivasa Murthy, 2008). Starting as an effort to involve families of mentally ill persons in the care of persons admitted to the Amritsar Mental Hospital in 1950s and isolated extension psychiatric clinics in primary health clinics, today the integration of mental health care in general services covers over 120 districts or about 20 percent of the country, along with a wide variety of community level facilities and initiatives to address a broad spectrum of mental health initiatives in the areas of care, prevention of mental disorders and promotion of mental health. From a situation of almost no community based services for persons with mental disorders, the country today has a framework for mental healthcare in the public, private and voluntary sectors. In moving forward India has been influenced by local challenges as well as by medical developments abroad. However, in recent times the movement of community psychiatry has come under criticism and termed variously as ‘ineffective’ (Kapur, 2004); ‘not based on cultural aspects of India’ (Jadhav and Jain, 2009); ‘bandwagon’ and ‘a failure’(Thara et al., 2008). This chapter is an attempt to present the development process and the progress of community psychiatry in India, its relevance to the development of mental healthcare and to identify the forces and factors driving the movement. The chapter concludes with the future directions for the community psychiatry movement. Each of the initiatives, reviewed here, have been addressed in detail in separate chapters in the book. The key questions that will be addressed in this overview are given in Box 1. Box 1:   Community mental health in India—key questions 1. What are the social realities that have driven the innovative approaches to care? 2. What are the forces that stimulated and sustained the community based innovative approach? 3. What has been the progress in the last six decades? 4. What are the limitations of each of the initiatives? 5. What are the future directions for development of the initiatives? CHALLENGING MENTAL HEALTH SITUATION IN INDIA Throughout the period of independent India, there have a number of challenges faced by the professionals in organizing the care programs (Box 2). Box 2:   Challenges for mental healthcare in India 1. There is a large ‘unmet need’ for mental healthcare in the community. 2. There is poor understanding amongst the general population that psychological distress requires medical intervention. 3. There is limited acceptance of modern medical care for mental disorders in the general population. 4. There are severe limitations in the availability of mental health services (professionals and facilities) in the public health services. 5. There is poor utilization of available services by the ill and their families. 6. There are problems in the recovery and reintegration process of persons with mental illnesses. 7. Institutionalized mechanisms for organization of mental healthcare are inadequate in the country.
  • 41. 4  Section I: An Introduction to Community Mental Health There is a Large ‘Unmet Need’ for Mental Health Care in the Community A large number of general population epidemiological studies (Gururaj & Issac, 2004; Badamath et al., 2007) have demonstrated the existence of the wide variety of mental disorders. Recently, the availability of information about ‘psychosis’ at the community level from an India perspective, as revealed by a World Health Survey (WHS) is an unique source of data (World Health Survey, 2006). The coverage of six states and the excellent methodology used makes it an important source of information. The objective of the WHS was to provide an evidence base on health expenditure, insurance, health resources, health state, risk factors, morbidity prevalence and health system responsiveness for inpatient and outpatient care. In India, the WHS survey covered six states, Assam, Karnataka, Maharashtra, Rajasthan, Uttar Pradesh and West Bengal. The health status was assessed from individual questionnaires administered to 9,994 adult population in the age group of 18 and above. Twenty-seven percent of the respondents were from urban areas and seventy-three percent from rural areas. The section on morbidity included diagnostic conditions of depression and psychosis and mental health symptoms like sleep disturbance, feeling sad, low or depressed, worry or anxiety, and dealing with conflicts and tensions (World Health Survey, 2006). From the entire report, the section given below relates to psychosis and depression. The report of the study provides data about the prevalence and service coverage across different population groups. The reference period was one year prior to the study. Percentage diagnosed and treated in the six states is given in Tables 1 and 2. Though the prevalence rates of depression are higher than psychosis, the rates treated are far lower in the former, pointing to the limited awareness about depression in the community. The rates of treatment were even lower among the rural population. Treated cases were higher in the urban areas (61.7 percent as compared to 47.5 percent). Treated Table 1: Prevalence of ‘psychosis’ and treatment status in six states State Need Covered (percentage diagnosed) (percentage treated) Assam 1.0 39.1 Karnataka 0.7 85.2 Maharashtra 2.2 48.7 Rajasthan 3.6 36.2 Uttar Pradesh 2.7 45.5 West Bengal 1.8 66.5 State Assam Table 2: Prevalence of ‘depression ’ and treatment status in six states Need Covered (percentage diagnosed) (percentage treated) 3.2 32.3 Karnataka Maharashtra Rajasthan Uttar Pradesh West Bengal 9.2 27.3 7.3 7.4 11.7 13.0 9.6 29.7 8.2 17.8 cases were also higher in the higher income quartiles (p.62-66). Indirect evidence of the large proportion of the ‘untreated’ patients come from another field study conducted in Andhra Pradesh, Karnataka, Kerala and Tamil Nadu. Basic Needs (India), as part of the caregivers in the community mental health study examined 201 persons with severe mental illness, of which nearly 50 percent were found to be suffering with schizophrenia. The duration of illness at contact was more than two years in 90 percent of the subjects, over five years in 70 percent of the subjects and in over 25 percent of the subjects the duration was over ten years (Janardhan & Raghunandan, 2009). There is Poor Understanding of the Psychological Distress as Requiring Medical Intervention in the General Population There are two aspects to the current lack of knowledge of the population regarding mental health and mental disorders. First among these are the existing beliefs and practices that have evolved through the course of human history. These, though relevant at different stages of evolution of the society, are often not in accordance with the current understanding of mental disorders and mental health. Secondly, stigma is an important barrier to mental health care (Srinivasa Murthy, 2010; Wig, 1987). The most recent of the stigma studies involved twenty-seven participating countries including India, describing the nature, direction, and severity of anticipated and experienced discrimination reported by people with schizophrenia, by use of face-to-face interviews with 732 participants. Negative discrimination was experienced by 47 percent of participants in making or retaining friends. Forty three percent experienced negative discrimination from family members. Twenty nine percent in finding a job. Twenty nine percent in holding down a job. Twenty seven percent in intimate or sexual relationships. Positive experienced discrimination was rare. Anticipated discrimination affected 64 percent in applying for work, training, or education and 55 percent seeking a close relationship. Seventy
  • 42. Chapter 1: The Relevance of Community Psychiatry in India  two percent felt the need to conceal their diagnosis. Over a third of the participants anticipated discrimination while seeking jobs or in close personal relationships even when no discrimination was experienced (Thornicroft et al., 2010). There is Limited Acceptance of the Modern Medical Care for Mental Disorders in the General Population As a reflection of the limited centralised treatment facilities as also inadequate number of professionals, there are immense treatment delays and treatment gaps (Chatterji et al., 2003, 2009; Srinivasa Murthy et al., 2004; Srinivasan et al., 2004; Thara et al., 2008; Thirthahalli et al., 2009a, 2009b). In India, during the last few years, four important research studies have addressed the situation of persons suffering from schizophrenia living in the community (Chatterji et al., 2003, 2009; Srinivasa Murthy et al., 2004; Srinivasan et al., 2004; Thara et al., 2008; Thirthahalli et al., 2009a, 2009b). These studies show that about half the patients of schizophrenia live in the community without treatment. It is further observed that such patients have significant disability, and are a source of huge emotional and financial burden on the family and caregivers. A recent study in Vellore has reported that a large proportion of the patients with schizophrenia have had a long duration of illness at first contact and further, the course of the illness and outcome of treatment is related to chronicity at first contact with treatment (Saravanan et al., 2010). It is important to note that all these studies show the benefits of regular treatment in decreasing the disability, thereby lowering the burden on the family. These studies also reveal that only few of the ill receive care and a large percentage came late in the illness for treatment. These studies also emphasise the need for community involvement in the care programs. India is home to pluralistic approaches to all types of care. There are not only other systems of health care, apart from Allopathy, such as Ayurveda, Unani, Naturopathy, Homeopathy (AYUSH), but also there are a large number of places where people go to seek help; especially religious places (Sebastia, 2009). The current approach of most professionals is one of ‘live and let live’. However, this approach leaves the situation unclear to the general public. It would be in the interest of professionals of all systems of care to initiate a dialogue and communicate the relative suitability and effectiveness of the varied interventions on the different aspects of mental health (prevention, promotion and treatment). There is no need for each of the systems and interventions to be equally suitable and effective in all the areas of mental health. There is also greater need for linkage of services on a need based approach. 5 There are Several Limitations in the Availability of Mental Health Services (Professionals and Facilities) in the Public Health Services The mental health infrastructure available in India is to a great extent limited to large custodial institutions which provide services to a small percentage of the population. These institutions are a great source of stigma. Two reviews of the mental hospitals have been undertaken in 1998 and 2008 to identify the needs of these institutions and to understand the changes that have occurred over a decade (National Human Rights Commission 1999, 2008). The findings of these evaluations illustrate the challenges these institutions present to mental health care. The condition of the mental hospitals at the time of the first review was highly unsatisfactory. ‘Thirty eight percent of the hospitals still retain the jail like structure that they had at the time of inception … nine of the hospitals constructed before 1900 have a custodial type of architecture, compared to 4 built during pre-independence and one post-independence … 57 percent have high walls … patients are referred to as “inmates” and persons in whose care the patients remain through most of the day are referred to as “warders” and their super visors as “overseers” and the different wards are referred to as “enclosures” (p.32) … overcrowding in large hospitals was evident … (p.34) … the overall ratio of cots:patient is 1:1.4 indicating that floor beds are a common occurrence in many hospitals (p.37) … in hospitals at Varanasi, Indore, Murshadabad and Ahmedabad patients are expected to urinate and defecate into open drains in public view (p.38) … many hospitals have problems with running water … storage facilities are also poor in 70 percent of hospitals … lighting is inadequate in 38 percent of the hospitals …89 percent had closed wards while 51 percent had exclusively closed wards … 43 percent have cells for isolation of patients (p.39) …leaking roofs, overflowing toilets, eroded floors, broken doors and windows are common sights (p.44) … privacy for patients was present in less than half the hospitals … seclusion rooms were present in 76 percent hospitals and used in majority of these hospitals … only 14 percent of the staff felt that their hospital inpatient facility was adequate (p.47) in most hospitals case file recording was extremely inadequate … less than half of the hospitals have clinical psychologists and psychiatric social workers … trained psychiatric nurses were present in less than 25 percent of the hospitals …(p.48) … even routine blood and urine tests were not available in more than 20 percent of hospitals … 81 percent of the hospital in-charge reported that their staff position was inadequate (p.54).
  • 43. 6  Section I: An Introduction to Community Mental Health The report notes “the deficiencies in the areas described so far are enough indicators that the rights of the mentally ill are grossly violated in mental hospitals” (p.50).’ The poor conditions of these institutions have negatively projected the mentally ill as violent, mental illnesses as chronic, and mental illness as untreatable. Though the second evaluation showed significant improvements in many of the institutions, there are still many unmet needs (National Human Rights Commission, 2008). The WHO Atlas (WHO, 2005) and recent statewise analysis of psychiatrists (Thiruvanakarasu & Thiruvanakarasu, 2010) highlight the low numbers of mental health professionals in India. The figures are worrisome, especially given the pandemic proportions of the figures of the mentally ill. The average national deficit of psychiatrists is estimated to be 77 percent. The deficit of psychiatrists exceeds 90 percent among more than one third of the population. Only Chandigarh, Delhi, Goa and Pondicherry can claim to have surplus psychiatrists. Kerala and Maharastra have less than a 50 percent deficit while the rest of the states have more than 50 percent deficit in psychiatrists. What is striking is the vast variation of the distribution of psychiatrists across the country. The figures for psychologists working in mental health care are not too different, and there is also a paucity of social workers and psychiatric nurses. The continuing constraints in availability of trained professionals in medical colleges and district hospitals need to be addressed by creatively bringing professionals from the private sector into the state mental health care program. This can be at many levels, ranging from training programs, treatment of specific conditions, follow-up care, certification, rehabilitation, etc. An active dialogue needs to be initiated to create a system of integrated and coordinated care across public and private facilities in the states. This requires cooperation among professionals and institutionalized methods of carrying out such collaboration. The current system of training of ‘counsellors’ with varying duration and content of training, also needs review and reorganization. There is Poor Utilization of the Available Services by the Ill Population and their Families As a reflection of the limited centralised treatment facilities and limited number of professionals, there are large treatment delays and treatment gaps (Chatterji et al., 2003, 2009; Saravanan et al., 2010; Srinivasa Murthy et al., 2004; Thara et al., 2008; Thirthahalli et al., 2009a, 2009b). It is important to note that a number of studies show the benefits of regular treatment in decreasing the disability, the burden on the family and costs to the families. These studies show that only few of the ill are receiving care and a large proportion of them came late in the illness for treatment. These studies also emphasise the need for community involvement in the care programs. The practical problems of continuing regular long-term care among the ill persons and their families are related to the distances they have to travel to treatment facilities, arranging for a caregiver to accompany the ill person, regular availability of medicines at treatment centres, rotation or changing of professional team members, availability of rehabilitation services for recovered persons and the ease of getting the welfare benefits. There is a need to change from the current system of cross-sectional care from clinics with emphasis on drug dispensing to coordinated total care in the community involving the ill persons (developing skills for self care, forming self help groups), their families ( creating a support group of afflicted families, helping them develop skills for care and rehabilitation, providing support through mobile phones), community (integration and non-discrimination) and the voluntary organizations (public awareness, support to families, rehabilitation). The shift in focus should be on cure/recovery/reintegration rather than only dispensing of medicines, similar to the more comprehensive approaches developed for the treatment and care of AIDS, tuberculosis and leprosy. The decentralisation of services by the reorganization of the District Mental Health Program (DMHP) is a priority (discussed in detail in Chapter 5). The DMHP should be strengthened in the following manner: • Revising the training programs to be undertaken by the district resources (medical colleges, private psychiatrists, etc.) • Revising computerized records linked to the indicators • Delineation of the tasks of the district mental health team members • Providing helpline support to the community and the PHC personnel, including telepsychiatry where possible • Organizing regular visits to the PHC facilities to review the quality of care provided • Arranging for enhanced community participation and mental health education to increase demand for services • Monthly monitoring of the program by the district mental health technical advisory body. There are Problems in Recovery and Reintegration of the Persons with Mental Illnesses Medicines can be adequate in the treatment of acute episodes. However, for the large majority of the patients with long
  • 44. Chapter 1: The Relevance of Community Psychiatry in India  standing illness (Janardhan & Raghunandan, 2009), there is a need for multifaceted interventions involving the family, community and voluntary organizations towards rehabilitation and reintegration. Since, all of these cannot be organized by the public health services, there is a need for specific programs to support the families and voluntary organizations in this area of activity. Institutionalized Mechanisms for Monitoring the Mental Health Care are Missing in the Country The most important lacunae of the mental health program is the lack of continuous technical support to the program. The technical capacity of the public mental health system of the states is limited and the capacity and competence to monitor the mental health program is inadequate. The current approach is fragmented, uncoordinated and lacks continuity (Wig & Srinivasa Murthy, 2009). There is a need for the formation of Mental Health Advisory Committees, consisting of professionals from different disciplines, public and private sectors and the voluntary organizations. Such Committees need to be at the National and State levels. These committees require to meet periodically to support, supervise, monitor the program and to develop the technical support materials for the program. Similar mental health advisory committees should also be formed at the district level to support, supervise and monitor DMHP and other district level initiatives. INTERNATIONAL DEVELOPMENT OF MENTAL HEALTH SERVICES The advancement of mental health care all over the world is best described as a developing process. WHO, 2001, described the changes over the last two centuries as follows: ‘Over the past half century, the model for mental health care has changed from the institutionalisation of individuals suffering from mental disorders to a community care approach backed by the availability of beds in general hospitals for acute cases. This change is based both on respect for the human rights of individuals with mental disorders, and on the use of updated interventions and techniques. The care of people with mental and behavioral disorders has always reflected prevailing social values related to the social perception of mental illness. Through the ages, people with mental and behavioral disorders have been treated in different ways . They have been given a high status in societies which believe them to intermediate with gods and the dead. In medieval Europe and elsewhere they were beaten and burnt at the stake. They have been locked up in large institu- 7 tions. They have been explored as scientific objects. And they have been cared for and integrated into the communities to which they belong. In Europe, the 19th century witnessed diverging trends. On one hand, mental illness was seen as a legitimate topic for scientific enquiry; psychiatry burgeoned as a medical discipline, and people with mental disorders were considered medical patients. On the other hand, people with mental disorders, like those with many other diseases and undesirable social behavior, were isolated from society in large custodial institutions, the state mental hospitals, formerly known as lunatic asylums. These trends were later exported to Africa, the Americas and Asia. During the second half of the 20th century, a shift in the mental health care paradigm took place, largely owing to three independent factors, namely (i) psychopharmacology made significant progress, with the discovery of new classes of drugs, particularly neuroleptics and antidepressants, as well as the development of new forms of psychosocial interventions; (ii) the human rights movement became a truly international phenomenon under the sponsorship of the newly created United Nations, and democracy advanced on a global basis, albeit at different speeds in different places and (iii) social and mental components were firmly incorporated in the definition of health of the newly established WHO in 1948.These technical and sociopolitical events contributed to a change in emphasis: from care in large custodial institutions to more open and flexible care in the community. Community care is about the empowerment of people with mental and behavioral disorders. In practice, community care implies the development of a wide range of services within local settings. This process, which has not yet begun in many regions and countries, aims to ensure that some of the protective functions of the asylum are fully provided in the community, and the negative aspects of the institutions are not perpetuated. The accumulating evidence of the inadequacies of the psychiatric hospital, coupled with the appearance of “institutionalism”—the development of disabilities as a consequence of social isolation and institutional care in remote asylums—led to the de-institutionalization movement. Deinstitutionalization is a complex process leading to the implementation of a solid network of community alternatives. Closing mental hospitals without community alternatives is as dangerous as creating community alternatives without closing mental hospitals. Deinstitutionalization has not been an unqualified success, and community care still faces some operational problems. Among the reasons for the lack of better results are that governments have not allocated resources saved by closing hospitals to community care; professionals have not been adequately prepared to accept their changing roles; and the stigma attached to mental disorders remains strong, resulting in negative public attitudes towards people with mental disorders. In some countries, many people with severe mental disorders are shifted to prisons or become homeless. In most developing countries, there is no psychiatric care for the majority of the population; the only services available are in mental hospitals. These
  • 45. 8  Section I: An Introduction to Community Mental Health mental hospitals are usually centralised and not easily accessible, so people often seek help there only as a last resort. The hospitals are large in size, built for economy of function rather than treatment. In a way, the asylum becomes a community of its own with very little contact with society at large. The hospitals operate under legislation which is more penal than therapeutic. In many countries, laws that are more than 40 years old place barriers to admission and discharge. Furthermore, most developing countries do not have adequate training programs at national level to train psychiatrists, psychiatric nurses, clinical psychologists, psychiatric social workers and occupational therapists. Since there are few specialized professionals, the community turns to the available traditional healers’. The changes in mental health services in economically affluent countries, during the second half of the last century and particularly in the last ten years have been largely driven by the movement towards ensuring human rights of persons with mental disorders, which have been reflected in deinstitutionalization, care received in the community and greater voice to users and the carers (UNCRPD, 2006). This is summarised as follows: ‘The practice of psychiatry in the second half of the 20th century, and especially in its last decade, has changed fundamentally. Mentally ill people have been moved out of the relative ‘simplicity’ of the large institution, with its clear structures and hierarchies and into the community. This necessitated new types of relationships between ‘health’ and ‘social’ care. A range of new facilities has been required for the treatment, care and support for people with mental health problems in the community, replacing many of the functions previously provided in hospitals. More agencies and staff (professional and non-professional) have declared an interest and entered the scene, often bringing new and quite different perspectives on the needs of those with mental disorders. Among these new voices in the community have been those of service users themselves. Increasing cultural diversity and respect for social difference have added to the range of value systems to be taken into account. At the same time, governments are taking an increasing direct interest in mental health issues, formulating more specific strategies, guidance, directives and legislation. (Thornicroft & Smuzkler, 2001). The shift has been the outcome of many forces as seen by the following quote: ‘Our problem in the West is, that somehow or other WE HAVE TO MAKE UP FOR THE FAMILIES who have disappeared and create a supportive structure—not for the patients but for the single relatives who are often desperately trying to cope with schizophrenia. It is, of course, very expensive to create a network of professionals who act as a SURROGATE FAMILY, but we have to provide that form of support, because it is even more expensive to keep hospitalising patients’. (Leff, 1996). Reflective of the shift in focus are the large number of initiatives undertaken, to understand disabilities of mentally ill persons, the impact of the ill person on the family, the coping by the family, user movement and the recently accepted UN Convention on the Rights of Persons with Disabilities (UNCRPD, 2006). Szmukler and Thornicroft (2001) define community psychiatry as follows: ‘Community psychiatry comprises the principles and practices needed to provide mental health services for a local population by: (i) establishing population-based needs for treatment and care; (ii) providing a service system linking a wide range of resources of adequate capacity, operating in accessible locations; (iii) delivering evidence based treatments to people with mental disorders’. In the above definition, it is important to note that the significant parts are- ‘needs of the population, wide range of services and accessibility of services’. Community psychiatry in affluent countries has come to represent a wide range of initiatives beyond what is provided by mental health professionals. For example, a recent book ‘Empowering People with Severe Mental Illness’ (Linhorst, 2006) encompasses empowerment in terms of treatment planning, housing, organisational decision making, policy making, employment, research and service provision. Similarly, the ‘Textbook of Community Psychiatry’ (Thornicroft & Smuzkler, 2001), covers a wide variety of subjects. For example, under the service system, the areas included are integration of components into the systems of care (multidisciplinary teams, sectorization and generic versus specialist teams, training for competence). Under the service components, the areas include—case management and assertive community treatments, emergency psychiatric services, partial hospitalization, day care and occupation, residential care, outpatient and inpatient treatment. Under the interfaces between mental health services and the wider community, the areas include—primary care, integrated health and welfare services, community alliances; and users and carers as partners. DEVELOPMENT OF MENTAL HEALTH SERVICES IN LOW AND MIDDLE INCOME COUNTRIES In contrast to the economically affluent countries, the development of community psychiatry in low and middle income (LAMI) countries, occurred against the background almost no
  • 46. Chapter 1: The Relevance of Community Psychiatry in India  mental health services and there are special challenges relating to lack of awareness in the community, existing systems of traditional care, stigma, poorly functioning institutions (National Human Rights Commission 1999, 2008), deliberated upon in detail in the earlier section of this chapter. Almost all persons with mental disorders, living in the community, are most often without the support of any organized services, with the family providing care in whatever form ranging from isolation to committed care. In a way, community psychiatry has developed in these countries as ‘the service’ and not as an ‘alternative’ to institutionalised care. This distinction of the development of community psychiatry is important to understand developments in the LAMI countries (Srinivasa Murthy 2008, 2011). DEVELOPMENT OF MENTAL HEALTH SERVICES IN INDIA At the time of India’s independence, there were almost no mental health services in the country. For a population of about 300 million, there were only 10,000 psychiatric beds, in contrast to over 150,000 psychiatric beds for about 30 million in United Kingdom at that time. The initial period of 1947-66 focussed on doubling of the psychiatric beds (Dube, 1963; Sharma, 1990), together with development of training centres to train psychiatrists, clinical psychologists, psychiatric social workers and psychiatric nurses. The period of 1960s and 1970s saw the emergence of general hospital psychiatric units in a big way both as service providers and training centres (Wig, 1978). The community psychiatry initiatives were taken up initially in the 1970s and in an extensive manner from the 1980s, following the adoption of the National Mental Health Program (NMHP) in August 1982 (DGHS, 1982). A striking aspect of the development of mental health services in India, is as much the location of the care in the community where most of the ill persons were already living as well as the utilization of a wide variety of community resources for the community. For instance, in the initial phase, family members were the focus, which was followed by the utilization of the existing general health care infrastructure through integration of mental health services with general health services. Subsequently, the increased use of school teachers, volunteers, counsellors, mentally ill persons, survivors of disasters, parents of children with mental disorders, took place (Srinivasa Murthy, 2006). In this manner, the three principles of community psychiatry, meeting population based needs, use of range of resources, and accessibility were partially addressed. 9 COMMUNITY MENTAL HEALTH INITIATIVES IN INDIA The section below recounts the major community mental health initiatives in the country. The focus is on presenting the forces for the initiatives and not on the details, as deliberation on each of these is covered in detail in separate chapters of the book. Family Support As mentioned earlier, at the time of Independence, in India, there were only 10,000 psychiatric beds for over 300 million population. This was in contrast to over 190,000 psychiatric beds in U.K. for less than one tenth of the population. In this context, most of the ill patients were living with their families or in the community. The challenge faced by the psychiatric community was the need to provide care with almost no specialized resources. Recognising the cultural factor of family commitment, psychiatrists looked to family members of the ill persons as the answer. India is a pioneer in involving family members in the care of ill relatives from the early 1950s. This first occurred at the Amritsar Mental Hospital (Vidya Sagar, 1973) soon followed by the Mental Health Centre in Vellore (Chacko, 1967; Kohmeyeler & Fernandes, 1963; Verghese, 1971) and the mental hospital in Bangalore (Bhatti, 1980; Bhatti et al., 1982; Geetha et al., 1980; Narayanan, 1977; Narayanan et al., 1972). In India, most persons with mental disorders live with their families. Care is taken by the family who ensure services and plan and provide for their future. Thus, in India the family care model is very important. The role of the family, therefore, becomes crucial when one takes cognizance of the acute shortage of affordable professionals rehabilitation services and residential facilities, whether in the private or government sector. We should also take note of absence of welfare facilities or benefits for persons with mental disorders. In India, family involvement started in the 1950s (Carstairs, 1974; Srinivasa Murthy, 2007; Vidya Sagar, 1973). Indian initiatives relating to families and mental health care have depended on family support for the mentally ill persons. Since the 1950s, families have been formally included to supplement and support psychiatric care by professionals. During this period, family members were actually admitted along with the mentally ill to be part of the care for the patients. This has largely been the pattern in most of the LAMI countries. During the 1970s and 1980s, efforts were made to understand the functioning of families with an ill person in the family and their needs (Bhatti, 1980; Bhatti et al., 1980, 1982; Bhatti & Verghese, 1995).
  • 47. 10  Section I: An Introduction to Community Mental Health Two centers namely, Postgraduate Institute of Medical Education and Research (PGIMER) Chandigarh and National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore systematically studied the needs of the families, the role of non-medical professional to provide support to the families (Suman et al., 1980). At NIMHANS, Bangalore (Pai & Kapur, 1982, 1983; Pai, et al., 1983, 1985), two similar groups of schizophrenic patients, undergoing two treatment modalities, namely, hospital admission and home treatment through a nurse were compared for the outcome in terms of symptoms, social dysfunction, burden on the family, cost of treatment and outcome at the end of six months. A nurse trained in patient follow-up and counseling visited the home regularly for the purpose of patient assessment and treatment. The findings revealed that home treatment through a visiting nurse had a better clinical outcome, better social functioning of the patient and greatly reduced the burden on the patients` families. Further, the treatment modality was also more economical. In a follow-up study, it was observed that the home care group of patients had maintained significantly better clinical status than the controls and this group had been admitted less often). In a further study, where the focus of family care by visiting nurses was chronic patients with a diagnosis of chronic schizophrenia, it was found that only two of the home care group were admitted to hospital over two years in comparison to eight patients in routine care. Together with this, was a study of factors contributing positively or negatively to the course and outcome of schizophrenia. Research into the special needs of mentally retarded and their families had also been studied (Russell et al., 1999, 2004). During the last ten years, a more active role for families is emerging in the form of formation of self-help groups and professionals accepting to work in partnership with families (Srinivasan, 2008; Srinivasa Murthy, 2006). However, many of the leads provided by pilot studies and successes of family care programs have not received the support of professionals and planners to the extent it could become a routine part of psychiatric care in the 21st century. It is interesting to note that in the last decade there is recognition of the value of family involvement in mental health care in developed countries (Selis, 2007; Shimazu et al., 2011). The value of the availability of family as a resource for professionals in LAMI countries can be understood by the challenges faced when families cannot be depended on for mental healthcare as pointed out by Leff (1996). We have to recognize that there are large unfinished tasks to make families a part of the community mental health movement. Reviewing the scene, Rao (1997), opined that ‘professional inputs have not kept pace’ and concluded that the family movement in India is one of ‘unfulfilled promises or great expectations for the future’. He says as follows: “ the vision for the family movement in India would see families from passive carers to informed carers , from receiving ser vices to proactive participation, from suffering stigma to fighting stigma. And it is the responsibility of the mental health system to facilitate this journey of care givers from burden to empowerment”. (p.285) However, many of the leads provided by pilot studies and successes of family care programs have not received the support of professionals and planners to the extent it could become a part of routine psychiatric care. In coming years, moving from passive utilization of the families to partnership and true empowerment of the families has the greatest potential in organizing mental healthcare in LAMI countries. The advances in communication technology (mobile phones) and the growing availability of information technology (internet) should be used creatively to share caring skills with families and to bridge the gap in professional resources. This will be building of mental health care from the ‘bottom of the pyramid’ as it has happened in the other developmental and commercial areas in developing countries (Prahlad, 2006). This area should receive the highest importance in future efforts. General Hospital Psychiatry Development-organized mental healthcare is essentially a post-independence phenomenon. Though the first 15 years of Indian independence saw the doubling of mental hospital beds to 20,000, the pharmacological advances in the treatment of mentally ill persons and the closing down of the mental hospitals in the western countries, gave a big push to the development of general hospital based psychiatric services. The initial General hospital psychiatry (GHP) units in Calcutta and Bombay came in the 1930s and 1940s (IPS, 1964). The big spurt in the GHP units happened in 1960 at the academic centres in Chandigarh, Delhi, Madurai and Lucknow. These centers also became centres for training of psychiatrists and for mental health research (Wig, 1978). It is relevant to note that the generation of psychiatrists in the 1960s and 1970s faced the challenge of moving mental healthcare beyond the isolated mental hospitals and bringing mental healthcare to the general medical care setting (liaison psychiatry). It was these two forces that led to the development of General Hospital Psychiatric Unit (GHPU). Another striking aspect of the Indian GHP units is their function as
  • 48. Chapter 1: The Relevance of Community Psychiatry in India  primary centers for mental healthcare. It has been a slow and quiet change but in many ways a major revolution in the entire approach to psychiatric treatment. The general hospitals psychiatric unit offered numerous advantages over the traditional mental hospital. They are more accessible, easily approachable and above all less stigamatised. They are situated in the community, hence more accessible and easily approachable. Families can frequently visit and relatives can even stay with disturbed patients. The stigma of a mental hospital is absent. There are limited legal restrictions to admission or treatment. Ambulatory treatment on an outpatient basis is available with the use of drugs, ECT and psychotherapy. Proximity of other medical facilities ensure thorough physical investigations and early detection of physical problems. It is important to note that the GHPUs have contributed richly to the development of liaison psychiatry (Garg et al., 1976, 1978), the training of psychiatrists and research. For instance, at the Chandigarh and Delhi centers it was seen that it is feasible to provide mental healthcare in a general hospital setting and the characteristics of the patients seeking care and their treatment utilization patterns. These centers also demonstrated the importance of psychiatry to medicine and surgery through research in matters of body and mind. An illustration of this was the collaboration with cardiology, examining the psychiatric symptoms following mitral surgery, measures of neuroticism and prediction of psychiatric disturbances in patients awaiting cardiac surgery, disturbance of body image in patients awaiting surgery, and problems of rehabilitation in patients undergoing cardiac surgery (Wahi et al., 1970, 1976). Also an illustration of this was the collaboration with nephrology to understand the psychiatric aspects of hemodialysis and psychiatric aspects of chronic uremia (Garg et al., 1976, 1978) and with neurology to study cerebral cysticercosis presenting in a psychiatric clinic (Kala & Wig, 1977) and other departments. In Delhi, studies demonstrated the prevalence of psychiatric problems in general medical wards and the different aspects of psychiatric problems of emergency room (Deshpande et al., 1989). Monthly joint case conferences with the departments of medicine and neurology were an excellent demonstration of the importance of the collaborative effort and recognition of the integrated approach to health issues. In the last decade, psychiatric units in all major hospitals have become a reality. This shifting of the place of care to the general hospital setting has contributed significantly to the process of destigmatization of psychiatric illnesses and psychiatric care. 11 Integration of Mental Health with General Health Care As an effort to take services beyond the isolated and centralized mental hospitals to GHP units, the integration of mental health with general health services is the next major innovation. This measure is one of the most important community mental health initiatives in India. The initial stimulus to this approach came from the recommendations of WHO in 1975, in the Expert Committee report ‘Organisation of Mental Health Services in Developing Countries’ (WHO, 1975). The chief recommendations were to: • Develop country mental health plans; • To choose priorities for mental healthcare; • Include mental health tasks in all healthcare personnel; • Provide essential psychiatric drugs in healthcare facilities; • Develop appropriate legislative support for these initiatives. India was the first developing country to formulate a National Mental Health Program (NMHP) in 1982 (DGHS, 1982). Twenty-five years later, WHO again re-emphasized the approach through the recommendation in the World Health Report, 2001 (WHO, 2001) to ‘provide treatment in primary care’. The integration of mental health care into general health services, particularly at the primary healthcare level has many advantages. These include, less stigmatization of patients and staff, as mental and behavioral disorders are being seen and managed alongside physical health problems; improved screening and treatment, in particular improved detection rates for patients presenting vague somatic complaints which are related to mental and behavioral disorders; the potential for improved treatment of the physical problems of those suffering from mental illness, and vice versa; and better treatment of mental aspects associated with ‘physical’ problems. For the administrator, advantages include a shared infrastructure leading to cost-efficiency, the potential to provide universal coverage of mental healthcare, and the use of community resources which can partly offset the limited availability of mental health personnel. In India, training primary healthcare workers for mental health was started in 1975 at the Bangalore and Chandigarh centers and integrating mental health with general health care (Chandrasekar et al., 1981; Issac et al., 1982, 1986; Parthasarathy et al., 1981; Sartorius & Harding, 1983; Srinivasa Murthy et al., 1978; Srinivasa Murthy & Wig, 1983; Wig & Srinivasa
  • 49. 12  Section I: An Introduction to Community Mental Health Murthy, 1980; Wig et al., 1981;). These experiences formed the basis of the National Mental Health Program (NMHP) formulated in 1982. Currently, the government supports over 125 district level programs in 22 states, covering a population of over 200 million (GOI, 2007). Following initial studies, other efforts to understand the integration of mental health with primary healthcare have occurred (Chisholm et al., 2000; Gautam,1985; James et al., 2002) and has been extensively reviewed in the book in a separate chapter. During the first 10 years of the NMHP, the initial small scale models of care (1975-84) by integrating mental health care with general healthcare were systematically evaluated (ICMR-DST, 1987). Realising the limited mental health resources in the country, from 1985-90, the district level model in Bellary district of Karnataka was developed and evaluated (Issac et al., 1986; Naik et al., 1996). These efforts dominated the first decade of community mental health movement in the country, and it is often confused as the only community psychiatry model in the country. During the next 15 years, (1993-2008), the district model called the district mental health program (DMHP) initially launched in 27 districts was later extended to 127 districts. Thus, within a relatively short period of time the basic approach to integrate mental health with general health care was adopted to cover a larger segment of the population (GOI, 2007). Developments between 1946-2003 have been critically and comprehensively covered by different professionals (Agarwaal et al., 2004). Though NMHP was introduced in 1982, the subsequent three Five-year plans did not make adequate fund allocations (Reddy et al., 1986). Furthermore, even the funds allotted were not fully utilised. It was only in the 9th Five-year Plan that a substantial amount of Rs 28 crore was made available and was increased in the 10th Five-year Plan to around Rs 140 crore. The availability of funds in 1995 for the DMHP has shown that once funds are available, states are willing to undertake intervention programs and professionals are willing to be a part of the process of integrating mental health with primary healthcare and also take up a wide variety of initiatives for mental health care. The projected funding for mental health program during the 11th Five-year Plan (2008-12), is approximately ` 1,000 crore. (GOI, 2007, Planning Commission, 2006). Given below are some of the limitations of the development efforts in the last twenty-five years, since the formulation of the NMHP (Agarwaal et al., 2004; Reddy et al., 1986; Srinivasa Murthy, 2004; Wig & Srinivasa Murthy 1980, reprinted 1993). • The extension of the district model has brought to the forefront a number of managerial and care issues. “India’s NMHP did envisage the diffusion of mental health skills to primar y health care centers at the village and district levels, and the integration of mental health care with primar y health care. However, poor monitoring and lack of co-ordination with the local state governments meant that such diffusion and integration efforts were not implemented, with the exception of a few sporadic programs” Even today the DMHP requires a great degree of fine tuning in areas such as, the quantum of training necessary for program managers, finalization of training material, public mental health education, measures to monitor the effectiveness and the impact of the program, support teams at the central, regional and state levels. Locating professionals to work as a part of the basic mental health team in districts has been a problem for a number of states, especially the nonmedical mental health professionals. Though professionals have accepted the NMHP, the effort to provide a sound foundation to the DMHP is still inadequate. There is a need to know the ratio of persons with mental disorders who seek care, and what could be achieved in a best-case scenario. Further, how can this be achieved in a phased manner. The failure in this field is stark when we see that the rest of the world is moving towards providing mental health care in primary health care. India, which initiated this approach thirty years ago has not been able to maintain its lead in this area of work. • The voluntary agency initiatives have been restricted to some pockets of the country. These have been limited in their reach and have not been adequately supported with funds by the government, both at the state as also at the center (Patel & Thara, 2003). • In spite of the many positive developments, state level planning has happened only to a limited extent. Only two states, namely Karnataka and Gujarat have developed state level plans. (Bhat et al., 2007; Srinivasa Murthy, 2003). • There are areas of mental health programs that have not received adequate attention. Of these, the following are important. The nationwide ICDS program has not received the impetus to make preschool education an effective mental health development force. The life skills education program for adolescents and the youth is still in its initial phase in a few centers (Bharath & Kishore Kumar, 2010). In spite of the attention being given to suicide by farmers, the number of centres providing suicide prevention is limited to few dozen centers when
  • 50. Chapter 1: The Relevance of Community Psychiatry in India  it should have been available in few hundred centers. The excellent models of disaster mental health care has not been a part of the earlier NMHP efforts. • The undergraduate training for basic doctors is extremely limited. The human resource development to meet the total mental health needs has not been fully addressed. • The issues of rapid social change together with the many changes in social institutions like the family, community and the methods to help the population experiencing the ill effects of these changes still do not receive adequate attention. • The current models are largely oriented to the rural population and viable models for the urban population are inadequate. The other recent criticism of community psychiatry in India (Jadhav & Jain, 2009; Kapur, 1997; Thara et al., 2008) is that: • It is top down • It is not based on the cultural aspects of the country • It is not effective • It is driven by WHO policies • The community voices have not been included • The program is a singular approach of DMHP. This criticism is not valid as can be seen from the review of the developments in the last four decades. Community psychiatry in India has been driven by the realities of the country (eg. involvement of families from 1950s, when the rest of the world was viewing the family as ‘toxic’). Development of the models of care were based on one decade of fieldwork to understand and meet the needs of the community by two academic centers (Wig & Srinivasa Murthy, 1980) and not in response to the WHO. These two centers based their interventions on the ‘community voices’ and these have been well documented. The development of policies of WHO were as much influenced by the Indian professionals as was the Indian movement driven by WHO. It is relevant to note that throughout the last twenty-five years, Indian professionals have played important roles in the WHO as regular staff at the Geneva office and at regional offices. At present, the Mental Health division of WHO is headed by an Indian psychiatrist. Recently, Issac & Guruje (2009) have reviewed the primary health care approach to mental healthcare and point out that, “the large unmet need for mental health services in many LAMI countries, despite the availability of effective and relatively affordable interventions, calls for an urgent effort to scale up primary care service in those countries. Efforts to scale up services must include a 13 comprehensive review of the training provided for primary care providers in the recognition and treatment of mental health problems and a reorganization of the primary healthcare system. Assumptions made about the relative autonomy of the primary healthcare system have led to an unsupported and unmotivated health workforce. A reorganization of primary healthcare system in the LAMI countries must recognize the need for an effective secondary care level., with a sufficient number of specialist mental health workers to provide training and support for primary care providers and back up for difficult cases requiring specialist interventions. Adequate resources are also needed. However, it has been estimated that the investment needed to scale up mental health care is not large in absolute terms, when considered at the population level and in comparison with other health sector investments (efforts to integrate mental health efficiently into primary care services are unlikely to work until public funded health systems are better resourced and made more effective)” (p83-84). Effectiveness of Care at the Community Level The question is not only about the feasibility and desirability of taking care to people, but its effectiveness. This issue has been addressed by a number of recent research studies. During the period beginning from 1980s, efforts have been directed to develop and evaluate the community based mental health care programs. One of the first such studies was from Chandigarh which examined the utility of a team consisting of a psychiatric nurse and psychiatric social workers in providing care in the community for persons suffering from chronic schizophrenia (Suman et al., 1980). This was soon followed by a major research effort which compared home-based care with hospital care (Pai & Kapur 1982, 1983; Pai et al., 1983, 1985). Recent research studies have addressed the situation of persons suffering from schizophrenia living in the community and the effectiveness of community level interventions (Chatterji et al., 2003, 2009; Srinivasa Murthy et al., 2004; Thara et al., 2008; Thirthahalli et al., 2009, 2010). These studies reveal that about half of the patients of schizophrenia are living in the community without treatment. It is further seen that such patients have significant disability, a cause of a great amount of emotional and financial burden on the family and caregivers. It is important to note that all these studies show the benefits of regular treatment in decreasing the disability, and lessening the burden on the family and costs to the families. These studies also emphasize the need for community involvement in the care programs as the following quote states : ‘community based initiati ves in the management of mental disorders however well intentioned will not be sus-
  • 51. 14  Section I: An Introduction to Community Mental Health tainable unless the family and the community are involved in the inter vention program with support being pr ovided regularly by mental health professionals’. If the belief is that chronicity of schizophrenia can be reduced and every person with schizophrenia can improve is coupled with an enthusiastic and aggressive management comprising both medical and social interventions, then it is possible that many patients can improve or recover and have meaningful and productive lives. Utilization of ‘non-specialists’ for Mental Health Care Limited human resources in terms of mental health specialists have been a perpetual barrier to providing mental healthcare to persons in need. Recognising the need to develop services to reach the total population, against a background of paucity of trained personnel, professionals have utilised a large variety of community resources for delivery of focussed mental healthcare (Srinivasa Murthy, 2006). These have included health workers, school teachers, volunteers, lay workers with specific training to care for specific groups like persons with dementia. A large number of mental health resources have been developed for the training of non-specialists (Issac et al., 1984, 1994; Sharma, 1986; Srinivasa Murthy et al., 1987; Wig & Parhee, 1984). A recent document “Mental Health by the People” (Srinivasa Murthy, 2006), which is an accumulation of over three dozen experience of contributors, show that the initiatives have not only been carried out in the health and education sectors but included the family carer initiatives for mentally ill and mentally retarded, the parent movement for learning difficulties, initiatives to reach the elderly population, suicide prevention by volunteers, disaster mental health care by non-professionals, efforts by voluntary agencies to fight stigma and discrimination. However, this initiative raises crucial questions (Srinivasa Murthy, 2007; Srinivasa Murthy & Wig, 1983). The involvement of ‘non-specialist mental health personnel’ require clarity about: • To what degree should the workers be involved in early identification and diagnosis? • To what level they should be given the responsibility for non-pharmacological methods of treatment? • How much should the worker be permitted to give pharmacological and biological interventions? • Can these workers be allowed to work independently or only under the direct and continuous supervision of other professionals? • Upto what level can they be involved in training of other workers? • To what degree should these people given the responsibility for certification of various types for legal as well as welfare benefits? • To what extent should these workers come under a system of licensing for taking up the work? Furthermore, regarding the involvement of non-specialist personnel, the following safeguards are essential: • The scope of the program should be spelt out (in writing) to the users and providers of help • All the providers of help should receive essential training for the task to be carried out • The providers should be imparted skills to do what they are expected to do (knowledge alone is not enough) • There should be a mechanism in place to support the providers of care, preferably with some trained professionals once a week but not less than once a month • There should be clear guidelines for referral to professionals so that no inappropriate actions are taken in the event of acute need (e.g. suicidal risk, violence) • There should be clear documentation of the process at all stages to allow for review both internally and externally • There should be an annual audit, preferably by an outsider to guide the group in its work. In view of the wide variations in the specialist human resources available in the country (Thirunavukkarasu, 2010), there will be a need to examine the human resources in each state and identify tasks in the seven areas outlined above, and allocate responsibilities to the different categories of personnel. In addition, these programs need to be periodically reviewed and the experience used for upgrading and modifying educational training programs for different categories of personnel. As indicated in recent books ‘Mental Health by the People’ (Srinivasa Murthy, 2006) and ‘NGO Innovations in India’ (Patel & Thara, 2003), the community psychiatry movement in India is not a ‘single model’ program but a wide array of initiatives involving a variety of community resources. Community Level Rehabilitation Another important development in community psychiatry in India, is the increasing role of voluntary organizations in developing small-size locally relevant community-based psychiatric care facilities like day care centers, vocational training centers, sheltered workshops, half-way homes and long-stay homes (Patel & Thara, 2003). These facilities have the advantage of
  • 52. Chapter 1: The Relevance of Community Psychiatry in India  limiting long term institutional care, incorporating the cultural sensitivities of the clientele, and utilising local resources. However, there is a need for evaluation of psychosocial care in community settings about the following aspects: • Characteristics of the clients, such as age, sex, literacy, occupation, income, social background, diagnosis, duration of illness, past treatment. • Reasons for seeking ‘institutional’ Psychosocial Rehabilitation (PSR)—the reasons could be a complex assortment of four factors, namely: (i) the nature of illness (e.g. chronic schizophrenia, personality disorder, etc.); (ii) specific therapy (e.g. supervised medication, therapeutic community, social skills training, vocational training etc.); (iii) family factors (elderly parents, single parent, siblings living abroad, etc.); and (iv) community factors (stigma limiting the reintegration of the recovered back into the community). The reason for collecting this information and analysing it is to direct interventions (either therapies, the social changes or stigma) depending on the chief factors. It can also be that the different centres can organise services disparately for the different reasons for ‘institutional’ care. Work in this area could also give information for the government to take up appropriate action rather than to depend solely on the private/NGO sectors. • Duration of stay: How many are terminated/discharged prior to completing the admission goals. • Outcome of the stay in PSR facilities: This will be both in terms of the client and the family. To what extent have the goals been realised and if not, the reasons for the same—illness, therapeutic setting, staff problems, social factors, etc. • Therapeutic processes during the stay of the client: It is vital to record this information not only for human resources development but also it is appropriate for the clients to understand the benefits of different interventions. At present, most of the center reports speak of counseling, group therapy, etc. without specifying what it really means. • Staff issues: This could include, the roles of the different categories of staff, their training needs, staff turnover, etc. • Crisis handling: Detecting types of crisis—suicide attempts, violence, etc. their frequency. • Human rights: The study from BAPU TRUST has analyzed the type of human rights abuses and lack of clarity in this area. It is important to record and develop norms for informed consent, ‘restrictions’, admissions 15 against willingness of clients, guardianship, remedial measures, etc. • Changes in practices over the life time of the organisation (last 10,20,30 years) and how the Institution has gained from its experiences. • Lessons learnt and needs for PSR for future development (Srinivasa Murthy, 2010). Religion All major religions give an important place to mental health (Ver Hagen et al., 2010). Religion has been used, both at the level of making sense of the illness as well as the involvement of religious leaders for the promotion of mental health and mental healthcare. In a number of religions like Buddhism and Hinduism there are practices such as yoga and meditation that have direct value in the treatment of some mental disorders and promotion of mental health (Srinivasa Murthy, 2010). However, there is need for research into the impact of use of these measures on individuals and communities as noted by Carstairs (1980) and Rao (1997): ‘India is an ancient and great cultural, spiritual and an anthropological laboratory. She has been the nursery of saints and sages, scientists and founders of the world’s major religions and promulgators of profound philosophy. Nevertheless, to be satisfied with the glory of the past is to turn into a fossil; but to interpret the old from a new point of view is to revitalise the past and bring in a current of fresh air into the monotonous present’ (Rao, 1997). ‘… one has to admit that there is little firm evidence that either meditation or religious observance significantly modifies… tens of thousands of Indians, young and old, have become disciples of teachers who support them in their twofold ambition to practice right conduct in accordance with Hindu dharma and to enhance their personalities by following a particular technique of meditation. If it could be established, with appropriate controls, that changes in symptoms and in personality traits do come about, and in the desired direction, then the possibility of collaborating between psychiatrists and gurus could be worth exploring,’ (Carstairs, 1980). Traditional Practices and Traditional Healers In the absence of modern mental healthcare, majority of the population has taken the help of traditional healers. (Kapur, 1979; Trivedi & Sethi 1979, 1980). There is significant ambivalence among the professionals about the way to respond to these practices (Sebastia, 2009). However, it is significant that no studies have been made in recent years.
  • 53. 16  Section I: An Introduction to Community Mental Health Public Mental Health Education Developing programs to educate the general population about the modern understanding of mental disorders and their treatment has been an important activity of professionals. These efforts have been directed not only to fight stigma and discrimination but to promote mental health, through mental health literacy efforts (Wig, 1987). There is a wide use of mass media for these efforts in addition to folk measures. Notable among these is the television program, Date in the 1980s, the currently running national television series, Mann ki baat (over 30 episodes) and the regional television program in Kannada, Manochintana (over 70 episodes) which are conveying information on mental health to the general population. The efforts of individual psychiatrists and other professionals in writing books for the general public have been commendable. The next frontier in this area will be the greater use of information technology and communication (mass media, mobiles, print media). This medium of information has a great potential to bring about changes in the general population together with a potential to stimulate ‘self-care’ and ‘informal care’. Research Research has become an important aspect of community psychiatry movement in India. The efforts were linked to the goals of national mental health programs (ICMR, 1982). Two notable examples are the ICMR-DST ‘Severe Mental Morbidity’ study in the 1980s, and the setting up of the Advanced Centre for Research on Community Mental Health by ICMR (1985-91). The other efforts have been towards an understanding of mental disorders and the role of biological and psychosocial factors. The Indian Council of Medical Research provided valuable support with a large number of research projects directly and indirectly related to emerging mental health programs during the 1970s and 1980s (ICMR, 2005). Research on the course and outcome of schizophrenia, acute psychosis, old age psychiatric problems and community psychiatry added the local knowledge to influence the NMHP (ICMR, 2005). Professionals (Barbui et al., 2010) have identified priority research questions (e.g. how effective are early detection, and simple and brief treatment methods that are culturally appropriate, implemented by non-specialist health workers in the course of routine primary care, and can these be scaled up?). The above efforts had laid greater emphasis on the care of persons with mental disorders, though there have been attempts on a smaller scale on the promotion of mental health and prevention of mental disorders. There is also growing recognition of the impact of social changes on the mental health of the population (e.g. growing suicide rates, domestic violence, violence in children, elderly mental health, migrant populations, displaced populations, etc.) which makes it necessary that future mental health programs should include promotion of mental health, prevention of mental disorders and care and rehabilitation of persons with mental disorders. INTERNATIONAL DEVELOPMENTS The last four decades, from the time of the WHO Expert Committee Report of 1975, and more specifically the last two decades have been an extraordinary period for mental healthcare all over the world (Desjarlais et al., 1995; DHSS, 1999; IOM, 2001; WHO, 2001). The most striking aspect of the movement for community mental health in the world is the continuing effort to develop and support movements such as the Lancet initiative of 2007 (Chisholm et al., 2007a, 2007b; Horton, 2007; Jacob et al., 2007; Prince et al., 2007; Saraceno et al., 2007; Saxena et al., 2007) and other international initiatives (Thornicroft et al., 2008; Thornicroft et al., 2010) and the WHO efforts to develop policies to support the movement (WHO, 2006; WHO, 2007; WONCA, 2008) (Appendix 1). This is a movement in the early phases and the complete story will unfold in coming years and decades when these initiatives will help in providing a better quality of life to the persons with mental disorders and to their families. PERSONAL REFLECTIONS OF LAST SIX DECADES I have been a part of the community psychiatry movement in the country since the 1970s, participating in many of the initiatives and a witness to other developments. In reviewing the progress, it would not be appropriate to view the wide variety of developments from a perspective of the present. Each of the successes and failures have to be placed in their historical perspective, the realities, policies, socioeconomic factors, personalities, national and international developments. An overview of the community psychiatry developments of the last six decades, present a picture of a large number of initiatives. These initiatives have been largely the response to a specific need at a specific time period. For instance, in the 1950s, the lack of human resources in mental hospitals was addressed by bringing together the families to become a part of the care programs. In the 1960s, the availability of the psychopharmacological agents for the treatment of mental disorders and the growing general hospitals, resulted in the setting up of general hospital psychiatric units. During the 1970s, the growth of the public sector health services
  • 54. Chapter 1: The Relevance of Community Psychiatry in India  and the influence of the Alma Ata declaration guided the development of the community mental health programs and the formulation of the NMHP in 1982. During the 1980s and 1990s, the need for non-mental hospital facilities for rehabilitation resulted in setting up of a number of community care facilities in different parts of India, mainly by voluntary organizations. The recognition of the human rights of the mentally ill persons is reflected not only in the improvement of the mental hospitals, but also with revision of the mental health legislation. Each of these initiatives have been started and guided by visionary professionals and have taken place at a particular time period and to address a specific need perception. One striking aspect is the innovativeness of the professionals and voluntary agencies to address the multiple needs using the available community resources. This has occurred in a number of areas. This, I consider is the strength of the Indian mental health movement. However, the negative aspect of these developments is the lack of depth in most of the initiatives. Even when initial results have been quite positive (e.g. nurse involvement in community care), the innovations have not received the kind of amplification and in depth understanding that should have happened. The lack of evaluation is seen uniformly in all the programs and I have considered the need for this aspect in each of the sections. The other aspect of significance is the largely person and center specific nature of the initiatives. There has been limited teamwork in carrying forward the effort beyond the initial initiators. A result of all of these factors has been the lack of theory building and influencing of policies at the national level. It is important that the next phase of development should address some of these in a more focussed manner. Recognizing the special value of the community mental health initiatives for India, there are two ways at looking at the developments. The positive aspects have been the story recounted so far. However, the reverse is the limitations of the most of the initiatives that have been outlined in the earlier sections. What could be the reasons for this? One possibility is that the initiatives that are non-institutional in their care setting were more difficult and will need more time to develop fully. Another possibility is that these were ideologically driven and not fully rooted to the realities of the country. The third possibility is that professionals have not fully accepted the processes of deinstitutional care, decentralization of care and de-professionalization of care, as it could affect their own identity and income. However, it can be clearly said that if the community mental health programs are to fully blossom and reach the needs of the population, 17 this will be an important contribution from India to the rest of the world (Wig, 1989). FUTURE OF COMMUNITY PSYCHIATRY IN INDIA The following section critically considers some of key areas for future work. In order to address the mental health needs of India in totality, there are a number of requirements for the development of community psychiatry in India. The specific areas which need further efforts have been considered under each of the initiatives in the earlier sections. The following section covers the broader issues of community psychiatry (Srinivasa Murthy & Kumar, 2008). The future needs of community psychiatry can be considered at three levels namely, professional level, community level and policy level. Professional Challenges Professional leadership has been an important force for the many community psychiatry initiatives. These efforts have to be continued. There is a need to simplify mental healthcare skills and continually review and develop innovative approaches to deliver them, in order to address the reality of the community needs and expectations. For care to be undertaken by health workers, teachers, volunteers, family members, there is a need for simple interventions. Professionals have to develop appropriate information in a simple format and identify the ‘level of care’ and ‘limits of care’ to be provided by these personnel. These should include choosing priority mental disorders to be addressed in training, limiting the range of drugs to be used by the general practitioners, develop strong referral guidelines and the non-pharmacological interventions to be used by non-physician personnel. There should be both a willingness to share mental health caring responsibilities with non-specialists, and overcome the fear by some professionals of losing their work, identity and income. The method should be not to convert the non-specialist into a mini-psychiatrist but to identify what is relevant, feasible and possible for the specific non-specialist to undertake. There is a need to decrease the amount of time devoted by specialist mental health professionals to individual clinical care and increase the time for training, support and supervision of other personnel. This is a huge challenge for clinicians who value directly caring for ill people by themselves. This change in role becomes meaningful when it is recognized that training of other personnel has a multiplier effect in providing mental health services to the population.
  • 55. 18  Section I: An Introduction to Community Mental Health There is a need to devote significant time to periodic support and supervision of the non-specialists. Reports of mental healthcare in developing countries have repeatedly shown the importance of support and supervision by psychiatrists to the non-specialist personnel. Fortunately, the easy and inexpensive availability of mobile phones, internet and satellite communication for telepsychiatry, allows for distant support to the non-specialists on a continuous and interactive basis. There is a need for professionals to acquire the skills to work with the community, education sector personnel, welfare sector personnel, voluntary organizations, and policy makers. This includes understanding the planning process, fighting for priority for mental health in health programs, becoming familiar with legislations and budget procedures, and developing skills to negotiate with different stakeholders. Community Level Challenges In India, there is a paradoxical situation of limited services and poor utilization of the available services, due to problems of stigma and lack of awareness in the general population. There is a need for bringing about a major shift in the thought process of the community in terms of understanding of mental health and mental disorders, decreasing the stigma and discrimination of persons and families with mental disorders, and the creation of a wide range of community care facilities and services. There is also a need to develop simple self-care information modules. For those requiring long-term care there is need to develop measures (for instance, the use of mobile phones, internet, community radio) to help in monitoring the progress of mental condition at the home level. In addressing these needs to cover the total population and in a manner that requires limited travel, there is a need to take advantage of available modern technology such as the world wide web, mobile phones, telemedicine, community radio to reach and continuously support the persons and families with mental disorders. Already some small scale initiatives have been made but these have to be widened to cover the entire population of the country. The use of information technology in spreading the agricultural information should give hope for similar success in the area of mental health. Policy Level There are a number of requirements at this level. The important ones are: • Greater amount of allocation of funds for mental health programs (this has occurred to a large extent in India, as the National Mental Health Programe budget has increased from ` 27 crore at the beginning of the 21st Century to over ` 1,000 crore in the current Five-year plan). • Recognition of human rights of the persons and families of persons with mental disorders in all development programs, especially in the areas of education, welfare, housing and employment. • Strengthening of programs to support the families. • Legislative support for non-specialists to provide mental health care. • Building a large number of community based care facilities. The mental health professionals have emphasized the need for public mental health and its challenges in the last decade (Desai 2005, 2006; Reddy, 2007; Singh, 2007). It is significant that on 15 April 2011, the Government of India set in motion a broad-based task force for mental health to develop the mental health policy of the country. This is timely and should give new life and momentum to the movement. In conclusion, development of mental health services all over the world, countries rich and poor alike, have been the product of the larger social situations (political, social, economic and human rights), specifically the importance that society gives to the rights of disadvantaged and marginalised groups (Wig, 1989). Economically rich countries have addressed the community psychiatry movement from the institutionalized care to community care building on the strength of their social institutions. India, though began this process more recently has made significant progress utilising the strengths of the community. 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  • 59. 22  Section I: An Introduction to Community Mental Health 19. Wig NN. The future of psychiatry in developing countries - The 1 need for national programs of mental health. NIMHANS Journal 1989;7:1-11. 120. Wig NN. Stigma against mental illness. Indian Journal of Psychiatry 1987;39:187-189. 21. Wig NN, Srinivasa Murthy R. Mental health careneed to expand 1 its reach. The Tribune, October 10, 2009. 122. World Health Organization. Organization of mental health services in developing countries, Technical Report Series, 564. Geneva, WHO, 1975. 23. World Health Organisation. World Health Report 2001 Mental 1 Health New Understanding, New Hope. Geneva, World Health Organization, 2001. 24. World Health Organization. Organization of services for mental 1 health: Mental health policy and service guidance package. World Health Organization, Geneva, 2006. 125. World Health Organisztion. WHO Mental Health Policy and Service Guidance Package. Geneva, World Health Organization, 2007. 26. World Health Organization. Mental Health Atlas. Geneva, World 1 Health Organization, 2005. 127. WHO-WONCA. Integrating mental health in primary care a global perspective, World Health Organization and World Organisation of Family Doctors. Geneva, World Health Organization, 2008. 28. World Health Survey, India, 2003. Health system Performance 1 Assessment, International Institute for Population Sciences (IIPS), Mumbai, World Health Organization, Geneva. New Delhi, World Health Organization-India-WR office, July, 2006. APPENDIX 1 WHO Mental Health Policy and Service Guidance Package 1. World Health Organization (2003). Mental Health Policy and Service Guidance Package: The mental health context. Geneva, World Health Organization. 2. World Health Organization (2003). Mental Health Policy and Service Guidance Package: Mental health policy, plans and programs (updated version). Geneva, World Health Organization. 3. World Health Organization (2003). Mental Health Policy and Service Guidance Package: Mental health financing. Geneva, World Health Organization. 4. World Health Organization (2003). Mental Health Policy and Service Guidance Package: Advocacy for Mental Health. Geneva, World Health Organization. 5. World Health Organization (2003) Mental Health Policy and Service Guidance Package: Organization of Services for Mental Health. Geneva, World Health Organization. 6. World Health Organization (2003). Mental Health Policy and Service Guidance Package: Quality improvement for mental health. Geneva, World Health Organization. 7. World Health Organization (2003). Mental Health Policy and Service Guidance Package: Planning and budgeting to deliver services for mental health. Geneva, World Health Organization. 8. World Health Organization (2005). Mental Health Policy and Service Guidance Package: Improving access and use of psychotropic medications. Geneva, World Health Organization. 9. World Health Organization (2005). Mental Health Policy and Service Guidance Package: Child and adolescent mental health policies and plans. Geneva, World Health Organization. 10. World Health Organization (2005). Mental Health Policy and Service Guidance Package: Human resources and training in mental health. Geneva, World Health Organization. 11. World Health Organization (2005). Mental Health Policy and Service Guidance Package: Mental health information systems. Geneva, World Health Organization. 12. World Health Organization (2005). Mental Health Policy and Service Guidance Package: Mental health policies and programs in the workplace. Geneva, World Health Organization. 13. World Health Organization (2007). Mental Health Policy and Service Guidance Package: Monitoring and evaluation of mental health policies and plans. Geneva, World Health Organization. All modules can be downloaded at: http://www.who. int/mental_health/policy/essentialpackage1/en/index. html
  • 60. Section II Historical Concepts and Evolution
  • 61. 2 Psychiatry in India: A Historical Perspective S Haque Nizamie, Mohammad Zia Ul Haq Katshu, Samir Kumar Praharaj INTRODUCTION HISTORY OF WORLD PSYCHIATRY In no other field of medicine is the influence of the sociocultural milieu as important as in the definition, manifestation and response to an illness in psychiatry. The development of psychiatry after the medical model leads to an oversimplified and uncritical growth of the ideas of objectivity, transparency and freedom from presupposition, and to a divorce from the sociocultural perspectives apparently inherent in all scientific disciplines. Although this leads to important advancement in the understanding and treatment of mental illness, it needs to be emphasized that even core scientific ideas and observations are grounded in a cultural context (Fulford, 1996). It becomes imperative, therefore, to understand the historical context of the development of a discipline for a proper understanding. The history of psychiatry in India dates back to the descriptions of mental ailments and their remedies in the Vedas, around 3,000 years ago. These early conceptualizations were later influenced by the growth of Buddhism, the Unani system of medicine brought by the Muslims and, later, by the Western medical model that came with British colonialism. These influences led to the development of parallel streams of thought in different cultural groups on one hand and, at the same time, influenced each other to a great extent. They have also been instrumental in shaping contemporary psychiatry in India. It is, therefore, important to trace historical developments to have a better understanding of contemporary psychiatry in India. This chapter aims to present an overview of the major developments in psychiatry from Vedic times to the present to sensitize the reader to the historical underpinnings of current psychiatric practice. The history of the development of psychiatry in India is reviewed in four distinct phases: in ancient India, in medieval India, during the colonial period, and the growth that occurred in the postindependence era, against a brief background of the history of world psychiatry. Accounts of mental illnesses have been documented since ancient times in various places. Around 2850 BC in Memphis, the temple of Imhotep (a great Egyptian healer) became a medical school where patients received sleep therapy, occupational therapy, and excursions on the Nile. In Mesopotamia, in 2000 BC, as recorded in the code of Hammurabi, which is preserved in cuneiform clay tablets, priest-physicians dealt specially with mental disturbances which were attributed to demonic possession, while ‘lay’ physicians dealt solely with physical injury. The earliest mental hospital on record was a Greek sanctuary at Epidauros. There are documents describing institutions solely for the mentally ill in Byzantium and Jerusalem in the fourth century AD (Menninger, 1995). Thereafter, Christian and Muslim religious institutions were places of refuge for the mentally ill where patients were treated by a variety of religious rituals. The first psychiatric hospital was built in Baghdad in 705 AD (Syed, 2002). In the tenth century, the Persian physician, Muhammad Ibn Zakariya Razi (also known as Rhazes), combined psychological methods and physiological explanations to provide treatment for mentally ill patients. His contemporary, the Arab physician, Najab ud-din Muhammad, described a number of mental illnesses such as agitated depression, neurosis, and sexual impotence (Nafkhae Malikholia), psychosis (Kutrib), and mania (Dual-Kulb) (Syed, 2002). The first modern mental hospital in the European world was the Bethlehem hospital in London which was established in 1247. The condition of mentally ill patients in these early institutions was one of neglect, restraint and abuse with poor clothing, unhygienic conditions, poor nutrition, and restrictions on movement because of the chaining of hands and feet, and a lack of stimulation. A scarcity of funds contributed a large part to this state, as did a lack of interest among the ruling aristocracy and the overcrowding of mental hospitals (Krishnamurthy
  • 62. 26  Section II: Historical Concepts and Evolution et al., 2000). In 1284, the Kalaoon Hospital in Cairo had separate sections for medical, surgical, eye diseases and mental disorders (Okasha, 2001). In the late eighteenth and early nineteenth century, Pinel revolutionized care of the mentally ill by propagating a humane approach. Around the same time, the York Retreat was established by William Tuke to provide a kind and tolerant approach towards the mentally ill. Dorothea Dix proposed setting up of state-run hospitals for the treatment of the mentally ill based upon Pinel’s moral approach (Menninger, 1995). By the mid-1940s, the treatment of the mentally ill took a new turn, with the advent of electroconvulsive therapy (ECT) and insulin coma therapy, and the use of frontal lobotomy. The mid-1950s saw the emergence of two major factors which influenced the evolution of modern psychiatry—the discovery of specific drugs like chlorpromazine for the treatment of mental illnesses and the antipsychiatry movement led by persons such as Goffman and Szaz, which along with economic recession were the motivating factors for the deinstitutionalization of mentally ill persons and the evolution of the concepts of community psychiatry (Jones, 1993). PSYCHIATRY IN ANCIENT VEDIC INDIA Traditional Indian medicine includes three predominant systems – Ayurveda, Siddha and Unani. Ayurveda (Ayur: Life; Veda: Science) has a history of theory and practice for over 3,000 years in the Indian subcontinent. Charak Samhita and Sushrut Samhita are the two main Ayurvedic classics (Bhugra, 1992). Ayurveda had eight major disciplines known as Ashtanga Ayurveda. Among them, the practice of psychiatry was known as bhoot-vidya (currently known as Mano-roga). The Ayurvedic physicians diagnosed illnesses by identifying three irreducible physiological principles called doshas through the palpation of the radial pulse. Doshas were considered to be the bodily energies reflecting a state of mental and physical health when in harmony and a disorder when imbalanced. Three doshas were identified—kapha (mucus), pitta (bile), and vata (wind); each having a distinct location and tactile vibratory quality on the radial pulse. Different types of personalities or constitutions (prakrutis) were identified according to the predominant dosha and each prakruti predisposed a person to certain illnesses (Bhugra, 1992). In the Vedic texts, there are descriptions of conditions similar to schizophrenia and bipolar disorder. Furthermore, these texts differentiated doctors practising magical medicine from scientific physicians and surgeons, who lived and practiced in cottages surrounded by medicinal plants. The ancient textbooks of Ayurvedic medicine, the Charak Samhita and the Sushrut Samhita by Charaka and Susruta, contain vivid descriptions of a condition akin to schizophrenia. A description of insanity, unmada, exists in the Atharvaveda that dates back to 1500 BC, which is one of the ancient Indian medical scriptures (Bhugra, 1992). Charaka defined unmada as having derangements in eight components: manas (mind); buddhi (decision); smriti (memory); bhakti (desire); sheela (habits and temperament); cheshta (psychomotor activity); achara (conduct) and sanjnanana (orientation and responsiveness). Unmada is broadly classified as endogenous (nij) type, which has been ascribed to imbalances of vata, pitta or kapha (combination of humors) or exogenous (agantuk) type, in which possession by bhutas (demons, of different varieties such as gandharvas, pisachas, yaksas and rakshasas) (Bhugra, 1992). The four basic elements of treatment described in these texts include the physician, the drugs, the attendant and the patient (Bhugra, 1992). The treatment of unmada consisted of cleaning and anointment with mustard oil, eating ghee for some days and later giving strong purgatives and emetics along with errhines and mustard oil. The Indian snakeroot (Rauwolfia serpentina) has been used by ancient physicians before reserpine was extracted from the root. The other treatment methods included talismans, amulets, charms, rituals and prayers. Treatment of bhutonmada (i.e. exogenous insanity) involved worshipping gods. Shock therapy was used in difficult and intractable cases using men trained as bandits, non-poisonous snakes, elephants, and lions (Bhugra, 1992). In India, the medical and religious use of cannabis probably began together around 1000 BC (mikuriya, 1969). The Atharvaveda mentions cannabis as one of five sacred plants, referring to it as a source of happiness, donator of joy and bringer of freedom; hence, it was part of numerous religious rituals (Touwn, 1981). Cannabis was used for medicinal purposes as an analgesic, anticonvulsant, hypnotic, tranquilizer, anesthetic, anti-inflammatory, antibiotic, antiparasitic, antispasmodic, digestive, appetite stimulant, diuretic, aphrodisiac or anaphrodisiac, antitussive and expectorant (Zuardi, 2006). The ancient Hindu scriptures, Ramayana and Mahabharata contain descriptions of depression and anxiety states and means of coping with them (Venkoba Rao, 1969). The Bhagavad Gita is a classical example of crisis intervention psychotherapy (Trivedi, 2000). Group therapy using the reading of shastras was also employed (Unnikrishnan, 1966). Close to the roots of Hindu mythology, Najabuddin Unhammad (1222), an Indian physician propagated the Unani system of medicine as he described seven types of mental disorders; Sauda-a-Tabee (schizophrenia); Muree-Sauda (depression): Ishk (delusion of love); Nisyan (organic mental disorder); Haziyan (paranoid state) and Malikholia-a-maraki (delirium) (Rao, 1975). In the Unani system, the interpreta­ tion of psychiatric disorders is based on the doctrines of
  • 63. Chapter 2: Psychiatry in India: A Historical Perspective  Galen and Avicenna, and the physiology of the four humors (blood, phlegm, yellow and black bile) that circle the body (Speziale, 2003). Humors are a combination of the four universal elements (fire, air, water and earth) and have four basic qualities (hot, cold, dry and moist). Individual health is a state of relative equilibrium of the humors, characterized by the dominance of one humor, which determinates mizaj, the individual temperament. For example, the dominance of phlegm or black bile determines the phlegmatic or melancholic characters, respectively. Alteration and excess of humors produces diseases, in particular black bile (cold and dry), which induces depressive disorders. Excess of yellow bile (hot and dry) leads to hysteria and maniacal disorders. Treatment aims at restoring the normal mizaj of the person, by different means. Treatment modalities include phlebotomy, cupping, Turkish baths, aromatherapy, poetry-reading, music therapy and psychotherapy (known as Ilaj-i-Nafsani in Unani Medicine) (Speziale, 2003). Siddha (meaning ‘achievements’) system is another old system of medicine in India practiced by Siddhars, or saintly persons. The great sage, Agastya (also known as Agasthiyar) wrote a treatise on mental diseases called as Agastiyar kirigai nool, in which 18 psychiatric disorders with appropriate treatment methods are described (Parkar et al., 2001). Eighteen Siddhars were said to have contributed towards the development of this medical system. Siddha medicine, similar to Ayurveda and Unani systems, is based on the belief that the ratio of vatham, pitham and kapam (vata, pitta and kapha) is essential for good health and its derangement produces disease. According to Siddha medicine, various psychological and physiological functions of the body are attributed to the combination of seven elements: saram (plasma), responsible for growth, development and nourishment; cheneer (blood), responsible for nourishing muscles, imparting color and improving intellect; ooun (muscle), responsible for shape of the body; kollzuppu (fatty tissue), responsible for oil balance and lubricating joints; elumbu (bone), responsible for body structure and posture and movement; moolai (brain), responsible for strength; and sukila (semen), responsible for reproduction. Three methods of treatment have been described in the Siddha system—devamaruthuvum (the Divine method); manuda maruthuvum (the rational method); and asura maruthuvum (the surgical method). This system of medicine emphasizes that medical treatment is oriented not merely to disease but has to take into account the patient, environment, the meteorological consideration, age, sex, race, habits, mental frame, habitat, diet, appetite, physical condition and physiological constitution. The first account of hospitals established for the care of the ill dates back to 230 BC, when King Ashoka is said to have founded at least 18 hospitals, with physicians and nursing 27 staff, the expenses being borne by the royal treasury. During that period, many hospitals were established for patients with mental illness (Parkar et al., 2003). According to the scribes of the Asoka Samhita, hospitals were built with separate enclosures for various practices including keeping the patients and dispensing treatments prevailing during those times, although this has been disputed. Travellers’ accounts of 400 AD mention similar services established by rich merchants (Jain, 2003). PSYCHIATRY IN MEDIEVAL INDIA The medieval period of Indian history is marked by the rise of the Cholas in the south leading to the consolidation of the Tamil culture, a short-lived rise of the Rajputs and the arrival of the Muslims. A temple of Lord Venkateswara at Tirumukkudal, Chingleput District, Tamil Nadu, India, contains an inscription on the walls dating from the Chola period (Parkar et al., 2001). The inscription mentions a hospital, named the Sri Veera Cholaeswara hospital, with 15 beds, and a school. Although, there is little evidence for the development of psychiatry in the Mughal period, there are references to some asylums in the period of Mohammad Khilji (1436-1469). There is evidence of the presence of a mental hospital at Dhar near Mandu, Madhya Pradesh during that period (Parkar et al., 2001). A physician, Maulana Fazulul-Lah Hakim, was in charge of this first Indian mental asylum (Parkar et al., 2001; Sharma & Varma, 1984). The growing European influence between 1500 and 1750 saw an increase in the attachment of European practitioners to the courts of kings all over India, including the Mughal emperors (Jain, 2003). The Portuguese introduced modern medicine and hospitals in Goa in the 16th century, but these had only a limited impact (Jain, 2003). Mental asylums were constructed away from cities with high enclosures creating a prison-like ambience; the prime objective being the protection of the community and not of the mentally ill. While traditional Indian Medical Systems, such as Ayurveda and Unani, identified mental illnesses as distinct disorders and necessary treatments were provided by medical practitioners, there was no separate setting or provider system for mental illness. It was after European colonization that separate services for persons with mental illnesses were provided (Ganju, 2000). PSYCHIATRY IN COLONIAL INDIA Early Colonial Period (1745-1857) The earliest mental hospital built during the colonial period in India was in Bombay (Mumbai) in 1745. It could accom-
  • 64. 28  Section II: Historical Concepts and Evolution modate around 30 mentally ill patients (Sharma & Chadda, 1996). Surgeon Kenderline started one of the first asylums in Calcutta (Kolkata) in 1787. Later, a private lunatic asylum was constructed, recognized by the Medical Board under the charge of Surgeon William Dick and rented out to the East India Company (Parkar et al., 2001). The first government-run lunatic asylum was opened on 17 April 1795 at Monghyr in Bihar (known as the Monghyr Asylum), especially for incarceration of mentally ill soldiers (Varma, 1953). The remains of this building are located now at Shyamal Das Chakravarty Road and is popularly known as the Paghla Ghar (house of lunatics). The first mental hospital in South India was started at Kilpauk, Madras (Chennai), India, in 1794 by Surgeon Vallentine Conolly. In 1817, the mental hospital in Calcutta, with clean surroundings and a garden, had 50 to 60 European patients, There, excited patients were treated with morphine and opium, given hot baths and sometimes had leeches applied for bloodletting as a form of treatment (Sharma & Chadda, 1996). The Bangalore Lunatic Asylum was established in 1848 (Jain & Murthy, 2000). In 1855, another lunatic asylum was opened in Murli Bazar, in Dacca (now Dhaka), which is now the capital of Bangladesh. Music as a form of treatment to calm excited patients was used for the first time during that period at the Dacca hospital (Varma, 1953). There is also some evidence on the use of cannabis to treat anxiety and stress disorders. This period is significant only for the establishment of separate institutions for those considered to be mentally ill by the East India Company. During this period, several asylums were built including those at Patna, Dacca, Calcutta, Berhampur, Waltair, Trichinopoly, Colaba, Pune, Dharwar, Ahmedabad, Ratnagiri, Hyderabad (Sind), Jabalpur, Banaras (Varanasi), Agra, Bareilly, Tezpur and Lahore (Ernst, 1987). The institutions set-up for Indian patients were little more than ‘refuges’ or ‘temporary receptacles’, while the system for European patients was geared to repatriating them to the UK (Ernst, 1991). Treatment for the mentally ill was virtually nonexistent at these institutions. Middle Colonial Period (1858-1918) In 1857, the East India Company lost control of much of India after a series of violent uprisings against the presence of the British. Thereafter, the British state took direct control of the country in 1858 from the private merchant house. The basic foundations of the modern psychiatric system in India were laid from that time until 1914, as an institutional network was established and a legal framework was laid out (Mills, 2001). The first Lunacy Act (also called Act no. 36) was enacted in the year 1858 for the incarceration of mentally ill Indians (Mills, 2001). The legal provisions for mentally ill criminals of the various administrations of India were also standardized in Chapter 27 of the Code of Criminal Procedure passed in 1861. The Act was later modified by a committee appointed in Bengal in 1888. It remained in force until the Indian Lunacy Act IV of 1912, was passed. The Lunacy Acts were designed primarily to protect society from ‘dangerous’ lunatics, rather than to safeguard the interests of the mentally ill. With the opening of the Lucknow Lunatic Asylum in 1859, there began two decades of unprecedented activity in providing buildings to contain those individuals in the Indian population that the British classified as ‘mad’ (Mills, 2001). It was in this period, especially the years between 1858 and 1880, the number of detainees in institutions designated ‘lunatic asylums’ increased most significantly (Mills, 2001). The Bengal Presidency had the most asylums in India and the greatest number incarcerated as ‘lunatics’; in 1865 the total population of all the asylums was 627 people, which by 1875 had risen to 1,147, an increase of 82 percent in 10 years. Throughout this period, it was unusual for patients to admit themselves voluntarily or to be admitted by the community into these asylums. It was the officers of the state who initiated the procedures leading to the incarceration of individuals. The largest portions of them bore the tag of wandering or dangerous lunatics. The other group named criminal lunatics, comprised of individuals who were arrested, tried, sentenced and committed to prison, and transferred to these asylums when they exhibited some mental disorder. Individuals found unfit to stand trial because of psychiatric problems were also incarcerated. Further, those acquitted because of psychiatric problems were kept under observation for a year or more in these institutions (Mills, 2001). There were a very few self-admissions, mostly by vagrants and beggars who identified the asylums as places of refuge from their harsh lives. There are scattered reports of descriptions of psychiatric disorders having psychological explanations in the late 19th century (Jain, 2003). An account of hysteria in a 14-year-old boy was described by Chetan Shah. Treatment of another case of hysteria by deva-rishis (faith healer) was described by Pandurang. A report of brief psychosis after watching a float that had actors enacting decapitation during a Moharram procession has been described during this period (Jain, 2003). Patients were, wherever possible, allowed to go about without physical restraints, and indeed the European pioneers of this system were quoted to justify this procedure: the system adopted in the asylum is what is called the non-restraint system, the object of which is the humane and enlightened
  • 65. Chapter 2: Psychiatry in India: A Historical Perspective  curative treatment of the insane (Mills, 2001). During the late 19th century, “current electricity” was frequently used in the native asylum at Dullunda (in Kolkata) by Dr Payne, the then superintendent of that asylum, who reported that the use of electric treatment yielded surprising results. However, he never practiced such treatment on European patients. Interestingly, Dr Payne dismissed the moral management of the mentally ill and instead advocated and justified the use of physical restraint. Comprehensive work schemes were devised by the medical superintendents similar to the ones used in the asylums of the West. Alongside the ‘moral management’ techniques of the early 19th century, however, forms of drug treatment for psychiatric conditions were also introduced into India during this period. These were largely aimed at controlling patient behavior and also for allowing some respite through sleep. The treatment for mental excitement consisted of bromide of potassium, hydrate of chloral, morphia, and tincture of digitalis (Mills, 2001). 29 Friedman, based on the use of the AC current, called the Ediswan System (Fig. 5). LP Varma, the first MD in Psychiatry (1943) in the country got a degree from the CIP under Patna University, Patna, Bihar, India (Nizamie et al., 2008). Owen Berkeley-Hill, the medical superintendent of the European Mental Hospital, Ranchi, Bihar, India, was deeply concerned about the improvement of mental hospitals in those days and his efforts culminated in a government notification in 1920 to change the term ‘asylum‘ to ‘mental hospital’. Berkeley-Hill, in 1929, founded the Indian Association Late Colonial Period (1918-1947) From 1918 to 1947, the institutional network planned by the British was shaped by new challenges such as the psychiatric casualties of the World Wars, the increasing use of the Western system by Indian families and the rise of a generation of Indian psychiatrists (Mills, 2001). There was an increased demand for institutional space in the psychiatric system because of the sudden need to deal with the patients among Indian soldiers who had returned from the War. This led to the expansion of existing hospitals. Also, during this period, there was an increase in the community use of mental hospitals by Indians. Two new mental hospitals were opened by the Government of Bihar in Ranchi, Bihar, India, as the climate was considered suitable for the purpose. The first opened in 1918 as a hospital for European patients (now the Central Institute of Psychiatry) and the second was founded in 1925 (now the Ranchi Institute of Neuropsychiatry and Allied Sciences) as a facility for Indians (Sharma & Chadda, 1996). The origins of psychiatric rehabilitation in India can be traced to innovative service programs which were initiated at the Central Institute of Psychiatry (CIP) in 1922, when the Occupational Therapy Unit was inaugurated here (Figs 1 and 2). In the same year, the CIP received affiliation from the University of London to start issuing a Diploma in Psychological Medicine. The CIP was one of the first centers outside Europe to introduce Cardiazol-induced seizure treatment (in 1938) and Electroconvulsive Therapy (ECT) (in 1943) ushering in a new era for the treatment of severe mental disorders (Figs 3 and 4). ECT was administered using a machine made by Wilcox and Fig. 1: A form mentioning the progress of a patient in the occupational therapy department at Central Institute of Psychiatry in 1929 (Courtesy: CIP archives) Fig. 2: An old undated picture of the occupational therapy department showing patients engaged in different activities (Courtesy: CIP archives)
  • 66. 30  Section 2: Historical Concepts and Evolution Fig. 3: A record of the cardiazol induced shock therapy being used at Central Institute of Psychiatry in 1938 (Courtesy: CIP archives) Fig. 5: An Ediswan ECT machine (Courtesy: CIP archives) Fig. 4: A report of a patient having received ECT in 1943 at the Central Institute of Psychiatry (Courtesy: CIP archives) for Mental Hygiene, which was affiliated to the National Council for Mental Hygiene in Great Britain (Berkeley-Hill, 1924; Berkeley-Hill, 1939). JE Dhunjibhoy was appointed as the Superintendent of the Ranchi Indian Mental Hospital in 1925. He pioneered the use of Sulfosin therapy, developed by Knud Schroeder in Denmark in 1930, just one year after its introduction (Ernst, 2010). In 1938, he also introduced Cardiazol-induced seizure treatment for schizophrenia which he learnt from Ladislaus von Meduna. Dhunjibhoy had experimented with another controversial treatment in schizophrenia, sub-shock nitrogen gas inhalation in excited patients (Ernst, 2010). There were many other treatments that Dhunjibhoy introduced for the first time, such as “glandular therapy” (1928), Soneryl as a hypnotic in excitement and insomnia (1930), and Benzedrine as a stimulant in depression (1937) (Ernst, 2010). RB Davis, Medical Superintendent of European Mental Hospital, Ranchi, (now CIP) introduced the EEG into India, conducted the first leucotomy, and first started modified ECT and insulin coma therapy (Davis, 2010) (Figs 6 to 10). Furthermore, this period saw the Indianization of senior positions in the asylums. Such positions started being offered to Indian Medical Officers who had been till then usually restricted to subordinate positions. Young doctors who chose to especialize in psychiatry during this period found their careers were not just limited to asylums, but that they had a role in the mental health units of some of the major general hospitals and in the emerging system of child guidance clinics.
  • 67. Chapter 2: Psychiatry in India: A Historical Perspective  Fig. 6: A 4-channel EEG graph record from the neurophysio­ogy lab of Central l Institute of Psychiatry (Courtesy: CIP archives) Girindra Shekhar Bose founded the Indian Psychoanalytical Association in 1922 in Calcutta, and with the help of Ernst Jones, secured its affiliation with the International Psychoanalytic Association (Nizamie & Goyal, 2010). The first psychiatric outpatient service, precursor to the present-day general hospital psychiatric units (GHPUs), was set-up at the Carmichael Medical College (now RG Kar Medical College), Kolkata in 1933 by GS Bose. The second such unit was organized by KR Masani at the 31 Fig. 7: An EEG report from the neurophysiology lab of the Central Institute of Psychiatry in 1953 (Courtesy: CIP archives) JJ Hospital, Mumbai in 1938 (Sen & Bose, 1931). In 1939, SM Ghoshal started a weekly psychiatric clinic at the Prince of Wales Medical College, Patna (now Patna Medical College Hospital), Bihar, India, at the suggestion of JE Dhunjibhoy, who was a lecturer in mental diseases at Patna University from 1925 (Chaudhury, 2010). At the Calcutta Medical College, the Department of Neurology and Psychiatry was established by an order of the Government of Bengal in 1939.
  • 68. 32  Section II: Historical Concepts and Evolution Fig. 8: An EEG being recorded with photic stimulation at the neurophysiology lab of Central Institute of Psychiatry (Courtesy: CIP archives) Fig. 9: A record of Prefrontal leucotomy done in 1947 at the Central Institute of Psychiatry (Courtesy: CIP archives) During this period, the seminal paper by Gananath Sen and Karthick Chander Bose, which reported on the use of an alkaloid extract from the Rauwolfia serpentina plant in the treatment of hypertension and insanity with violent maniacal symptoms (Sen & Bose, 1931), paved the way for the modern era of psychopharmacology. Siddiqui and Siddiqui (Siddiqui & Siddiqui, 1931; Siddiqui & Siddiqui, 1932; Siddiqui & Siddiqui, 1935) were two chemists working at Aligarh Muslim University who succeeded in extracting several compounds, such as ajmaline, ajmaciline and serpentine Fig. 10: A view of the Operation Theater used for Psycho­surgeries at the Central Institute of Psychiatry (Courtesy: CIP archives) from the Rauwolfia serpentina plant. Chopra and colleagues (1933), in a series of papers, demonstrated its use in both hypertension and insanity. A report in The New York Times on RA Hakim, from Ahmedabad, Gujarat, India, who was using inexpensive Ayurvedic medicines in the treatment of mental illnesses, drew attention to the use of indigenous medicines during that period (Jain & Murthy, 2009). Most of the asylums in British India were in a poor condition, as was brought out vividly in the monumental Bhore Committee Report in 1946, based on a landmark survey of 17 mental hospitals by Col M Taylor (Nizamie & Goyal, 2010). Col Taylor was the medical superintendent of the European Mental Hospital, Ranchi, Bihar, India. The survey revealed that the majority of the mental hospitals were out of date and designed more for custody than for care. The only “island of excellence” was the European Mental Hospital, Ranchi, Bihar, India. This was mainly due to its exclusive character: it was meant almost entirely for European patients and was staffed by British Army doctors. The mentally ill from the general population were taken care of by the local communities and by traditional Ayurveda and Unani doctors. There are reports of use of Ayurveda and Siddha systems of medicine by John Dhairyam along with other treatment at Government Mental Hospital, Kilpauk, Madras, India (Somasundaram, 2010). PSYCHIATRY IN POSTINDEPENDENCE INDIA—THE COLONIAL HANGOVER AND DEVELOPMENT OF MODERN PSYCHIATRY From Independence in 1947, Indian Mental Health was dominated until very recently by the patterns established in the colonial period. At the time of Independence, India had about 17 institutions for the mentally ill, 10 of them
  • 69. Chapter 2: Psychiatry in India: A Historical Perspective  33 having been built prior to the twentieth century. The Bhore Committee, 1946, recommended the creation of a primary care infrastructure to cater to the needs of the vast rural population, improvement in the existing mental hospitals and a phased increase in the number of mental institutions. In keeping with Western models of that era, the mental health infrastructure was exclusively asylum-based and custodial in its outlook, which imposed limits on the number of patients who could receive services. Mental Health Care Three distinct phases can be demarcated in the development of mental health care in independent India. In the initial phase, the establishment and remodeling of mental health institutions took place. On the recommendation of the Bhore committee, the All India Institute Mental Health was set-up in 1954 in Banglore (Bengaluru). This became the National Institute of Mental Health and Neurosciences (NIMHANS) in 1974. In 1978-79, the first Primary Health Care training program was started (Parkar et al., 2001). The Mudaliar Committee (Mudaliar, 1962) also noted the serious shortage of trained mental health manpower and recommended the development of the Hospital for Mental Diseases, Ranchi (now CIP), Bihar, India into a full-fledged training institute and urged that ‘ultimately each region, if not each state should become self-sufficient in the matter of training its total requirement of mental health personnel’. The Shanta Vashisht Committee (a subcommittee of the Mental Health Advisory Committee, Ministry of Health, Government of India, 1966) identified the need to offer advanced training for students of social work in mental health. Based on the recommendations of this committee, training in psychiatric social work was initiated at NIMHANS, Bangalore, Karnataka, India. CIP, Ranchi, started the Department of Clinical Psychology in 1949, which happens to be the first clinical psychology laboratory in the country (Nizamie et al., 2008) (Fig. 11). CIP also took initiatives in community mental health services when one of the earliest rural mental health clinics was started at Mandar, near Ranchi in 1967. An industrial psychiatric unit was started at the Heavy Engineering Corporation at Hatia, Ranchi in 1973 (Nizamie et al., 2008). In 1970, CIP, Ranchi, started a course in psychiatric social work. In the second phase, which started in the 1950s, there was a rapid growth in the number of General Hospital Psychiatry Units (GHPUs) in India (Wig, 1978). In 1957, Dutta Ray started a psychiatric outpatient service at Irwin Hospital (now GB Pant Hospital), in New Delhi. In 1958, NN Wig started a GHPU at Medical College, Lucknow, Uttar Pradesh, India with both in-patient and out-patient psychiatric Fig. 11: A Rorschach report from the psychology laboratory of the Central Institute of Psychiatry in 1953 (Courtesy: CIP archives) services and a teaching program as part of the Department of Medicine. Neki started a similar unit at the Medical College, Amritsar a few months later. In 1966, SD Sharma started a GHPU at the Medical College, Baroda (Vadodara), Gujarat, India. In the decades since then, this movement has gained momentum and most of the teaching hospitals and major general hospitals in the private or government sectors now have psychiatric services available. GHPUs provided greater public acceptance of psychiatric services because of, first, a smaller degree of stigma than that associated with mental hospitals and, second, because they were situated in the community, greater accessibility. Admissions were largely
  • 70. 34  Section II: Historical Concepts and Evolution voluntary, of a shorter duration, and family members could stay with the patients during the period of admission. Most had associated outpatient services and the liaison with other departments was greater. Although the colonial asylum system persisted, a parallel provision for care had developed in the medical colleges. Furthermore, voluntary organizations initiated activities in major urban areas (Ganju, 2000). The third-phase was marked by the establishment of the National Mental Health Programme (NMHP), which led to the decentralization of the mental health care to the primary health centers. As the Government of India embarked on an ambitious National Health Policy that envisioned “Health for All by the year 2000,” early drafts of the NMHP were formulated in February 1981 at Lucknow. The final draft was submitted to the Central Council of Health and Family Welfare during 18–20 Au­­ gust 1982 for its adoption as the NMHP for India. The major recommendations were that: (a) mental health must form an integral part of the total health programme and, as such, should be included in all national policies and programmes in the field of health, education, and social welfare; and (b) strengthening the mental health compo­ nent in the curricula of various levels of health profes­ sionals (NMHP, 1982). The major achievement during the Seventh Five-Year Plan was the creation of awareness about mental health through workshops for planners, mental health professionals and key administrators and paramedical personnel in different parts of the country, and the development of support material for NMHP at CIP, Ranchi; NIMHANS, Bangalore; and PGI, Chandigarh. The Ranchi Model, developed at CIP, was one of the earliest and focused on training the trainers (Nizamie et al., 1992). Thereafter, other models followed with the aim of integration of mental health with primary health care, beginning with the Raipur Rani in the North and Sakalawara in South India. The initial years of experience with the NMHP led to the development of more pragmatic approaches in the form of the District Mental Health Programme (DMHP). In 1984, NIMHANS launched a pilot model program in the Bellary district to implement the NMHP at a district level in collaboration with the district administration and the Director of Health Services, Karnataka. Under this program, the personnel of the Primary Health Centres (PHCs) in the district were trained to recognize and manage psychiatric patients in the community, thus establishing the practicability of a district mental health team initiating mental health care. Following the implementation of this module and its recommendation by the Central Council of Health and Family Welfare in October 1995, it was resolved, at the workshop of Health Administrators held in February 1996, to launch the DMHP with a community-based approach in four districts, one each in the States of Andhra Pradesh, Assam, Rajasthan and Tamil Nadu in 1996-97 on a pilot basis under the NMHP. Nevertheless, there were serious deficiencies in the implementation of the NMHP. Therefore, a re-strategized NMHP, which incorporated the five basic components of the National Mental Health Policy (2001), was launched at a National Workshop held at Vigyan Bhawan, New Delhi on 22 October 2003 (Haq et al., 2008). Recently, it has been proposed that the NMHP should be integrated with the National Rural Health Mission (NRHM) and the National Urban Health Mission (NUHM), to reach mentally ill patients in both rural and urban areas. The involvement of families in the care of patients started with the concept of cottages constructed within hospital premises in the 1920s, where patients would be admitted along with the family members, at CIP, Ranchi—a practice which continues at the institute till date (Nizamie et al., 2008). A more comprehensive and large-scale involvement of families in the care of the patients was started by Dr Vidya Sagar at the Amritsar Mental Hospital (Vidyasagar, 1971) and at the Mental Health Centre, Christian Medical College (CMC), Vellore (Chacko, 1967; Verghese, 1971). This approach ensured a faster recovery and the aftercare of psychotic patients and facilitated their acceptance within and returns to their community. In the 1960s at NIMHANS, these efforts led to establishment of the family ward (Narayanan & Reddy, 1968). Development of Psychiatric Research Research in psychiatry started rolling with commencement of the publication of the first journal dedicated to mental health, the Indian Journal of Neurology and Psychiatry in 1949. Psychiatric research conducted in the initial three decades in India after independence has two fairly clear-cut phases, as reviewed by Wig and Akhtar (1975). In early years (1947 to 1960), it was a slow phase of growth due to the lack of researchers and of clarity in the issues involved. Most of the research was psychoanalytically oriented and theoretical in nature. Psychological interpretations focusing on individual dysfunction formed the central themes. There was scant literature on phenomenology and epidemiology which was a major handicap in planning of services. During the second phase of psychiatric research (1960–1972), research publications became broader in their orientation and moved from individual psychopathology to
  • 71. Chapter 2: Psychiatry in India: A Historical Perspective  the interface between the individual and society and group behavior. The cross-fertilization of ideas between sociology, psychology and psychiatry was very beneficial from a public health perspective, thus sowing the seeds for communityoriented research and programme planning. The major epidemiological studies of the early days (Ganguli, 1968; Gopinath, 1968; Sethi, 1967; Surya et al., 1964) helped to establish the magnitude and nature of mental health problems in the community. Dubey (1970) carried out studies on both rural and urban populations and covered a much larger population than the previous studies. The third phase may be noted in the era after 1975, which shifted to more specific and focused work on several specific disorders, standardization of methodologies and development of interventions. Mental Health Legislation The first draft of the Mental Health Act (MHA) which subsequently became the Mental Health Act of India (1987) was written at Ranchi in 1949 by RB Davis, then Medical Superintendent of CIP, SA Hasib, from Indian Mental Hospital (now RINPAS), Ranchi and J Roy, from Mental Hospital, Nagpur, Maharashtra, India (Nizamie et al., 2008). The Mental Health Act was enacted in 1987 and superseded the draconian Lunacy Act of 1912. It was implemented in all States and Union Territories of India only in 1993. The MHA, 1987, recognizes the crucial role of the treatment and care of mentally ill persons, safeguards the interest of the mentally ill, protects their human rights and calls for humanitarian consideration in dealing with the mentally ill. It also has guidelines for the establishment and maintenance of psychiatric hospitals and nursing homes. Later on 29th December, 1990, State Mental Health Rules were framed that would come into force in a state on the date of commencement of the MHA, 1987, in that State. Under the State Mental Health Rules, each state had to constitute a State Mental Health Authority that would act as a licensing body for the establishment of mental health care centres to ensure minimum standards of care of the mentally ill (Anthony, 2000). The Narcotic Drugs and Psychotropic Substances Act (NDPSA), Act 61 of 1985 as amended up to Act 2 of 1989, along with Narcotic Drugs and Psychotropic Substances Rules, 1985, was enacted on 16th September, 1985. It is an Act to consolidate and amend the laws relating to narcotic drugs, to make stringent provisions for the control and regulation of operations relating to narcotic drugs and psychotropic substances to provide for the forfeiture of property derived from, or used in illicit traffic in narcotic drugs and psychotropic substances and to implement the provisions of the international conventions on narcotic 35 drugs and psychotropic substances. The Act came into force on 14th November 1985. It repealed the Opium Act of 1857, the Opium Act of 1978 and the Dangerous Drugs Act of 1930 (NDPS Act, 1985). On 22nd December 1995, the Persons with Disabilities (Equal Opportunities and Full Participation) Act, 1995 was introduced for the benefit of disabled persons. The act seeks to place the disabled person on a par with other sections of the society in respect to jobs, education and vocational training. The main purpose of the Act is to define the responsibilities of the Central and State Governments with regard to the services for disabled individuals so as to make full contribution in accordance with their disability conditions. Blindness, low vision, leprosy, hearing impairment, locomotor disability, mental illness, and mental retardation are the seven disability conditions covered under the Act (PwD Act, 1995). As a measure of social security, the Government of India has created a National Trust for those families who have children with mental retardation, cerebral palsy, autism and multiple disabilities and are unable to look after them. The National Trust for Welfare of Persons with (Autism, Cerebral Palsy, Mental Retardation and Multiple Disabilities) Act (1999) is for single-parent family or for aging parents or where the parents have died and the siblings are unable to look after the disabled individual. The National Trust plans to take over guardianship rights as well as to receive properties bequeathed by the family. This Act provides for the constitution of a body at the national level for the welfare of the disabled. It received the assent of the President of India on the 30th December 1999. Manpower Development in Psychiatry and Allied Disciplines On the recommendation of the Bhore Committee, the All India Institute of Mental Health (now NIMHANS) was established by the Government of India. A formal training program for clinical psychologists (Diploma in Medical Psychology) also commenced in the year 1955 and was later converted into an MPhil in Medical and Social Psychology in 1978. In keeping with the recommendations of the Mudaliar Committee, CIP, Ranchi, started training clinical psychologists in 1962. The BM Institute of Mental Health, Ahmedabad, Gujarat, India began training clinical psychologists in 1972. Later in 1966, the Shanta Vashisht Committee recommended advanced training for students of social work in mental health, thus paving way for training programs in psychiatric social work, initially started at NIMHANS, Bangalore, Karnataka, India, and, in 1970,
  • 72. 36  Section II: Historical Concepts and Evolution Fig. 12: Participants at the Annual National Conference of the Indian Psychiatric Society from 31st Jan to 3rd Feb 1971 at Hyderabad (Courtesy: CIP archives) at CIP, Ranchi. Psychiatric nursing in India had its birth at CIP, initially in the form of short training courses of three to six months’ duration,. These were recognized by the Royal Medical Psychological Association. In the postindependence period, the first organized course in psychiatric nursing (Diploma in Psychiatric Nursing, DPN) started at the All India Institute of Mental Health (now, NIMHANS, Bengaluru) in 1956 followed by similar courses at CIP, Ranchi and Lokpriya Gopinath Bordoloi Regional Institute of Mental Health (LGBRIMH), Tezpur, Assam. Development of Professional Bodies in Mental Health The Indian Psychiatric Society (IPS), which is among the oldest mental health professional bodies in the country, came into being in 1947, and the first Annual Conference of the society was held in 1948 (Fig. 12). The Indian Journal of Neurology and Psychiatry came into being in 1949 and, during the eleventh conference of the IPS, the journal assumed its present name The Indian Journal of Psychiatry. The Indian Association of Clinical Psychologists was established in 1968. Multi-prong Approach to Psychiatric Care: Integration of Western and Traditional Medicine The Indian Systems of Medicine have age-old acceptance in the community in India and, in many places, they form the first line of treatment for common mental disorders. Most of the psychiatric patients visit traditional healers before seeking allopathic treatment. Therefore, in March 1995, the Department of Indian Systems of Medicines and Homoeopathy (ISM&H) was created under the Ministry of Health and Family Welfare, Government of India. It was renamed the Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy (AYUSH) in November 2003. Its inception, there has been continuous development in education in these indigenous systems of medicine. Recently, a course has been started in psychiatry for specialist AYUSH practitioners aiming at the development of manpower in this area (AYUSH in India, 2007). Further, NRHM seeks to revitalize local health traditions and mainstream AYUSH, to strengthen the public health system at all levels using traditional systems of medicine. Although such efforts in development of AYUSH are praiseworthy, there has been little groundwork to integrate both allopathic and traditional medical systems in the care of mentally ill. HOW FAR WE HAVE COME? Apart from being an intellectual exercise, the study of history holds important lessons for the future. The history of modern psychiatry in India reveals a gap in the conceptualization of mental health, illness and services between mental health professionals trained mainly on the western medical model and the mental health service consumers who come from varied socioreligio-cultural backgrounds. This leads to poor utilization of services and results in difficult situations. In a glaring example, in 2001, at Erwadi in the Ramanathapuram district of Tamil Nadu, India, 26 mentally ill patients who had been chained died in a tragic fire accident. It is interesting to note that DMHP in its current form was implemented in this district, but such a tragedy could not be prevented. The NMHP, which was formulated almost three decades ago, has been a failure due to the lack of basic health care infrastructure and trained manpower. It appears that the decision to integrate NMHP with primary health care is premature. Similarly, the existing mental health legislation in India has the colonial tinge which aims at the seclusion of mentally ill rather than the application of modern methods of care. Also, the adoption of multiple indigenous methods of care for mentally ill (AYUSH) is ill regulated, resulting in substandard care. Hence, there is a need to understand the historical roots of the beliefs and practices of the mental health service consumers on one hand and an adaptation of the western medical model to the local mores and values rather than an uncritical and dogmatic application. A more
  • 73. Chapter 2: Psychiatry in India: A Historical Perspective  historically informed training in psychiatry coupled with research into the history of psychiatry from different perspectives is needed to understand contemporary psychiatry in India and to shape it towards a better tomorrow. People having strikingly similar histories may emerge from them in strikingly different ways. (Isaiah Berlin) Bibliography 1. Antony JT. A decade with the Mental Health Act, 1987. Indian Journal of Psychiatry 2000;42:347-355. 2. AYUSH in India. Planning and evaluation cell. Department of Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homoeopathy (AYUSH). Ministry of Health & Family Welfare, Government of India. Available at: http://indianmedicine.; 2007. 3. Berkeley-Hill O. The Ranchi European mental hospital. Journal of Mental Sciences 1924:LXX:38-45. 4. Berkeley-Hill O. All Too Human: An Unconventional Autobiography. London. Peter Davies, 1939. 5. Bhugra D. 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  • 75. 3 General Hospital Psychiatry Prakash B Behere, Manik C Bhise INTRODUCTION Psychiatry, as a branch of medicine, has evolved over time in different phases. In the beginning, the care of the mentally ill was mainly restricted to mental asylums. The Indian scenario was also similar to the rest of the world. Now, psychiatric care has moved out from large mental hospitals to separate units in general hospitals. This is a welcome change for psychiatry as a specialty and for the community as well. With the integrated care model of health adopted by the Government of India, the best care to the mentally ill can be provided by building new units and upgrading old units of psychiatry in general hospitals. These offer numerous advantages over traditional mental hospitals. They are more accessible, more easily approachable and, above all, less associated with stigma. Thus, psychiatry is integrated with the general health system. THE CONCEPT OF GENERAL HOSPITAL PSYCHIATRY UNITS India is known for its ancient culture. We have known about the interplay of mind and body since antiquity in India. The concept of general hospital psychiatry units (GHPUs) probably originated from a shortage of sufficient funds for the creation of new lunatic asylums. The general hospital psychiatry unit (GHPU) is a broad term that implies the provision of psychiatric services alongside many other specialty services under one roof in general hospitals. These new units need very few resources and less manpower to provide health care. They are situated right in the community and seem to be more easily approachable to patients (Behere and Behere, 2000). Families can frequently visit and even stay with the patients. There are not many legal restrictions on admission and treatment. Ambulatory treatment on an outpatient basis is also available. Proximity to medical facilities ensures thorough physical investigation and early detection of physical problems (Fig. 1). All this has brought new hope for psychiatric patients. People are reaching psychiatrists much earlier than they used to reach the mental hospitals. Medical colleagues are more tolerant and supportive to psychiatry. The stigma of psychiatric treatment is being reduced. The inclusion of these units in medical colleges along with other general hospital specialties has had a great impact on undergraduate medical training. Medical education is now receiving more exposure to this branch of medicine and this leads to the building up of concepts as well as interest among students. More and more bright students are opting for this branch for specialization. Psychiatry is poorly represented in medical education, hence the importance of psychiatric training in medical education needs to be highlighted (Behere et al., 1990). Psychiatric practices in general hospitals can take many forms. The psychiatrist as a specialist in the general hospital treats the mentally ill as do other specialists for other medical illnesses. Another form of psychiatric practice in general hospitals is psychosomatic medicine. It comes from the idea Fig. 1: Concept of general hospital psychiatry unit (GHPU)
  • 76. 40  Section II: Historical Concepts and Evolution that psychological factors are important in the etiology and course of many physical disorders (Mayou, 2008). This was an influential concept especially in the United States and German-speaking countries in the early twentieth century. Another method for the practice of psychiatry in GHPUs is consultation liaison psychiatry. Here, a psychiatrist is invited to visit and assist in the treatment of patients admitted to wards for physical illness. Nowadays, this has emerged as a subspecialty within psychiatry in the developed world, especially in the United States and the UK. There are different models of consultation, including patient-oriented consultation, crisis-oriented therapeutic consultation, consultee-oriented consultation focusing on the consultee’s problems with a given patient, and situation-oriented consultation concerned with the interaction between the patient and the clinical team, and expanded psychiatric consultation. HISTORY India has a long-standing history of medical sciences. The Charak Samhita (200 BC) discusses bhoot vidya and other mental illness and their treatments along with descriptions of other systemic disorders. In the West, the earliest inpatient ward for mentally ill in a general hospital was probably opened by Rhazes (865–925 AD), also known as the Persian Galen, the physician in chief at Baghdad hospital. Due to a lack of any successful treatment, this unit was discontinued and mentally ill patients were kept in asylums. In 1284, the Kalaoon Hospital in Cairo had a separate section for the mentally ill (Okasha, 2001). In the UK, there were some general hospitals with separate sections for mentally ill patients in the eighteenth and nineteenth centuries (Mayou, 1987). The first general hospital in Britain to admit lunatics to a special ward was Guy’s Hospital in 1728. In 1902, the Albany Hospital in New York started the first liaison psychiatry service. As early as 1929, Henry suggested guidelines to the consultant psychiatrists who wished to work in collaboration with physicians. He recommended straightforward and jargon-free communication based on careful observation. We might speculate that the birth of GHPUs in India was due to a lack of funds available to open up new psychiatric asylums. In 1933, Girindra Sekhar Bose (1886–1959) opened a psychiatric unit in a general hospital (RG Kar Medical College, Calcutta) for first time in India. This was followed by the opening of more psychiatric units in general hospitals, for example, at the JJ Hospital, Bombay by Dr KK Masani in 1938, at the KEM Hospital also in Bombay by NS Vahiya (1947), and with the creation of a separate unit in the Lucknow Medical College in North India in 1958. By 1970, there were over 90 such units in general hospitals all over India. By 1982, there were 83 departments of psychiatry in 106 medical colleges in India. At that time, there was no legal provision for the opening of inpatient wards in other general hospitals. This was overcome by the Mental Health Act, 1987. Initially, medical professionals from other specialties reacted adversely to the admission of mentally ill patients in general hospitals, but they soon realized the benefits of the availability of psychiatrists for consultation, teaching and research work. It was recognized that there was a significant number of cases of organic brain syndromes, psychological overlays of existing medical illness and troublesome neurotics in medical, surgical outpatient and inpatient departments. When one looks at the reasons for such a rapid spread of GHPUs in India, the effect of the psychoanalysis movement in the West comes first. Other probable reasons were the availability of a new pool of psychiatrists trained at the All India Institute of Mental Health, Bangalore (later renamed the National Institute of Mental Health and Neurosciences), the development of new antipsychotic and antidepressant drugs in the 1950s, as well as financial considerations, as the Government could not afford to open new mental hospitals (Wig and Avasthi, 2004). Patients also responded favorably to this development. The stigma associated with mental hospitals was no longer a problem for patients. Follow-up treatment was also more accessible. Most of all, they got mental health services at their doorstep. Khandelwal et al., (1981) studied patients at a walkin clinic and found that 71 percent were received immediate help, 3.48 percent underwent detailed evaluation at the main clinic on same day, and 0.8 percent needed admission while 14.8 percent were referred to other outpatient departments. The reasons for emergency referrals to psychiatry units from other specialties have been extensively studied in India. Kelkar et al., (1982) found that in a teaching hospital 50 percent of the referrals were for somatic symptoms, altered sensorium, attempted suicide and excitement. Wig and Shah (1973) found a majority of referrals are for differential diagnosis between functional and organic illnesses in a general hospital setting. Western GHPUs differ from Indian ones in terms of patient overload and the availability of services. In the USA or Europe, there is an extensive networking of psychiatric hospitals. Any acutely disturbed patient is immediately transferred to the nearest psychiatric care unit. This is not possible in India. The majority of acutely ill patients are to be managed in psychiatric units in general hospitals because of a shortage of mental hospitals nearby. INTEGRATING PSYCHIATRY WITH GENERAL HEALTH CARE SYSTEM IN INDIA The integrated model of health care has been accepted in India for a long time. The provision of comprehensive health care through the available three-tier system of infrastructure
  • 77. Chapter 3: General Hospital Psychiatry  to all citizens has been an essential part of health care policies so far. Specialty services are provided by the Government at civil hospitals (District Hospitals) and at tertiary care centers such as medical colleges. With the implementation of the National Rural Health Mission (NRHM), a flagship program of the central government, it is expected to provide specialty psychiatry services at all district hospitals. Local authorities can engage specialists on a contract basis where full-time consultants are not available. This could change the face of psychiatric services in India as there is still a dearth of psychiatrists at many places all over the country. Indian culture has been more accepting of psychiatric illness. Patients in our country are brought by their relatives who stay with them in hospitals for the care of the ill. This scenario is similar to other specialties as well. In psychiatry, this gives the added advantage of being able to study interaction patterns among various caregivers and family members. For developing countries like India, the integration of psychiatric services in general health care is very cost-effective. The opening of smaller units situated at shorter distances will reduce the burden on the patient. Alternately, the doubling of drugs purchased and dispensing of drugs for longer periods will reduce the financial burden on patients. These smaller units can be the units in general hospitals that are near the patient’s home. The integration of psychiatry units in general hospitals in India has redefined the role of the psychiatrist from merely treating the mentally ill to providing positive mental health to people in the community (Shah, 1997). Other added responsibilities in these units widen the scope of comprehensive care by the psychiatrist. ROLES OF General Hospital Psychiatry Units in INDIA General Hospital Psychiatry Units (GHPUs) have diverse roles to play in the Indian context. These can be divided into various sub-headings listed below: Services Provided at GHPUs Psychiatry units in general hospitals provide a wide range of services. These include: Early Detection and Treatment of Psychiatric Problems Psychiatric illnesses are common in community settings as well as in general hospital settings. In India, the treatment of these ailments is easily available through psychiatry units in general hospitals. These units cater to a large section of the population and are usually the first point of contact with a specialist for patients in the community. Psychiatrists 41 in GHPUs have a dual role in identification and treatment of mental illness among people in the community, as well as in the detection and treatment of psychiatric symptoms in patients suffering from medical illness. The early detection of mental illness in a community setting can be achieved through the appropriate training of supporting staff and also of primary care workers. In hospital settings, psychiatrists are usually called up to treat psychiatric symptoms that can be associated with an array of medical illnesses. Early Detection and Treatment of Medical Problems Those with mental illness are at increased risk of suffering from various medical illnesses. Medical complications can arise due to underlying illness per se, as the side effects of treatment (e.g. metabolic complications with antipsychotics, hyponatremia due to antidepressants) or they can be due to independent factors such as infections. Psychiatrists in these units should always be careful to evaluate patients for any concomitant medical illnesses. Once identified these patients are to be referred to the specialist units. The advantage of GHPUs is the easy availability of expert opinion and care from other specialties to the psychiatric patients. Linkage with Primary Health Care System As new GHPUs were being set up nationwide, Dr NN Wig said, psychiatry had broken the walls of the mental hospitals but was yet to break the mental walls of hospital-based psychiatry and become a larger community-based mental health movement (Wig, 1978). GHPUs play a vital role in creating a link with and training of medical personnel in the primary health care system for the appropriate management of mental illness. The Indian health system ultimately delivers most of its services at the primary health care level. Linking up with this level means that the psychiatric referral system is set up so that mentally ill patients in the community are identified and referred for further treatment at the earliest stage. Once they are diagnosed and prescribed a particular treatment, patients can be sent back to the primary care level so that their treatment is continued in the community under the supervision of these professionals. This could be a very cost-effective as well as highly efficient psychiatric care model for a developing country like India. Ambulatory Treatment Facilities The concept of ambulatory care in medical practice is used for many illnesses. Due to a limited number of psychiatrists and also a limited number of psychiatric care units, many parts of the country are lacking in mental health care. Ambulatory clinics can be an effective way of providing mental
  • 78. 42  Section II: Historical Concepts and Evolution health care in these areas. This involves conducting specialist clinics at primary health care centers and also at the level of the village. This can play the dual role of providing care and knowledge as well as reducing the stigma attached to mental illness. This is a method that takes mental health services right to the doorstep of the patient. Involvement of Family Members in Delivery of Mental Health Care Family members play a crucial role in the treatment of the mentally ill. In contrast with the West, we have very strong family support for the mentally ill. Most of these patients are cared for by family members. Health care providers in GHPUs have many opportunities to interact with member of the family. This is an advantage GHPUs have compared to large mental asylums where relatives are not allowed to stay with patients. Family members need education about psychological illness. They should be well informed about the nature and course of the illness as well as of the need for good compliance in treatment. Decisions about treatment should be shared choices between the therapist, the patient and family members. They should be motivated to follow-up with the patients regularly and also to keep a close watch on adherence to treatment in the community. This can prevent frequent relapses which is a common course in mental illnesses. Preventive and Rehabilitative Services a single roof facilitates interdepartmental coordination, the discussion of new research topics and also generates valuable documented data in other departments for patients with psychiatric symptoms in different specialties. This research is a valuable contribution to understand the biological basis of psychiatric symptoms. It also expands the knowledge and scope of psychiatry beyond its usual boundaries. As can be inferred from contributions listed under different sections in this chapter, a large body of research is available from interaction with different branches of medicine. Biological Underpinning of Psychiatric Disorders Psychiatry began with observations and systematic studies of various behavioral disturbances centuries ago. Now, however, there is a large body of accumulated evidence for the biological basis of psychiatric illnesses. The current understanding of mental illness is it can arise from disturbances in various parts of brain. For instance, Korsakoff ’s psychosis is now attributed to degeneration of mamillary bodies. Similarly schizophrenic patients consistently show abnormalities in the structure and functioning of different parts of the brain. Now we have a biological basis for most psychiatric illnesses. Receptor studies and various neural mechanisms underlying different illnesses are being rapidly explored. Most of these biological investigations are carried out in general hospitals where all the research facilities are available under a single roof. Psychiatrists in general hospitals are key players in the prevention of mental illness and the rehabilitation of the mentally ill. They are in direct contact with the community to implement preventive strategies. Important among these are suicide prevention, stress management, the identification of those at risk of mental illness, early detection and treatment of common ailments and the rehabilitation of those recovering from illness. GHPUs provide a unique opportunity to monitor the rehabilitation of patients in the community as these units are usually placed close to the community. Also, the family and other significant people around the patient can be involved in rehabilitation activities. Minor Psychiatric Disorders Research Most of the psychiatry units in general hospitals in India are attached to medical colleges as separate departments of psychiatry. As of 2008, almost 25 percent medical collages did not have a separate psychiatry department. Where they existed, these units provide an opportunity, and sometimes the only opportunity for undergraduate medical students to learn psychiatry. The current medical education curriculum makes it mandatory to undergo 15 days’ training and theory classes for undergraduate courses. A proper training at this Interdepartmental Research Psychiatry is being integrated with other methods of treatment. The alienists and exorcists who practice traditional cures are now an integral part of the research in neural and behavioral sciences. General hospital psychiatry units provide a unique opportunity to do research involving various streams of medical sciences. The availability of all the specialties under GHPUs serve a large population base. Studies on minor psychiatric illnesses and those illnesses included in the research category of current classification systems can best be performed in these units. Diagnoses of minor depressive disorder made in settings of underlying organic illness can be best studied in GHPU settings where a large number of such patients are readily available. Training Training of Undergraduate Medical Students
  • 79. Chapter 3: General Hospital Psychiatry  stage can influence these students in terms of early identification, referral and possible treatment of mental illnesses. Many of these students are now considering psychiatry as a career choice. Jiloha and Parkar (2010) recommended psychiatry training for undergraduates under the Indian Psychiatric Society’s task force for psychiatric education. Postgraduate Students Training Postgraduates pursuing a career in psychiatry are best trained in the settings of general hospitals. Here they receive proper training in the management of not only psychiatric illnesses but also of psychiatric symptoms arising in other medical illnesses. There is a scope for healthy academic discussions with other specialties that would prove useful in increasing the knowledge base of all trainees. Apart from the training of psychiatry residents, these units serve as training centers for postgraduate students of other disciplines, such as neurology, pediatrics, internal medicine, family medicine and other allied branches. Training of Other Mental Health Care Professionals, viz. Nurses, Paramedical Workers The nursing curriculum has psychiatry as a separate subject with two months’ compulsory training in psychiatric units. General hospitals usually have nursing collages attached to them. The training of nurses and paramedical workers in mental health has long-lasting implications in terms of community mental health services and also for the prevention of mental illnesses and the rehabilitation of patients in the community. Psychiatric nursing is also emerging as a specialisation within nursing. Other students that are trained at these units include social workers, psychologists and other allied health care workers. Social Change Reduction of Stigma Mental illness is associated with social stigma for the patients and relatives. The bizarre behavior of some mentally ill individuals, the melodramatic reporting of crime, and negative portrayal by the media all contribute to this stigma. Psychiatrists in general hospitals, being close to the community, have an important role in the reduction of stigma surrounding mental illnesses in the community. As people come to these units, they gain more and more awareness about illnesses and also acquire confidence in the treatment. When a functionally impaired, socially isolated mentally ill person returns to the community having made a good recovery, he becomes an ambassador for psychiatric treatment in the community, 43 bringing more and more patients for treatment from that area. This, over a period, acts to reduce the stigma attached to these illnesses. Acceptance of Patients in Community This is the most important and challenging task for mental health professionals in general hospitals. When in a recovery phase, patients often need support to help them return to the community. Both vocational and social rehabilitation are an important part of the management of this process. Social skills training, supported employment, etc. can be very valuable measures in this regard. INTER RELATIONSHIP BETWEEN PSYCHIATRY AND OTHER SPECIALTIES The following is a discussion of the various studies done in integrated setups where psychiatrists have opportunity to study patients from other disciplines. Medicine and Allied Branches Internal Medicine The psychiatrist has an intimate role to play in the management of general medical patients. Hypochondriacal symptoms are common in medical patients. Prakash and Sethi (1978) found that 47 percent of medical patients had anxiety neurosis. Behere (1981) found that the psychological reaction to leprosy is inversely related to the duration of illness. Various drug compounds can produce psychiatric symptoms. Commonly implicated classes of drugs include anticholinergics, antitubercular, antiepileptics, antimalarials, analgesics, etc. (Behere and Pariahar, 2001). Psychiatric symptoms associated with malaria and antimalarial drugs have been extensively reviewed (Behere, 1989). Psychiatric symptoms in malaria can present themselves with delirium, acute psychosis, obsessive symptoms, neurasthenic symptoms and changes in personality (Behere and Gupta, 2001). Patients admitted to psychiatry wards in general hospitals are also likely to get their diagnosis changed to some medical illness as found by Behere and Ramakrishna (1982) where 0.58 percent of patients with psychiatric symptoms were later found to have brain tumors. The usual sites for brain tumors to produce psychiatric symptoms are the frontal and temporal lobes (Verghese, 1964). Temporal lobe tumors are commonly associated with a change in behavior like automatisms, fugue and twilight states, hypersexuality, etc. Alcohol-related mental health problems are another important area of interface between psychiatry and other specialties. Alcohol-dependent patients can be presented to a psychiatrist for deaddiction services and alcohol induced psychiatric disorders. The same
  • 80. 44  Section II: Historical Concepts and Evolution patient may initially be presented to a physician because of alcohol-related or totally unrelated illnesses, or to a surgeon because of acute abdomen due to pancreatitis or in emergency with upper gastrointestinal bleeding. In any circumstance, a psychiatrist is called upon for help for the treatment of withdrawal symptoms or, once the patient is stable, for deaddiction services. Studies have shown that alcoholic neuropathy is found in higher proportions in subjects who consumed alcohol for less than 10 years. Withdrawal seizures are the second most common neurological presentation of alcohol in general hospitals (Jain et al., 2003). The study of psychological aspects of chronic medical illnesses is a field of potential investigation for future research. Cardiology Cardiovascular disease has significant psychological morbidity for patients. Myocardial Infarction (MI) patients usually undergo more distressful and anxiety-provoking life situations. The distress score worked out reveals that MI patients had suffered more distressing events over a period in their lives (Lal and Ahuja, 1987). Among patients attending cardiac OPDs, a very high prevalence (75%) of diagnosable psychiatric morbidity was reported by Goyal et al., (2001). Depression was the most common (38.67%) diagnosis, but panic disorder was the main diagnosis (38.10%) among purely psychiatric patients. Twenty-one percent of the patients had no organic pathology and had consulted the department of cardiology because of their visceral (cardiac) symptoms. In general hospitals, cardiologic consultation is frequently taken for cardiac complications in psychiatric patients. Shah et al., (1997) reported cardiac abnormalities after ECT. The most common effect was arrhythmias which include atrial premature beats, ventricular premature beats, nodal premature beats, supraventricular tachycardia. Psychotropic medications like antipsychotics (e.g. clozapine) and antidepressants (tricyclic antidepressants) are all associated with cardiac side-effects demanding close monitoring and consultations where needed. The Madras study by Cornelio et al., (1977) revealed that the majority of patients with myocardial infarction had obsessive, aggressive and schizoid traits. Mitral valve prolapse has been associated with anxiety and a hyperadrenergic state (Chatterjee and John, 1982). Lithium therapy is associated with sinus node dysfunction, T-wave inversion and ventricular ectopic beats (Kurpad et al., 1999). Congestive cardiac failure and other valvular heart diseases are associated with the significant psychological trauma to patients of the prospect of chronic disability and of the burden being placed on the family. Also, these patients are in a chronic hypoxic state and are likely to have cognitive impairments. Both these conditions are a common problem in our country. GHPUs in India can contribute a great deal of research in this area. Gastroenterology Excited psychiatric patients are reported to have high gastric acidity as compared to those in a nonexcited state (Garg et al., 1978). There was a decrease in acidity without any specific treatment. Life studies of patients with peptic ulcer disease by Dutta (1978) and Kumar et al., (1996) showed that patients with peptic ulcer disease had a significantly higher number of stressful life events. John Alexander et al., (1993) reported that 69.7 percent of patients with nonulcer dyspepsia have psychiatric morbidity, with anxiety and depression being more common. Neuroticism levels were significantly elevated in patients with nonulcer dyspepsia (NUD) and irritable bowel syndrome (IBS). Higher scores were observed on somatization and hysterical personality traits in cases with IBS (Jain et al., 1995). Rajgopalan et al., (1996) found significant depressive symptoms in almost all patients with irritable bowel syndrome. Forty percent had scores of 16 or more on HAMD. A high prevalence of psychiatric comorbidity is found in patients with functional gastrointestinal disorders (50.7%). Anxiety and depression are the most common associates of these disorders (Jain et al., 2007). Stressful psychosocial conditions have been associated with the development of ulcerative colitis. These events include demands of performance; severe financial pressures, physical illnesses, etc. and act as precipitating factors before the onset of ulcerative colitis (Chakraborty et al., 1983). Psychiatric disorders are frequent in nonulcer dyspepsia. Chronic abdominal pain is a common presentation in gastroenterology practice. Chronic abdominal pain is sometimes a physical manifestation of an underlying depressive disorder. In a study, Kachhawaha et al., (1994) reported dysthymic disorder as the most common psychiatric illness (22%) associated with chronic abdominal pain. Chronic pain may reflect an underlying depressive state in a pain-prone personality. Colonic pseudo-obstruction can be a side effect of tricyclic antidepressants and early diagnosis can avoid inadvertent surgical procedures for its treatment (Ghorpade, 2005). The role of psychological factors in chronic immunological conditions like ulcerative colitis and Crohn’s disease needs further research. Nephrology Chronic renal failure is associated with significant physical restraints and stress. These patients need to undergo weekly dialysis procedures which in themselves are very painful. Restrictions on fluid and food intake along with the financial burden of health care put them under constant stress. Garg et al., (1978) studied 30 patients with chronic renal failure and found that 53 percent of them had definite psychiatric symptoms, 26 percent had depressive reaction. In most of the patients manifesting psychiatric symptoms, an admixture of symptoms was generally observed. Various combinations
  • 81. Chapter 3: General Hospital Psychiatry  of two or more features, like depression, anxiety, delirium and irritability were usually noted. Renal transplantation is associated with psychiatric problems. Procedure causes emotional stresses to the recipient, the donor, the recipient’s family, the donor’s family and even to the staff of the renal unit. The psychological reactions to these stresses include denial and depression, difficulties in self-concept, irritability, hysteria, compulsions and psychotic reactions (Kuruvilla et al., 1976). Pawar et al., (2006) reported a high prevalence of depression (86%) in patients with end-stage renal disease and renal transplantation led to significant improvement in depressive symptoms and cognitive and emotional states of these patients. Renal abnormalities are commonly seen in patients on lithium treatment, warranting frequent monitoring of kidney functions (Kuruvilla et al., 1988). Oncology Cancer is still a grave illness with major implications on the psychology of sufferers. Cancer: the very name is associated with a great degree of distress and suffering. Distress is both psychological and physiological in nature. Various psychosocial interventions have been shown to lead to an improvement in the quality of life of cancer patients (Behere et al., 2000). Psycho-oncology is being rapidly established as subspecialty in psychiatry. There is an independent psycho-oncology unit in Manipal. It is well recognized that endocrine and immune functions are considerably affected by psychological stimuli and thus it is probable that through these mechanisms, psychological processes may influence the course of cancer (Devitt, 1979). The study of psychiatric morbidity in patients with hematological malignancies by Kulhara et al., in 1990 revealed that the depressive reaction is short-lasting and responds favorably to antidepressant therapy. A patient with terminal cancer goes through various emotional stages—denial, anger, bargaining, depression and, finally, acceptance. In the stage of depression, one might experience hopelessness and fleeting suicidal thoughts. A cornerstone of the management of depression in cancer patients is consistent emotional support by the therapist. The choice of antidepressant medications in the treatment of terminally ill patients must be guided by the particular risk versus benefit variable of the individual case and pharmacological agent (Chaturvedi and Chandra, 1998). Tricyclic antidepressants are most commonly used in the treatment of depression in cancer patients (Singh et al., 2000). Reactions to cancer may be dependent on such physical and psychological variables as pain, awareness of the diagnosis, understanding of the meaning of cancer in terms of its course, prognosis and outcome, social support, previous coping style and financial standing. 45 In developing countries, breast cancer is often detected in advanced stages (T3 and T4) which are usually managed with surgery and adjunctive chemotherapy. This duly interferes with general health-related parameters and the social life of patients. As compared to Western data, Indian women with breast cancer were found to have poor quality of life parameters (Pandey et al., 2000). Most frequently employed coping strategies by women suffering from malignant breast cancer are the acceptance of a gloomy prognosis and mirroring a fatalistic attitude (Roy et al., 1983). The site of illness and disability as a result of the illness might affect the mood of the patient. Terminally ill cancer patients were examined for presence of suicide ideation and death wish by Latha and Bhat (2005). Most patients (79.7%) denied having suicidal thoughts or wishing for an early death; only 9.2 percent had severe suicidal ideation. Four percent with severe suicidal ideation had a past history of major depression. Factors such as the presence of pain, awareness of the diagnosis and understanding of the illness contributed to depressive mood states. Authors concluded that suicidal ideation and a desire for death appear to be linked exclusively to the presence of a mental disorder. In addition, poor pain control, and awareness of the diagnosis may also contribute to suicidal ideation. Mahapatro and Parkar (2005) studied the various concerns of mastectomized and lumpectomized (breast-conserved) patients, the coping mechanisms employed and the resolution of concerns in them. They concluded that concern regarding sexual role and performance was resolved to a lesser extent in the mastectomized group. Specific psychological intervention is necessary to enhance coping strategies with regard to concerns of body image, and sexual role and performance. Indian clinicians have recognized role of psychosocial factors since a long time, however, active research and interventions have been pursued only over the last decade or so (Chaturvedi et al., 1993; Chaturvedi and Vyas, 1993). Rao et al., (1992) studied the psychosocial characteristics of children with leukemia, and concluded that, conduct disorder, anxiety disorders, depression and psychotic symptoms were more common in leukemic children as compared to nonleukemic medically ill children. Antidepressants can be safely and effectively used in palliative care for terminally ill cancer patients (Chaturvedi and Chandra, 1996). Palliative care is the comprehensive care of patients at the end of their lives. Apart from depression, these patients may be helped by planned psychological interventions. Sharma et al., (2007) found a significant relationship between quality of life and psychosocial factors in patients with colorectal cancer. They recommended the use of comprehensive psychosocial evaluation of these patients. Among patients
  • 82. 46  Section II: Historical Concepts and Evolution with colorectal cancer who underwent surgery, extroversion as a personality trait was found to be associated with short postoperative length of stay (Sharma et al., 2008). Considering the large number of patients needing palliative care in India, studies evaluating the efficacy and cost-effectiveness of psychological interventions, various approaches to reduce the cost, etc. are the need of the hour. Dermatology Dermatitis artefacta is a psychocutaneous disorder in which the skin is the target of self-inflicted injury. Patients intentionally produce lesions to assume the sick role and typically deny the self-inflicted nature of the disorder. Here, the patient creates skin lesions to satisfy an internal psychological need, usually a need to be taken care of. The prevalence is about 0.3 percent among dermatology patients with the highest frequency during adolescence and young adulthood (Tamakuwala et al., 2005). Srivastava et al., (1977) studied personality traits in patients with neurodermatitis. These patients were disturbed by recurrent illogical thoughts, a tendency to recheck and to ponder over insignificant matters and a need to strictly adhere to a particular routine. The neurodermatitis patients did not differ from normality as far as extraversion was concerned. An early age of onset and somatic preoccupation are hurdles in the management of this disease. Chaudhury et al., (1998) found that patients with psoriasis had significantly higher levels of anxiety and depression as compared to normal controls and also to hospitalized patients with fungal skin infection. They also noted a higher incidence of stressful life events in these patients. Psychopharmacological agents can also cause various skin reactions. Chlorpromazine causes photosensitivity; valproate is associated with acne, hirsutism and the curling of hair. Lithium is commonly associated with dermatologic side effects in the range of 3 to 45 percent. Common side effects are acne, exfoliative dermatitis, psoriasis, pytyriasis vesicular, diffuse nonscarring type of alopecia (12–19%). Lithium aggravates cutaneous conditions associated with neutrophilic infiltration. On the other hand, lithium is also used to treat seborrheic dermatitis and genital herpes (Mohandas et al., 2007). Srinivasan et al., (1991) reported four cases of alcoholrelated psoriasis and concluded a need for studies on the immunological effects of alcohol. In a comparative study of patients with vitiligo and psoriasis, Mattoo et al., (2001) found psychiatric morbidity rates as 33.63 percent and 24.7 percent for vitiligo and psoriasis, respectively. The ICD-10 psychiatric diagnoses in these cases were: adjustment disorder (56% vs 62%), depressive episodes (22% vs 29%) and dysthymia (9% vs 4%) in vitiligo and psoriasis, respectively. Mattoo et al., (2005) found a rate of 22.33 percent psychiatric disorders in patients suffering from vitiligo. The profile of psychiatric diagnosis was 65 percent adjustment disorder depressed type, 30 percent depressive episodes and 4 percent dysthymia. However, no anxiety disorders were detected in their study. Hematology Hematological malignancies are associated with psychological reactions in the sufferers and caregivers. The existence of psychopathology in these groups favors the beneficial effects of close ties between the oncologists and mental health professionals. This also underscores the need for consultation liaison psychiatry in such disorders. In their study, Kulhara et al., (1990) noted that a large number of patients (28.98%) had depressive symptomatology and diagnosable depressive neurosis. Depressive phenomena in these patients were transient and responded favorably to psychopharmacology and supportive psychotherapy. Kulhara et al., (1998) have studied the burden of care on parents of children with childhood hematological malignancies, namely, acute lymphoblastic leukemia and Hodgkin’s disease. These two diagnostic groups were taken for the study because both these conditions are quite common in children. Their investigation clearly shows that parents of children with hematological malignancies do perceive a moderate to severe burden. These parents experienced their burden despite the fact that the majority of the children were either in remission or their disorder was under control. Both the groups of parents had high scores on neuroticism. It is quite likely that the stress of caring for a sick child as well as level of perceived burden lead to this. Antipsychotics, especially clozapine, are associated with severe agranulocytosis. This is a life-threatening complication. The use of granulocyte-colony stimulating factor (G-CSF) in the treatment of severe clozapine-induced agranulocytosis has been shown to be effective (Srinivasan and Kuruvilla, 1998). Another case report by Eranti and Chaturvedi (1998) observed marked variations in platelet count without thrombocytosis in a patient receiving clozapine. They concluded that: (i) thrombocytopenia has occurred at doses of 200 mg/day which has ceased on either stopping the drug or reducing the dose to 150 mg/day; (ii) thrombocytopenia was followed by thrombocytosis on the two occasions; (iii) there was no relationship between variations in platelet count and leukocyte count. This finding argues for the more detailed scientific studies on need for monitoring of platelets in patients receiving clozapine. Neuroacanthocytosis, a rare neurohematological disorder has psychiatric comorbidity in the form of depression, anxiety, personality change, cognitive impairments and obsessive compulsive symptoms (Srivatsa et al., 2004).
  • 83. Chapter 3: General Hospital Psychiatry  Diabetes Diabetes is a common endocrinological problem in mentally ill people. Diabetes per se can cause psychiatric symptoms while the treatment of psychiatric conditions can also lead to diabetes mellitus. Singh et al., (2006) studied 250 consecutive psychiatric outpatients for associated physical illness. Diabetes was reported to be the fourth most common physical illness, being present in 10 percent of patients. The psychosocial profile of diabetics is a well-studied phenomenon. Juvenile diabetics have a significantly higher frequency of behavioral deviations and their parents have an overprotective attitude towards the patients. There was an increased incidence of psychiatric morbidity in juvenile diabetics as compared to normal adolescents irrespective of the family environment (Dass et al., 1999). Sanyal and Basu (1996) studied role of stressful life events in diabetic patients. They found a high impact of stressful life events occurring over the past six-month period on the short-term control of diabetes mellitus. Praveen and Singh (1999) identified maladjustments and stress as important contributing factors in diabetes mellitus. In their study, Jainer et al., (1992) found that symptoms such as depressed mood, decreased work and activities, and loss of weight were present in more than 60 percent of patients belonging to insulin- and noninsulin-dependent diabetes mellitus. The severity of depressive symptoms was significantly higher in insulin-dependent patients as compared to noninsulindependent diabetics. Grover et al., (2005) compared the cost of care of patients with schizophrenia with that of diabetics. They concluded that the cost of care of schizophrenia is equivalent to that of diabetes in developing countries. Mishra and Shukla (1988) studied sexual dysfunction in diabetic males and found that nearly three-fourths (73.4%) of the diabetics had sexual disturbances, the most common presentation being impotence and premature ejaculation. Effective interventions are not available at present for erectile dysfunction in diabetes. Studies are required to evaluate the available treatment options in this particular population. Pediatrics Children with breath-holding spells (BHS) have certain temperamental traits which predispose them to behave in certain way. They seem to have low frustration tolerance, which leads to adamant behavior. Vigorous crying, through various mechanisms, precipitates BHS. Their temperamental traits such as their threshold of responsiveness, mood, level of activity, intensity of emotions, distractibility and rhythmicity are significantly different from those of children without BHS (Subbarayan et al., 2008). Two factors, namely sociability and energy level are significantly higher in breath-holders. Raghunathaman and Cherian (2003) studied 47 temperament in children with unexplained physical symptoms and concluded that children with somatoform disorder and dissociative (conversion) disorder had characteristic temperaments of low activity, low emotionality, low rhythmicity and low distractibility. Children with somatoform disorder were less approachable than children with conversion disorder; otherwise temperamentally there were no differences between these two disorders. Poor parenting styles have been repeatedly associated with criminal/delinquent behavior in children. Inconsistent parental discipline and harsh physical punishment are strongly correlated with delinquency in children. Physical punishment by slapping, hitting and punching provide a pattern to be modelled when youngsters themselves are frustrated (Rao, 2007). Parental loss in childhood and its association with physical illness was studied by Ramchandran et al., (1977). They found that 31 percent of asthmatics, 25 percent of tuberculosis patients and 26 percent of normal population suffered parental loss in childhood. Emotions have been recognized as precipitating acute attacks of bronchial asthma. Desai et al., (1981) reported anger, anxiety and other emotions as cause of precipitation of asthmatic attacks in majority (70%) of their studied patients. The major presenting complaints of children with severe mental retardation to a health care service are in the areas of self-help, language, epilepsy, motor problems and behavior problems (Thuppal and Narayan, 1990). Infection in brain, birth anoxia and trauma are major etiological categories for mental retardation in addition to a large number forming an unknown category. In July 1979, students of Thyavana primary school of Sringeri taluk, in the Western part of Karnataka experienced an epidemic of possession cases (Chandrashekhar et al., 1982). It was found that possession by spirits and demons was culturally acceptable in that community. These behaviors were also positively reinforced many times. Malhi and Singhi (2002) studied clinical characteristics of children with conversion disorder and concluded that the short-term outcome in children with conversion disorder is generally good. They also stressed the importance of a collaborative team work between pediatricians and child psychologists for the management of children with conversion disorder. Surgery and Allied Branches Surgery Surgery is interrelated with psychiatry in various ways. Psychosurgery for psychiatric illnesses is a treatment known since ancient times when trephination was a treatment for psychiatric ailments. Egas Moniz, was awarded the Nobel Prize in 1949 “ for his discovery of the therapeutic value of
  • 84. 48  Section II: Historical Concepts and Evolution prefrontal leukotomy in certain psychoses” (Rao and Chinnian, 1974). The follow-up of patients treated with temporal lobectomy showed beneficial effects in epilepsy and personality disorder (Kennedy and Hill, 1958). It was supposed that this was due to inclusion of uncus, Ammon’s horn and amygdaloid nucleus in the resected tissue. A consultation liaison psychiatrist in general hospitals frequently attends patients in surgical wards for organic psychosis, nonorganic psychosis, neurosis, etc. at the bedside (Avasthi et al., 1998). The psychiatrist’s opinion is also sought for patients with nonmedical-surgical diagnosis. Elderly patients admitted to surgical wards for common surgical illness were found to have high levels of cognitive impairment (Tirupati and Punitha, 2005). This means that a brief hospital admission may be an invaluable window of opportunity to identify and initiate treatment for a previously unrecognized mental disorder. The high prevalence of cognitive decline in elderly inpatients in this study highlights the need for physicians and surgeons to be aware of the condition in their patients. Ear, Nose and Throat (ENT) Ear infections had been postulated as etiology of schizophrenia in the past. In a comparative study among the mentally ill, Mahendru et al., (1978) found that deaf psychiatric patients had a higher incidence of schizophrenia as compared to nondeaf patients. Conductive deafness was significantly more common among schizophrenic patients than other patients. Paranoid symptoms are very commonly seen in patients who are hard of hearing. Obstetrics and Gynecology The psychological sequel of medical termination of pregnancy has been widely studied in India. Wig et al., (1978) found that a majority of women were from the upper socioeconomic class and experienced relief from the anxiety and depression which was caused by the unwanted pregnancy. A study on the acceptance and rejection of advice for the medical termination of pregnancy in an outpatient psychiatry clinic revealed that most of the acceptors belonged to the higher socioeconomic strata of society and the rejecters to the lower strata. Another pertinent observation was that the percentage of non-Hindus was higher in the rejecter group (Dash and Dash, 1979). Infertility is associated with psychiatric comorbidities. Depression and anxiety are common among couples with infertility. Thara et al., (1986) showed that 40 percent of infertile couples had psychosexual dysfunction. Wig (1977) used Cornell Medical Index Health Questionnaire and Maudsley Personality Inventory (in Hindi) on women after tubal ligation and found it to be useful in predication of psychopathology in them. There were predominant features of anxiety and depression in these patients. Twenty percent of those undergoing hysterectomy are reported to suffer from depression in the first year of follow-up (Subramanium et al., 1982). Sood and Sood (2003) found the prevalence of depression 8.3 percent, 20 percent and 12.8 percent in the third trimester of pregnancy, in the early postpartum period and late postpartum period respectively. The incidence was 16 percent and 10 percent in the early and late postpartum period respectively. Further analysis revealed that depression in pregnancy correlated significantly with depression in the early postpartum period, but not with the late postpartum period. The prescription of psychotropic medications in pregnancy and breastfeeding needs special considerations. During pregnancy and lactation, of all SSRIs fluoxetine is the most studied with no good evidence of teratogenicity or risk to the baby after breastfeeding. All commonly used mood stabilizers are teratogenic. Valproate and carbamazepine are associated with neural tube defects while lithium is associated with Ebstein’s anomaly when used during pregnancy (Behere and Bansal, 2010). There is no evidence for an increased risk of miscarriage or intrauterine foetal death in women treated with lithium. There is a real, but modest, teratogenic risk of Ebstein’s anomaly following first-trimester lithium exposure (Chandra et al., 2009). The incidence of major malformations in the foetus due to lithium exposure ranges from 4 to 12 percent. The risk of Ebstain’s anomaly is especially high if the drug is taken 2 to 6 weeks postconception (Mohandas and Rajmohan, 2007). Classification and categorization of psychiatric illnesses in puerperal period is a subject for research at present. In view of the upcoming revisions of DSM and ICD, it is pertinent to undertake field trials in this area. Other Areas of Interaction Medically Unexplained Symptoms This group of patients presents physical symptoms that resist a conventional biomedical explanation. This is very common in both primary care and a general hospital setting and make up the largest single diagnostic problem encountered in these settings (Hotopf and Wessely, 2010). There is yet no consensus on the definition of these symptoms as yet. There are different approaches to explain this presentation. In a primary care setting, it is conceptualized by somatization with the assumption that patients with anxiety and depression present with physical rather than emotional symptoms and it is the doctor’s job to identify and treat medical disorders. In a secondary care setting, it is explained via functional somatic syndromes. Each medical specialty has created its own functional somatic syndrome, for example, irritable bowel syndrome in gastroenterology. The most consistent
  • 85. Chapter 3: General Hospital Psychiatry  49 association of these medically unexplained symptoms is the female gender. Other common associates are depression and anxiety disorders, genetic factors as supported by twin studies in chronic fatigue syndrome and irritable bowel syndrome, childhood sexual abuse, chronic physical illness, acute and chronic stresses, etc. The management of these patients needs skillful psychosomatic assessment. These patients need to be assured that their physical symptoms are taken seriously and perform a detailed history and examination. During this procedure, the patient should be given a feeling of being understood. Next, it is time to change the agenda by assisting the patient in finding alternative explanations for the symptoms other than a biomedical one. Finally, comes the time to make the links by giving the patient an explanation of how mental disorder and recent stress can cause these symptoms. Sometimes treatment with antidepressants might help. The treatment of these medically unexplained symptoms still remains a challenge for psychiatrists in general hospitals. Diagnosis in psychiatry itself is also amenable to change over time. Behere and Tiwari (1988) in their inpatient study found that 12.8 percent patients had a change of diagnosis in subsequent admissions. A change in symptomatology on subsequent admissions was the most common (83.3%) reason for the change in diagnosis. Chadda et al., (1991) studied the presentation of physical symptoms in psychiatric practice. Subjective weakness, pain in different parts of the body and vague somatic sensations were the common physical symptoms. Depression was the most common psychiatric diagnosis, while 39 percent patients were in not otherwise specified category of DSM-II-R. Large collaborative studies are needed in general hospitals in which a large number of these patients are referred to psychiatric units. emotionally unstable (Impulsive and Borderline) personality disorder, while in the elderly, anankastic personality disorder was the most common personality disorder associated with deliberate self-harm. Further studies are needed to explore the medical comorbidity in deliberate self-harm. Deliberate Self-Harm FUTURE OF GHPUs IN INDIA Deliberate self-harm is often a reason for emergency psychiatric consultation in a general hospital setting. There are varied presentations and causes for deliberate self-harm. A study of psychiatry referrals for intentional self-harm from Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, reports that 9 percent of the patients had a past history of intentional self-harm. Current psychiatric diagnosis apart from deliberate self-harm included depression (unipolar/bipolar) in 31 percent, adjustment disorder (9%), schizophrenia (5%), emotionally unstable personality disorder (5%) and other psychiatric diagnoses (4%). This study also revealed that about half the patients with deliberate self-harm did not meet any other axis one diagnostic criteria (Das et al., 2008). Personality disorders associated with deliberate selfharm were studied by Nath et al., (2008). They found that in young persons the most common personality disorder was Mental illness causes immense suffering and disability to the affected individuals and to their families, although this suffering may not be highly visible. Mental illness is responsible for 20 to 25 percent of all disabilities in the community. With the methods for treatment and prevention available, the chronicity and disability can be avoided in about 80 percent of the cases (Sethi et al., 1984). Considering the burden of the large number of cases in India, large mental hospitals are not fully capable of handling this burden. The Government had already stopped building new mental hospitals in the country. The future of psychiatry in India is now fully dependent on small general hospital psychiatry units present across country. Steps are required to build new units and to provide all possible modern facilities in these units so that the mentally ill get proper care in India. A new amendment of the existing mental health act is being drafted. A proposed blueprint of Delirium Acute delirium is another condition where emergency psychiatric consultation is usually requested from medical and surgical wards. Delirious patients are often confused and become aggressive and perplexed due to associated perceptual disturbances. Acute delirium can be a presentation of poisoning by belladonna alkaloids, atropine eye drops or due to atropine used in treatment of organophosphorous poisoning (Venkatesan et al., 1983). In a prospective follow-up study of patients with cataracts, Chaudhury et al., (1992) found that only 4.5 percent of the patients developed postcataract surgery delirium. Those who developed delirium were in their fifth decade of life without any associated medical illness or renal dysfunction. Delirium is a common phenomenon in hospitalized geriatric patients. Age and associated physical illness is the proposed etiology for the high prevalence of delirium in this age group. Khurana et al., (2002) studied the occurrence of delirium in a hundred consecutive geriatric in-patients. They found an overall incidence of 27 percent. These patients had pre-existing cognitive impairment. Psychopharmacological agents like valproate and clozapine have been associated with delirium. Delirium is a syndrome with varied aetiologies. Detailed studies are required establishing correlations between various aetiologies and socio-demographic factors (Gupta et al., 2008).
  • 86. 50  Section II: Historical Concepts and Evolution the draft, which is available now, has many changes relevant to general hospital psychiatry. The definition of the treatment setting for the treatment of the mentally ill has been changed from ‘mental hospitals’ to ‘all places where the persons with mental illness are treated except home’. This revision is important for GHPUs which are part of the general hospitals and not the mental hospitals per se. It proposes the inclusion of alcohol and other substance abuse in the definition of mental illness. Since substance-related disorders are a major part of psychiatry practice in a general hospital setting, it is a major move for general hospital psychiatry units (GHPUs). A whole chapter on the protection of the rights of mentally ill persons is being added. This provides an opportunity for mental health professionals in general hospitals to interact with caregivers and the community to promote and protect the rights of the mentally ill. General Hospitals Psychiatry Unit (GHPUs) should be the focus of attention for any mental health plan in future. Considering the aforementioned issues, we may expect that, in the near future, general hospital psychiatry units are going to be the centers for the care of the mentally ill in India. bibliography 1. Avasthi A, Sharan P, Kulhara P, Malhotra S, Varma VK. Psychiatric profiles in medical-surgical populations: need for a focused approach to consultation-liaison psychiatry in developing countries. Indian Journal of Psychiatry 1998;40:224-230. 2. Behere PB. Psychological reaction to leprosy. Leprosy India 1981;53:246-248. 3. Behere PB, Ramkrishna P. Psychiatric aspects of brain tumours: A brief review with some observations. The Medicine and Surgery 1982;20:17-20. 4. Behere PB, Tiwari K. 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  • 89. 4 Towards Community Mental Health Care: Primary Health Care Model Sunder Lall, Shanker Prinja INTRODUCTION India is predominantly rural as most of its population – around 72 percent lives in rural areas spread over in 6,40,000 villages. The services and infrastructure for mental health services in the public sector are inadequate and mostly confined to bigger cities and hospitals. The District Mental Health Programme has just taken off and is striving for community-based mental health services. Primary health care in India has been universalized in terms of availability and accessibility. The infrastructure for primary health care has been built from village level upward to the community block development level to provide comprehensive primary health care services. Integrating mental health services into primary health care services makes more sense and yields a high pay off. The minimum package of mental health services can be best delivered through primary health care. VILLAGE LEVEL At the village level, we have over 10 lakh Anganwadi workers, 8 lakh accredited social health activists, besides traditional birth attendants, to reach families/households. These are the voluntary/honorary workers chosen by the community, resident in the same village and part of the community, accountable to the village Panchayat. In each village, a Village Health and Sanitation Committee (VHSC) has been constituted to undertake a household survey and prepare a village health action plan with the help of local functionaries and the medical officer in-charge of the public health center. Once a month, a village health and nutrition day is organized at the Anganwadi center for intensive health activities like immunization, growth monitoring, the promotion of contraceptives and iron and folic acid prophylaxis for anemia besides the treatment of common ailments, and for mothers’ meetings. The system of integrated child development services (ICDS) is universal in India and one of the largest outreach service models in the world. It can reach the most vulnerable children, adolescent girls, and women. The Anganwadi worker is the key functionary in the provision of integrated services for health, nutrition and education, to lay the foundation for the physical, mental and social development of young children. Creative activities and environmental stimuli of a graded nature are provided with a focus on human resource development. In a way, the Anganwadi is the hub of convergence for overall development services by self-help groups, women’s organizations, as well as the Departments for Community Development, Education and Health. Furthermore, the institution of Anganwadi has been recognized as the sheet anchor in personality development of young children and this is one of the finest examples of development of positive mental health. Any international program developed by the WHO to stimulate mother-child interactions has much greater chance of success if it is pursued actively within the family through the ICDS system. This system involves families and parents in total child development through integrated services in nutrition, health and education, relying on intersectoral coordination (Fig. 1). SYSTEM OF SUB-HEALTH CENTERS Over 1,45,000 subcenters have been established in the country. Each subcenter covers a population of 5,000 in rural areas and of 3,000 in tribal areas. Skilled manpower in the form of multipurpose health workers (both male and female), supported by health supervisors and the medical officers of primary health centers are available to provide basic primary health care services to the rural community. These multipurpose health workers (paramedical personnel) are able to contact most families on a regular basis to assess their primary health care needs and to meet their needs through annual action plans. The National Rural Health
  • 90. 54  Section II: Historical Concepts and Evolution Fig. 1: Health system infrastructure in India Mission has further strengthened these sub-centers by upgrading the infrastructure and provided annual untied grants of ` 10,000 for local planning. This skilled manpower can be effectively used to provide essential/emergency mental health care services after training and continued education. The basic curriculum of these workers should include a mental health component (primary care in mental health). The health management information system (subcenters report) should have an inbuilt mechanism for reporting on services provided in the area of primary mental health care. This would form the basis for monitoring of mental health services at the community level. As a matter of fact, multipurpose health workers, female and Anganwadi workers have been linked to provide primary health care at the village level. Their functions have been integrated to a large extent and medicine kits have been provided to them which could be further enriched. These workers could be stepping stones for the promotion of positive mental health, by raising the level of awareness though education programs besides the recognition and referral of common mental ailments at the community level. This resource could be used to measure the burden of mental disorders in the community through annual household surveys to recognise suspect cases by a syndromic approach. Recently, Indian public health standards have been prescribed for subhealth centers to provide assured quality services as per local needs and sensitivity. SYSTEM OF PRIMARY HEALTH CENTERS This is the first portal of contact with professionally qualified (MBBS and AYUSH) doctors. Over 25,000 Primary Health Centers have been established in the country. At this level, the services of qualified doctors of allopathic or AYUSH systems are available. Each Primary Health Center (PHC) supports and provides referral services to six subhealth centers covering rural populations of 30,000 in the plains and 20,000 in tribal areas. The promotive, preventive, curative and managerial functions of the PHC have been well-defined. It also holds the responsibility for providing promotive and preventive services for schoolchildren and adolescents, besides providing services under various national mental health programs, including the National Mental Health Programme. Thus, mental health services are an integral part of primary health care and can be best delivered though this system. Investment in primary health centers and medical officers on a continuous basis through a continuing education system could prove most rewarding. The undergraduate medical education system could be strengthened through the inclusion of the relevant components of mental health in the curriculum. PHCs have been further strengthened by the National Rural Health Mission by the provision of one additional medical officer, staff nurses and untied funds for local planning and an annual maintenance grant besides the provision of essential drugs. Around 50 percent of PHCs will be able to function 24X7, that is, around the clock everyday of the week, by the end of 2012. Each PHC has been provided between four and six observational beds. To improve the coverage and quality of assured primary health care at the level of the PHC, Indian Public Health Standards have been adopted under the National Rural Health Mission. To increase the participation of civil society in the management, planning and control of PHCs, Rogi Kalyan Samitis or Patients’ Welfare Committees have been constituted at each PHC. A Citizens’ Charter has been displayed at each PHC to let people know their rights and entitlements. By and large, the medical officer in-charge of the PHC is now accountable to the Panchayati Raj institutions. SYSTEM OF COMMUNITY HEALTH CENTERS Community Health Centers (CHCs) have been designed to provide specialist medical, surgical, obstetric and pediatric services to a population of 120,000. Each CHC provides referral services to four Primary Health Centers under its jurisdiction. It houses 30 bedded indoor ward facilities for indoor admission. All the CHCs are being upgraded as first referral units (FRU) to provide emergency obstetrical services. Around 4,500 CHCs have been setup in the country. These have been further strengthened by the National Rural Health Mission in terms of additional staff, equipment, buildings (physical infrastructure) to meet Indian public health
  • 91. Chapter 4: Towards Community Mental Health Care: Primary Health Care Model  standards. Untied grants, annual maintenance grants and an improved health information management system under the National Rural Health Mission are promised for quality health services as per Indian public health standards. This level can provide referral support for mental health services, continuing education to various functionaries besides intersectoral coordination. The Rogi Kalyan Samitis (civil society organizations working in the field of health) can further mobilize resources and strengthen the services of the mental health program and all other national health programs. The citizens’ charter informs the people of their rights and entitlement to assured services provided by the CHC. MOVING AWAY FROM MENTAL INSTITUTIONS—TOWARDS COMMUNITY MENTAL HEALTH CARE The National Mental Health Programme, initiated in 1981 and implemented in 1982, has recently recommended a community-based approach for sustainability of action as well as enhanced accessibility. The development of the District Mental Health Programme is a step in the right direction, but its progress and the extension of coverage is too slow to make any significant mark on the amelioration of the problem. A nodal agency has been identified in each state to undertake an in-service training program for the medical officers and paramedical workers as well as to provide technical support to the district training program. It adheres to the prescribed manual prepared by NIMHANS, Bengaluru. A two-week training program is already being perused at the level of the medical college by the Department of Psychiatry (at the tertiary level of care). This decision undermines the capacity of the district health agencies or district training teams recently developed as a training institution for the program of continuing education of medical and paramedical personnel. It is recognised that the effective delivery of primary health care including mental health care would largely depend upon the nature of education and the appropriate orientation towards community health of all categories of medical and health personnel and their capacity to function as an integrated team. The basic training curricula of all categories should incorporate sufficient time for building essential skills of medical and paramedical personnel so that they are able to deal with the problems of mental health within the framework of primary health care. In general, we must address the issues of quality of medical education for undergraduates and specifically to the training of students in the discipline of psychiatry, to lay a firm foundation for the development of mental health services at a primary health care level. This should be considered a real investment in the development of psychiatric health services in the community. 55 The Training of Trainers (TOT) is essential to impart need based and relevant training in the key areas of mental health and counseling. The assessment of training needs and the pursuit of hands-on training with case material and within the community should become the primary focus with trainers of medical and paramedical personnel. The medical education cell and each State’s Institute of Health and Family Welfare can be entrusted with the task of the training of trainers. The National Health Policy and the program on mental health and their key strategies must be made available to the trainers. To maintain the uniform standard of training, manuals prepared by NIMHANS, Bengaluru should be distributed in local languages. The services training manual prepared by NIMHANS focuses largely on technical subjects and hospital-based training, confirming an established impression that the solution to mental health problem lies in big hospitals and nothing worthwhile can be done/achieved at the community level. A substantial part of the training of medical officers and paramedical personnel should be at the community level to focus on critical areas like the role of community, institutions, the family and the individual to tackle mental health problems. The focus of the training should, of necessity, be on the methods of interviewing and contact with the individuals and families, skills required when listening to clients, assessing their needs, counselling and the identification of high-risk families and clients, as also group meetings and dynamics besides community organization and mobilization of resources. Continuing education should be part of routine meetings. Health teams (multipurpose health workers, Anganwadi workers, Gram Sewikas and health guides) should be trained together for a better understanding of each other’s roles and responsibilities. Awareness generation and mental health literacy drives at the level of the community through the active involvement of Panchayati Raj institutions, influential groups, non-formal leaders and other organized groups on a regular basis can be most productive. The awareness generation campaign must have the support of district mental health services, the community health center, primary health center and subcenter system. The ownership of the program by the district health organization and the area is essential for sustainability and endurance. If the training program and the development of strategies are evolved far away from the real situation, this might create a negative impact and generate a sense of dependency, as well as killing local initiatives. Building district capacity for training and continuing education as well as for developing services should be the real role of the nodal agency.
  • 92. 56  Section II: Historical Concepts and Evolution If one looks at the basic curriculum of MBBS students and paramedical staff (multipurpose health workers, both male and female), one finds that the subject of mental health is covered adequately but the implementation thereof is questionable. Even the available services for mental disorders are being poorly utilized. Nearly two-thirds of persons with known mental disorders never seek help from health professionals and most clients utilize the services of other agencies and resort to harmful practices and keep visiting faith healers, delaying treatment until the patients’ condition deteriorates to a stage where they feel compelled to seek treatment from established government institutions. Stigma, discrimination and neglect prevent care and treatment reaching people in need. Mental health literacy needs to be built strongly in the community to scale up the utilization of the mental health services available. In the first instance, the services and infrastructure for mental health services in the public sector are inadequate and mostly confined to bigger cities and hospitals. The District Programme of Mental Health Services has just taken off, the primary health care infrastructure, on the other hand, is reasonably well developed and is almost universally accessible in rural and urban areas. The minimum package of mental health services for all can be best delivered through the primary health care system. Preventive and promotional programs along with awareness generation can be undertaken on sustainable basis through this infrastructure. NIMHANS has rightly picked the ICDS system to involve them in the National Mental Health Programme through District Mental Health Services. They are being imparted five days’ training in a program at the district level. Their training would be critical, as these workers will serve as link workers between the community and the formal health services system. Since Anganwadi workers are locally resident voluntary workers, deeply rooted in the community, they can be most effective in the dissemination of knowledge on the mental health program and in the identification of clients at the earliest stage of morbidity, because of their continuous contact with families. Strengthening this institution can be most rewarding and should have greater pay-off effects in the long run. The National Population Policy envisages enlarging the sphere of the ICDS to cover school-going children up to the age of 9 years. Continuous on-the-job training of Anganwadi workers through supervisory support can further enrich the nonformal education program. The in-service training on mental health should be undertaken by supervisors or trained Child Development Program Officers and it should focus on child development, personality development and “learning through play” activities. Adolescent boys and girls who are the parents of the future need more mental health services to develop valuebased learning and balanced personalities. The teachers’ training program for a balanced development of the physical, mental and social faculties of school-going children is essential for healthy life styles. Teachers, along with parents, can shape balanced personalities. The District Mental Health Services Programme should incorporate this program very thoroughly and entrust the responsibility for teacher training to district health teams. Even though teachers are trained in child psychology during their teachers’ training program, they need continuous education in balanced personality development of children. The District Mental Health Programme should not lose this opportunity, as it can be a real investment in preventive, promotional and positive mental health or what we could call extended community mental health. The outreach district mental health services should embody this component of the program on a sustainable basis. WHO’s ‘Life Skills’ educational curriculum, which attempts the teaching of wide range of skills amongst school children to improve their psychosocial competency through problem solving, critical thinking, communication, equity, tolerance, interpersonal skills, empathy methods to cope with emotions, can be made effective through school teachers and parentteacher interaction on a continuous basis and through much more ‘child friendly schools’. Government or Public Mental Services are just one resource for mental health services. Private sector and NonGovernment Organizations, as also diverse health care providers, such as practitioners of Indian systems of medicine, should be considered a potential resource for primary health care, including mental health services. Their involvement can increase the base of accessibility of services to the masses. Some of the techniques of Indian Systems of Medicine can be utilized for the treatment of mental disorders. The district program of mental health services may be given the liberty to utilise the service of these agencies. Resource mapping for primary health care, as well as mental health care, should not lose sight of other available organizations contributing to the care or services related to the mental health program. Partnership between the Government and the private sector is an important area for the development of the Mental Health Services Programme at community level. It is widely claimed that community care is more effective as well as more humane than in-patient stays in mental hospitals. It is, therefore, essential to develop mental health services in the community setting as an integral part of primary health care; to root out stigma, myths and misconception and discrimination against mental disorders. The
  • 93. Chapter 4: Towards Community Mental Health Care: Primary Health Care Model  World Mental Health Report, 2001 advocates communitybased mental health programs and the active involvement of families, consumers and the community in the delivery of programs. People and the community are the most important resources available in India. Many of the problems in the area of mental health can be effectively dealt with by the people and within the resources available close to them. Large-scale dissemination of knowledge and of simple skills to people and health volunteers should be addressed through primary health care. The capacity of the family must be built, and primary health care infrastructure should support the family to build their capacity, to prevent and manage the mental health problems within the available means. What people do with their lives and those of their children affects their health far more than anything that Government does. Building knowledge and awareness of families can make a real difference. Health guides, Anganwadi workers and health workers as well as Non-government Organizations (NGOs) should raise the level of awareness of people on the value of a sound mind in a sound body and on the attainment of positive mental health, both through their own actions and practices as well as through the utilization of available services. Operational research studies on community-based mental health services are called for. We have just two models evolved a while ago in Chandigarh and Bengaluru in 1975 which are indeed insufficient. These two models limited their approach to curative services at the community level through primary health care. The District Mental Health Programme was initiated at Bellary (Karnataka). The success of operations in program conditions at the ground level needs to be documented further. The outcome and impact of the district training program in terms of coverage of mental health services and the awareness level in the community needs to be explored through operational research studies. The task can be undertaken by a nodal agency, or an independent institution could be entrusted with this task. A built-in system of monitoring and evolving parameters of mental health in the community would be another area of interest. Similarly, a longitudinal follow-up of pre-school children and school children for personality development would be another worthwhile area of research. Many more interventional studies can be evaluated in adolescents in and out of schools in community settings. The delineation of the role of NGOs, Panchayati Raj Institutions and the partnership of the public and private sectors in the delivery of mental health services 57 can be potential areas of exploration. The working of drug de-addiction centers, their cost-benefit ratio and impact should form part of community-based operational research. CONCLUSION In conclusion, it can be stated that mental health services of necessity have to be integrated with the primary health care system. The District Mental Health Programme has to be integrated into the District Health Action Plan (DHAP) under the National Rural Health Mission. Integrating mental health services within the community by supporting families, community and the greater involvement of village Panchayats, ASHAs, Village Health and Sanitation Committees and Rogi Kalyan Samitis in the management of services can increase the coverage and raise the level of mental health literacy as well as the better utilization of existing services. Components of mental health services should be built into the basic continuing education programs of medical and paramedical personnel. Intersectoral coordination and convergence of services at the community level can further enrich the mental health service and can be an effective instrument to reduce stigma and misconceptions. Regular monitoring and evaluation of primary mental health services through a health management information system besides a community monitoring system can usher in better planning and improvement of the mental health program and services. BIBLIOGRAPHY 1. Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS): Features of Mental Disorder—A Folder. ICMR center for advanced research on Community Mental Health. Bengaluru, NIMHANS, 1987. p. 8. 2. Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS): Mental Health Manual for Health Workers: ICMR Center for Advanced Research. Bengaluru, NIMHANS, 1990. 3. Issac MK. Severe Mental Morbidity. ICMR Bulletin 18 (12); 1988. 4. Ministry of Health and Family Welfare. National Mental Health Programme for India: Recommendations of the Central Council of Health and Family Welfare. New Delhi, MOHFW, 1982. 5. Ministry of Health and Family Welfare: National Health Policy 2002. New Delhi, MOHFW, 2002. 6. Trivedi S, Srinivasa DK. Report of National Workshop on Undergraduate Medical Education in Mental Health (sponsored by WHO) 1985, Pondicherry, JIPMER, 1985. 7. World Health Organization. The World Health Report 2001— Mental Health: New Understanding, New Hope. Geneva, WHO, 2001.
  • 94. 5 National Mental Health Programme Rajesh Kumar, Dinesh Kumar The promotion of mental health has been accepted as an integral part of the national health policy in India. In recent years, the judiciary has re-established the human rights of the mentally ill. Considerable legislative progress has been made since the enactment of the Mental Health Act of 1987. However, mental health policies and programs have not yet been fully integrated into the general health services of the country, although there has been sufficient movement away from the mental asylum approach. In the last century, the concept of mental hospitals underwent a major change. Their role and functioning were re-defined. The first General Hospital Psychiatry Unit was established in Calcutta (Kolkata) in 1933. The Health Survey and Development Committee headed by Sir Joseph Bhore (1942-46) had assumed the population of mental patients to be 2/1000 population due to the nonavailability of data on the burden of mental disorders at that time. In 1954, based on the Bhore Committee recommendations, the All India Institute of Mental Health, Bangalore was set up to increase the availability of trained mental health manpower in the country. To address the needs of the mentally ill, the Mudaliar Committee (1959) recommended the establishment of a psychiatric clinic with 5 to 10 beds in each district (Agarwal et al., 2004). During the 1970s and 1980s, several studies demonstrated the feasibility and cost-effectiveness of extending mental health services to the community through primary health care outreach (Kapur et al., 1982; Mathai, 1984; Wig et al., 1980). Half (52%) the districts in India did not have psychiatric facilities and there was an acute shortage of psychiatrists (a shortfall of 77%), psychologists (a shortfall of 97%) and psychiatric social workers (PSW) (a shortfall of 90%). Hence, integrating mental health care with the general health services using standard treatment guidelines was considered one of the important means of providing basic mental health care (Murthy, 2004). To overcome the shortage of mental health professionals, the training of primary care doctors, the active involvement of the family, indigenous methods of psychotherapy and rehabilitation work therapy have been recommended (Agarwal et al., 2004; Menon 1996; Sriram et al., 1990). The tackling of other limitations, such as ignorance and the stigma attached to mental disorders, the long duration of treatment, the initial side effects of drugs, and the distance to the health facilities, were intended to increase the ability of the health services to provide mental health care (Wig et al., 1980). Alongside the treatment, proper systems for follow-up and referral were found to be important for strengthening mental health care (Gururaj et al., 1988). The use of affordable, simple drugs in a general health care setting was reported to improve clinical outcomes (Patel and Kleinman, 2003). Several projects in India demonstrated the feasibility of primary mental health care following the Alma Ata declaration of the 1970s. This was why the Government of India focused its attention on mental health as a component of the National Health Programme. National Mental Health Programme In 1980, an expert group discussed various factors of mental health with mental health experts. The National Mental Health Programme (NMHP) was discussed at a workshop of mental health experts at New Delhi in July 1981. Following the discussion, the proposed program was again presented on 2 August 1982 at another workshop. This time the opinions of experts from fields other than mental health, such as from education, administration, law and social welfare were sought and incorporated. The final draft of the NMHP was adopted by the Central Health Council at its meeting held from 18 to 20 August 1982. The NMHP was launched with the stated objectives being to 1. Ensure the availability and accessibility of minimum mental health care for all in the foreseeable future,
  • 95. Chapter 5: National Mental Health Programme  particularly to the most vulnerable and underprivileged sections of the population. 2. Encourage the application of mental health knowledge in general health care and in social development. 3. Promote community participation in the mental health service development and to stimulate efforts towards self-help in the community. To achieve the aforementioned objectives, the following activities were to be completed: By the first year: a. Each state was to adopt a plan of action in the field of mental health. b. The Government of India was to appoint a focal point within the Ministry of Health, specifically for mental health action. c. A National Coordinating Group was to be formed, comprising of representatives of all states, senior health administrators and professionals from psychiatry, education, social welfare and other related professionals. d. A Task Force to work out the outlines of a curriculum for mental health workers identified in the different states as the most suitable to apply basic mental health skills, and for medical officers working at Primary Health Centers (PHCs). In five years: e. At least 5,000 of the target nonmedical professionals were to undergo a two-week training program on mental health care. f. At least 20 percent of all physicians working in PHCs were to undergo a two-week training program in mental health. g. The creation of the post of a psychiatrist in at least 50 percent of the districts. h. Psychiatrists at the district level to visit all PHC settings regularly and at least once every month, for the supervision of the Mental Health Programme and for continuing education. i. A fully operational Mental Health Programme in at least one district in every State and Union Territory and in at least half of all districts in some states. j. Each state was to appoint a program officer responsible for the organization and supervision of the Mental Health Programme. k. Each state was to provide additional support for incorporating community mental health components in the curricula of teaching institutions. l. On the recommendation of a task force, a list of appropriate psychotropic drugs for use at the PHC level was to be included in the list of essential drugs in India. m. Psychiatric units with inpatient beds were to be provided in all medical college hospitals in the country. 59 The goals of the NMHP were ambitious to start with and not enough attention was paid to its implementation or feasibility. Subsequently, three Five-Year Plans did not make adequate funding allocation for the program. Even the funds allotted were not fully utilized. It was only in the NinthFive-Year Plan (1997–2002) that a substantial amount of ` 28 crores was made available and ` 106 crores was utilized from the allocated ` 190 crores in the Tenth Five-Year Plan (2002–07). Evolution of District Mental Health Programme In 1995, the District Mental Health Programme (DMHP) was evolved as a strategy to implement the NMHP. The availability of separate funds for the District Mental Health Programme has shown that states are ready to take up intervention programs once funds are made available. During the Tenth-Plan period, the major areas being addressed were the modernization of mental hospitals, strengthening of medical college departments of psychiatry, information, education and communication (IEC), training and research. An all-India Action Plan with a Vision for 2020 was proposed with the focus on the efforts that need to be undertaken under the umbrella of the district health care system (Agarwal et al., 2004). The strategy of implementation between 1995 and 2000 of the District Mental Health Programme (DMHP) continued to be one of the extension services provided to the district hospitals by professional psychiatrists, rather than one-based on a true integration of mental health within the primary health care system. Due to a shortage of mental health resources across the country, even the extension of mental health services could be taken-up only in selected districts of the country. Standardized treatment facilities could not be made available to persons with mental illness, even though the Mental Health Act 1987 had made it compulsory. States did not frame the rules to set up mental health cells. The Mental Health Act did not consider the private sector and also mental health care standards were limited to licensing requirements only. Thus, the Mental Health Act 1987 itself became one of the limiting factors for the extension of community mental health services. The factors related to the health care delivery system, such as a shortage of drugs and an inadequate infrastructure, untrained manpower, and nonstandardized management protocols, also lead to a poor coverage of mental health services especially in the rural areas. Social factors, like stigma, distance, the long duration of therapy, and incurability also contributed to the improper utilization of mental health
  • 96. 60  Section II: Historical Concepts and Evolution services by the community. These led to either no treatment or to the late treatment of mental illness as the family was unaware of the condition of the patient. To address the constraints faced by the DMHP strategy, the NMHP objectives were modified (Murthy, 2007) to: 1. Strengthen families and communities for the care of persons suffering from mental disorders. 2. Organize a wide range of mental health initiatives to support individuals and families, with special focus on the immediate delivery of the most essential services to the ones with the greatest needs. 3. Support through mental health initiatives, rebuilding of social cohesion, community development, promotion of mental health and the rights of the persons with mental disorders. In order to achieve the afore-mentioned objectives, the following activities are planned: Organizing Mental Health Services Community-based services within the primary health care settings should be the core activity in the planning of the provision of mental health care. The World Health Report (2001) also recommended this approach as its first-two recommendations: a. Mental health in primary care: As many persons already seek help at a primary care level, the management of mental disorders through primary care is an important step to increase the access of mental health services to population. In order to implement standardized mental health care, the primary health care personnel need to be trained to enhance mental health care knowledge and skills. Training helps to disseminate timely application of interventions to a larger population. It should be considered in all medical and paramedical courses. b. Availability of psychotropic drugs: Standardized mental health care also ensures that essential psychotropic drugs are available at health institutions like subcenter, primary and community health center, district and regional hospitals. They should also be included in the list of essential drugs. These medicines help to relieve symptoms, reduce disability, check the course of the disease and prevent relapse. Community Mental Health Care Facilities Due to the limited utilization of primary health care institutions, community care facilities are also required to meet the needs of the patients and their families. This also ensures timely intervention and helps to reduce stigma. Community care also requires the availability of health workers and rehabilitation services at the community level. it can be delivered through day care centers, half-way homes, long-stay homes, sheltered workshops, de-addiction centers and suicide prevention centers. Support to Families The family is a primary care provider for a mentally ill person. Therefore, improving the knowledge of families towards mental disorders along with the imparting of skills to carers helps the mentally ill. This also ensures compliance with the requirements of medication, management of the early signs of relapse, crisis management, and decreases social and personal disability. Visiting community nurses, with the involvement of self-help groups, can provide support to families. The state can further extend services by: a. Providing financial support to families that participate in the network of self-help groups. b. Offering public places in the community for their meetings and support the organization of day care activities. c. Developing a system of visiting nurses to support families (with at least one nurse for a 100 families). d. Involving the families in the planning of the Mental Health Programmes. Human Resource Development The availability of trained professionals is important for the provision of mental health services. There is a deficiency and unequal distribution of mental health specialists, leaving a major part of the area without professionals. The situation is even worse in towns and villages. The following measures need to be taken for meeting this need: a. Undergraduate training in psychiatry for medical students: Mental health training can be increased to a full two months with the inclusion of psychiatry as a subject of examination. Currently, it is for just two weeks and is not a examination subject. It provides the skills to take care for the mentally ill as part of their general health service duties. b. Psychiatrists: Psychiatrists are required at medical colleges, district hospitals and to support voluntary organizations to provide community care. As a short-term measure, experienced medical officers can be considered as program officers and trained at postgraduate training centers for a period of three months. In the long-term, qualified professionals can be recruited. c. Paramedical staff: The inadequacy of numbers in this group of professionals is even greater than that of the psychiatrists and nurses. As with psychiatrists, one
  • 97. Chapter 5: National Mental Health Programme  should provide training to the existing work force for mental health care at the postgraduate level and post them to work in different settings. The duration of the short training can be: 1 to 3 months for nurses, and 2 to 6 months for psychologists, social workers, and rehabilitation workers. Public Mental Health Education A sustainable effort at public education and the creation of awareness on mental health is also an important public health strategy. There should be greater awareness of mental disorders, signs and symptoms and of the available services and rights of people with mental illness. It should be widely disseminated among the general population and among professionals. All India Radio, Doordarshan, the print media and folk media should be involved in the effort. State Health Plans about the involvement of health education bureaus at state and district level is to developed and implemented. Private Sector Mental Health Care The private sector has a larger role to play in both the health care system in general and specifically in mental health. Its involvement helps to understand mental health epidemiology and the provision of treatment. Individuals from the private sector can also be involved as honorary consultants to medical colleges and regional hospitals, in the training of PHC personnel, and in supporting the NGOs in their mental health initiatives, for starting special mental health programs and public mental health education. Support to Voluntary Organizations Voluntary organizations are an important community resource for mental health. They are more familiar with ground realities and can play an important role in the absence of a formal or well-functioning mental health system, thus helping to fill the gap between community needs and the available community mental health services. Promotion and Preventive Activities A wide variety of interventions are possible to promote mental health and prevent mental disorders, such as life skills education programs for school children. NIMHANS, Bangalore has undertaken some initial efforts to develop suitable material for schools in Karnataka. Similarly, the psychosocial care of survivors of disasters can be the part of all relief, rehabilitation, reconstruction and reconciliation programs following man-made and natural disasters. 61 Administrative Support Currently, in most states, there are part-time administrative officers from the Directorate of Health Services to manage the program. The program manages the mental health program in addition to other health programs. In view of the importance of the Mental Health Programme and the magnitude of the initiatives to be undertaken, a full-time Joint Director (Mental Health) should be appointed at the Directorate of Health Services. Such an officer should be a psychiatrist and should have additional staff (including a statistician) to support the Mental Health Programme. At the district level, there should be two mental health teams, one in the district medical office and the other at the district hospital. Such teams will be able to take care of both clinical services and the integration of mental health in general health services at the peripheral institutions. The mental health budget was also correspondingly increased. In order to strengthen the DMHP strategy several steps have been taken in recent years, especially a rise in the allocation of resources for the NMHP and including planning for the District Mental Health Programme as a part of the National Rural Health Mission. National mental health programme in Eleventh Five-Year Plan (2007–12) The role of the National Mental Health Programme (NMHP) has been refined under the Eleventh Plan. A total of ` 1,000 crores has been provided with a budgetary allocation is ` 338.12 crores. The following activities have been planned: Center of Excellence in Field of Mental Health Centers of excellence are to be established by upgrading and strengthening identified mental institutes/hospitals to address the shortage of staff and to provide state of the art mental services. The financial support involves capital work like establishing academic blocks, lecture theaters, library, hostels, supporting departments. Preference is given to states which display the presence of a dedicated faculty and provide annual recurring expenditure. At least 11 such centers are to be established with a budgetary allocation of ` 30 crores per center with full budgetary commitment by the State Government after the Eleventh Plan. Scheme of Manpower Development To provide expert manpower, mental health training institutes (government medical colleges, general hospitals, state-run
  • 98. 62  Section II: Historical Concepts and Evolution mental institutes, etc.) are supported to run postgraduate courses with an increased capacity. This involves establishing/ improving the institutes, equipment, tools, and basic infra­ structure (hostel, library, etc.). Support is to be provided for setting up/strengthening of 30 units each for psychiatry, clinical psychology, psychiatric social work, and psychiatric nursing. Upgradation of Psychiatric Wings of Government Medical Colleges/ General Hospitals Psychiatry Departments of Government Medical Colleges are to be supported. General/district hospitals are to be funded for establishment of a psychiatry wing. A grant of up to ` 50 lakhs per college for the upgrading of facilities and equipment as per the existing norms is to be provided. Preference is given to colleges/hospitals planning to start/increase seats of postgraduate (MD/DPM/DNB) courses in psychiatry. Modernization of State-run Mental Hospitals A grant of up to ` 3 crores per mental hospital is to be provided to mental hospitals for the modernization of facilities and equipment as per the existing norms which have not been funded previously. District Mental Health Programme and national rural health mission The existing districts where the District Mental Health Programme (DMHP) is presently under implementation continue to be supported under the NRHM on the existing norms. The National Mental Health Programme (NMHP) is mainstreamed now by integrating it with the National Rural Health Mission (NRHM) and the National Urban Health Mission (NUHM). All the funds for the NMHP for the states are to be routed through the State Health Society. States Governments are to map the mental health resources in their respective states and include the components of NMHP in the Program Implementation Plans (PIPs) for the NRHM. The steering committee on the NMHP under the chairmanship of the Secretary of the Ministry of Health and Family Welfare has been authorized to carry out any operational modifications as may be warranted for the better implementation of the program. States are required to submit proposals under various schemes of the program. Based upon the proposals/PIP from the states, funds are released to the State Health Society for implementation as per the scheme guidelines. The state nodal officer for the NMHP is to represent the NMHP in the State Health Society and get the grant released for various districts and institutions as per the scheme/guidelines. At the district level, the Program Officer represents the DMHP in the District Health Society and facilitates proposals related to the running of the DMHP. For effective implementation of the DMHP, the help of credible and community-based organizations could be enlisted at the state and district level. The advantages of the mainstreaming of the National Mental Health Programme through primary health care by its integration with the NRHM framework are: a. Optimal use of existing infrastructure at various levels of the health care delivery system. b. Use of NRHM platform for transfer/flow of funds to the states/UTs for better accountability and flexibility in respect of implementing various components of the program. c. State/district level health authorities play a role in the monitoring and implementation of the program. d. Integrated IEC activity under NRHM. e. Involvement of NRHM infrastructure for training related to mental health in the district. f. Use of NRHM machinery for procurement of drugs for use in NMHP. g. Involvement of community/Panchayati Raj Institutions. h. Building of credible referral chains for appropriate management of cases detected at lower levels of the health care delivery system. i. Using improved linkages/communication under the NRHM for MIS (Management Information System) in respect of NMHP. j. Sustaining DMHP after expiry of the period of central assistance in the district by its integration in the district health system. k. Mid-course corrections as and when required through the Empowered Programme Committee (EPC)/Mission Steering Group (MSG) of NRHM. The achievement of Indian Public Health Standards (IPHS), including the prescription of drugs, is to be ensured under the NRHM, by providing resources, flexibility, and powers, as given in Tables 1 and 2. Conclusion The NMHP was started with the vision of improved mental health in the country which has long been a neglected issue. Inadequate budget outlays in the initial 15 years diluted the implementation of the program. Under the NMHP, the authority to prepare plan of action for mental health was delegated to states which did not accord due priority to mental health. It was only after 1995 that states showed some interest in taking-up the Mental Health Programme
  • 99. Chapter 5: National Mental Health Programme  63 Table 1: Additional activities proposed on those existing in IPHS S.No. Health facility 1. Subcenter 2. Primary health center Community health center Subdivisional hospital 3. 4. 5. District hospital Existing in IPHS Additional activities that are proposed to meet the requirements under NMHP Health workers—male and female One medical officer and 14 staff 64 staff including 6 MBBS doc­tors 7 MBBS doctors and 22 general health staff (nurse and pharmacist) • Training of male and female health worker under NMHP One psychiatrist • • • • • • Psychotropic drugs Training of staff under NMHP Training of general duty medical officers and health staff under nmhp Provision of psychotropic drugs Training of general duty medical officers and health staff under NMHP Provision of psychotropic drugs • • MBBS doctors • Staff Nurse and Pharmacist • • Social worker/counselor 1–2 • 1 psychiatrist/program officer 1 clinical psychologist/trained psychologist 1 psychiatric social worker/social worker 1 psychiatric/community nurse 1 record keeper Training of program officer, psychologist, social worker and community nurse under NMHP • Training of MBBS doctors and general health staff including pharmacist • Provision of psychotropic drugs Table 2: List of drugs to be available at facilities under the proposed IPHS S.No. Drugs A. Available at all levels 1. Tab. chlorpromazine 2. Tab. risperidone 3. Tab. promethazine 4. Tab. imipramine 5. Inj. fluphenazine 6. Tab. trihexyphenidyl 7. Tab. diazepam 8. Tab. phenobarbitone 9. Tab. diphenylhydantoin B. District Hospital with Psychiatrist (in addition to above drugs) 1. Tab. lorazepam (Instead of Tab. Diazepam) 2. Tab. lithium carbonate 3. Tab. carbamazepine 4. Inj. haloperidol 5. Cap. fluoxetine 6. Tab. olanzapine once funds were allotted under the DMHP strategy. The DMHP requires psychiatrists at the district level but their availability has been a major hurdle due to the shortage of psychiatrists in the country. Even now, most districts do not have psychiatrists in the public sector. Undergraduate medical training in psychiatry has not changed, and this still is a Dose (mg) 100 2 40 75 25 2 5 30 and 60 100 2 300 200 10 20 5 barrier to the existence of adequately trained primary care doctors in mental health. An increase in the mental health workforce, which should include the training of medical officers in psychiatry, has to be a priority. Short-term training can be supported by a telemedicine link for consultation from regional hospitals
  • 100. 64  Section II: Historical Concepts and Evolution and medical colleges. Program-related and administrative responsibilities should be delegated to public health consultants at the district and block level so that psychiatrists and medical officers can devote more time to patient care. Understanding the disease burden and the risk factors is also important to fine tune the program in order to increase its effectiveness. The inclusion of mental illnesses in the routine health management information system (HMIS) and the Integrated Disease Surveillance Project (IDSP) will help to a realistic estimate of the burden and of the trend of illness at the community level. The chronic nature of mental illness and the associated social stigma raises concerns among persons living with mental illness. Supervised treatment and support remain fundamental for illness management. Families have a vital role in long-term care. A two-way referral from family to health center/hospital with support from community-based workers such as Accredited Social Health Activists (ASHA) needs to be established. Bibliography 1. Agarwal SP, Icchpujani RL, Shrivastava, Goel DS. Restructuring the national Mental Health Programme. in Mental health—an Indian perspective 1946–2003. Agarwal SP (Ed). New Delhi, Directorate General of Health Services, Ministry of Health and Family Welfare, Government of India 2004.pp.119-131. 2. Gururaj G, Reddy GNN, Subbakrishna DK. Service utilization pattern in extension services of NIMHANS. NIMHANS Journal 1988;6:85-91. 3. Kapur RL, Chandrashekar CR, Shamsundar C, Isaac MK, Parthasastry R, Shalini S. Extension of mental health services through psychiatric camps: a new approach. Indian Journal of Psychiatry 1982;24:237-241. 4. Mathai JP. Psychiatric practice through satellite units-Report of an experience. Indian Journal of Psychological Medicine 1984; 7:66-72. 5. Menon S. Psychosocial rehabilitation: Current trends. NIMHANS Journal 1996;14:295-305. 6. Murthy RS. Mental health in the new millennium: research strategies for India. Indian Journal of Medical Research 2004;120: 63-66. 7. Murthy RS. Mental Health Programme in the 11th Five Year Plan. Indian Journal of Medical Research 2007;125:707-712. 8. Patel V, Kleinman A. Poverty and common mental disorders in developing countries. Bulletin of the World Health Organization 2003;81:609-615. 9. Sriram TG, Chandrashekar CR, Isaac MK, Murthy RS, Shanmugham V. Training primary care medical officers in mental care: an evaluation using a multiple-choice questionnaire. Acta Psychiatrica Scandinavica 1990;81:414-417. 10. Wig NN, Murthy RS, Mani M, Arpan D. Psychiatric services through peripheral health centers. Indian Journal of Psychiatry 1980;22:311-316. 11. World Health Report 2001: Geneva, WHO, 2001, p. 36.
  • 101. 6 District Mental Health Programme BN Gangadhar, KV Kishorekumar INTRODUCTION Mental health, as much as physical and social health, is vital for individual welfare. These elements are, in fact, interwoven and deeply interdependent. As the understanding of this relationship grows, it becomes clear that mental health is crucial to the overall well-being of individuals, communities and societies (World Health Organization, 2001). Mental health is as important as physical health. Yet, there is a wide gap between what scientists know and what actually reaches the general public. For example, a mere fraction of the millions of people suffering from mental or behavioral disorders receive treatment. Advances in neuroscience and behavioral medicine have shown that, like many physical illnesses, mental and behavioral disorders are the result of a complex interaction between biological, psychological and social factors. However, most health problems are seen as only either physical or mental disorders. While there is still much to be learned, we already have the knowledge and power to reduce the burden of mental and behavioral disorders and to promote the mental health of individuals (World Health Organization, 2001). The Mental Health Care Programme in India has evolved in a ‘bottom to top’ approach over the last three and half decades. This has been possible because of commitment on the part of the government, mental health professionals, health administrators, policy makers and the community. The initial work done under the program demonstrated that mental illness is uniformly distributed in rural and urban areas and that very wide treatment gaps exist in the community due to a lack of mental health services and poor awareness about mental disorders on the part the community (Chandrashekhar et al., 1981). In addition, poverty and its consequences contribute and complicate the situation in the family. The scenario described above results in significant disability and chronicity of the illness in the person, which places a burden on the concerned family. It was recognized that the professional resources available in the field of mental health were inadequate to meet the needs of the ailing population in the community. Decentralizing mental health care by involving other health professionals like general medical doctors, primary care doctors, health workers, and other paramedical personnel was recognized as a practical and feasible alternative to meet the urgent mental health care needs of the community, covering the rural, urban and tribal populations of the country. This approach was also advocated as being an important practical alternative means to respond to the mental health needs of the community, particularly in developing countries (WHO, 1975). It is interesting to note that this involvement of general practitioners, nurses, health workers and other paramedical workers has become a universally accepted approach to address the great challenge of mental health care all over the world in both developing and developed nations. Therefore, decentralized mental health care using existing resources is a not just a cheap alternative found to compensate for a lack of mental health professional resources but a scientificallytested, pragmatic, community-based, economically viable and accessible system to provide care. THE MAGNITUDE OF MENTAL HEALTH PROBLEMS: THE NEED FOR DECENTRALIzED MENTAL HEALTH CARE Mental health problems are undoubtedly very common. A recent WHO report suggests that one in four families is affected by mental health problems in their lifetime. A World Health Organization coordinated the study carried out simultaneously in 15 countries, which reported that one in four patients who attended a primary health center had at least one diagnosable mental health problem and nearly a third of these patients had current depression. About twothirds of the patients had anxiety, depression and other mental health problems. It was interesting to note that majority of
  • 102. 66  Section II: Historical Concepts and Evolution patients were not recognized by the primary care doctors. It was found that primary care doctors were able to detect only very severe disorders based on the behavior of the patients, while recognition using clinical skills was poor. Most of the person with mental health problems were either treated with placebos or sub-therapeutic doses of psychotropic drugs (Ustun and Sartorious, 1995). A review of prevalence studies of mental disorders in India also supports the hypothesis of a high prevalence (i.e. 58.2 per thousand population) of these disorders (Reddy and Chandrashekar, 1998). training in mental health and neuro-sciences in the country. Similarly, many innovative approaches have been adopted to increase human resources for the DMHP in the country. As an interim measure, three-month and one year courses have been developed and states like Jammu and Kashmir, Gujarat, Haryana, Madhya Pradesh and Karnataka have benefited from this scheme. THE BURDEN OF MENTAL DISORDERS Several models of training were developed to facilitate mental health skills among non-mental health professionals (Isaac et al., 1982; Krishnamurthy et al., 1981; Shamsunder et al., 1982; Srinivasamurthy, 1982). These models can be broadly divided into centralized training (lasting two weeks or longer) and decentralized training for three days (at the district headquarters). Both models have been found useful in the dissemination of skills for medical officers and multipurpose workers to provide essential mental health care in primary care settings. The decentralized model of training is very economical and less disruptive to the functioning of the health care system and therefore suitable for the District Mental Health Programme. The DMHP model has been adopted in many countries in the developing world and it is very encouraging to note that the population covered using this approach is nearly 50 percent in countries like Iran (World Health Organization, 1995). This approach decreases the treatment gap, chronic recurrence of illness, and disability in the person, the burden on the family and, ultimately if indirectly, prevents the increase in poverty. Considering the aforementioned evidence, mental health care in the community is too important to be undermined or neglected because of a lack of manpower or other constraints. India has a long history of initiating community-based mental health care program over the last three decades and such efforts has resulted in the formulation of the National Mental Health Program for India as early as 1982. Till recently (the early 1980s), most psychiatric care was provided by the state-run mental hospitals (formerly called asylums). Thanks to the development of general hospital psychiatry, more general hospital-based services (mostly from medical colleges) and more psychiatric services were added by early the 1980s. Yet, access to the rural masses remain elusive. Some centers reached out to them by way of extension clinics. Examples are the Sakalawara Center (Kapur, 1977) and other extension clinics, (Reddy, 1983), and the Raipur Rani Center run by PGI, Chandigarh (Wig et al., 1981). These models were rarely emulated by other centers. It was estimated that, in 1990, mental and neurological disorders accounted for 10 percent of the total DALY’s (Disability Adjusted Life Years) lost due to all diseases and injuries. This loss was 12.4 percent in 2000. By 2020, it is projected that the burden of these disorders will increase to over 16 percent. Common conditions, which usually cause severe disability include-depressive disorders, substance use disorders, schizophrenia, epilepsy, Alzheimer’s disease, mental retardation, and disorders of childhood and adolescence (Murray and Lopez, 1996). CURRENT RESOURCES FOR MENTAL HEALTH CARE Mental health manpower is very poor in India. There are approximately fewer than 3,500 psychiatrists in the country. This is based on the directory of the Indian Psychiatric Society and the publication, Doctors in India 2009. Similarly, the number of clinical psychologists, social workers and psychiatric nurses are even fewer. In comparison to any developed nation with respect to mental health manpower, the resources available in India are far from satisfactory (Gangadhar, 2008). The lack of human resources is compounded by yet another phenomenon. While most of our population is rural, most mental health professionals and even the hospitals are in urban locations. This skewed distribution has deprived the majority of our community from the ability to obtain prompt mental health services when in need. This led to a search for alternative approaches to supplement resources. Attempts are being made to increase the number of mental health professionals through the development of centers of excellence (COE) (Government of India, 2007). Ten COEs have been identified and funded by the Ministry of Health, Government of India. They have been modelled on the lines of the National Institute of Mental Health and Neuro-Sciences (NIMHANS) based in Bangalore (Now Bengaluru). NIMHANS is one of the premier centers for CAPACITY-BUILDING FOR PRIMARY CARE PERSONNEL TO DELIVER MENTAL HEALTH CARE
  • 103. Chapter 6: District Mental Health Programme  Observations from the running of these services indicated that general medical practitioners can identify and manage mental disorders given some training. Health workers too could recognize a proportion of even severe mental disorders. These could be effectively managed in the community with these resources and with no need for hospitalization (Srinivasa Murthy et al., 2004). These observations culminated in the development of viable public health models to provide mental health services to community. The National Mental Health Programme (NMHP) (1982) had the following objectives: i. To ensure the availability and accessibility of minimum health care for all in the foreseeable future, particularly to the vulnerable and under-privileged sections of population. ii. To encourage the application of mental health knowledge in general health care and in social development. iii. To promote community participation in mental health care development in the country and to stimulate efforts towards self-help in the community. The District Mental Health Programme (DMHP) was conceptualized to understand the feasibility of providing basic mental health care for the entire district. The experience with respect to integration of mental health care in primary care before this was largely confined to the population reached through primary health centers. The DMHP was pilot-tested to understand the feasibility of Mental Health Care Programme on a public health platform in the District of Bellary, Karnataka, covering a population of 1.5 million people. The effectiveness of the District Mental Health Programme in Bellary resulted in the implementation of this model in several states in the country. Currently, over 125 districts implement the DMHP with financial assistance from the Ministry of Health, Government of India. THE ADVANTAGES OF PLANNING MENTAL HEALTH CARE AT THE DISTRICT LEVEL Organising mental health care using the public health infrastructure of the district has several advantages: a. Training for the medical officers, paramedical workers, nurses, pharmacists, gram panchayat members can be conducted in a very short period of time at the district headquarters. b. The district is an independent administrative unit with Deputy Commissioner/Collector as its head. c. The District Health Officer/Chief Medical Officer has administrative powers to plan activities in the district and 67 to initiate any specific administrative action depending on the need without waiting for instruction from the state headquarters. d. Inter-sectoral coordination is possible at the district level. e. Mobilization of additional resources is possible. f. All existing staff can be best utilized by involving the total district for the program of care. g. The district and not the Primary Health Center (PHC), is the unit for planning and implementation for most other health and welfare programs. AIMS AND OBJECTIVES OF THE DMHP The aim of the District Mental Health Programme is to extend mental health services to persons suffering from mental disorders in the district through the existing health care personnel and institutions. The mental health services should cater to the need of persons with psychosis, depression, neurosis, mental retardation and childhood mental health problems, substance use disorders and epilepsy. The trained PHC personnel are to be provided support and supervision on a regular basis to empower them to provide holistic care to the population. The progress of the DMHP is to be monitored by developing systemic mechanisms like review meetings, on-the-job training to refine skills, and improved coordination between the agencies to facilitate implementation of the DMHP. Specific Objectives • To develop and implement a decentralized training program in mental health for all categories of health personnel, appropriate to their levels of functioning with the least disruption to the ongoing general health care activities. • To provide a range of essential drugs (anti-psychotics; both oral and parenteral), anti-depressants, anticonvulsants and minor tranquilizers for the management of persons with mental disorders. • To develop a system of simple recording and reporting of care by health care personnel. • To monitor the effect of the service program in terms of treatment utilization and outcomes with treatment. THE PROCESS OF IMPLEMENTATION OF THE DMHP IN THE DISTRICT Methodology The most important aspect of the DMHP is the training of the PHC personnel (doctors, health workers and pharmacists)
  • 104. 68  Section II: Historical Concepts and Evolution to implement essential mental health care by their integration into general health services. The DMHP will be launched in all the states of the country after training the psychiatrist/ program officers and other members of the team in the philosophy of decentralized care within the district as in any other national program. Following this, the district mental health team consisting of the psychiatrists/program officer and the district psychiatrist will conduct training programs for the primary health care personnel to provide essential mental health care for the entire population of the district through the primary health care services in an integrated manner. The training program will last for three weeks and refreshertraining programs will be conducted every six months on a regular basis for doctors. The training program for health workers and other paramedical staff will be for one day, with refresher training programs every six months. The approach is used to ensure that all the staff of the district health services are trained in a short period of time so that identification, referral, diagnosis and management, education of the mentally ill persons and their family members, sensitization of the community, following the progress made by patients and their rehabilitation using local resources occurs in a coordinated manner in the entire district. The district team will address practical difficulties that might come up in the process of implementation in a structured and predictable manner. This support is ensured by regular visits to the PHC and by conducting regular review meetings with the staff. The DMHP team will provide support to the trained primary health care personnel by organizing regular visits to the PHC, PHU and Taluk hospitals in the district. This support and supervision will provide the DMHP team with an opportunity to understand the difficulties faced by the primary health care personnel in providing care. These insights form the basis for providing handholding or support by providing on-the-job training, clarification and suggestions for the provision of effective and appropriate care. Such visits will boost the morale of the primary care team and increase the confidence of the team to provide care. The progress of activity under the DMHP activity is monitored every month by the DMHP team and the district health authorities and this process facilitates incorporation of a mental health component into the existing general health services by the following: 1. Training of personnel: The district mental health team should be formed and these professionals should be trained in skills for the dissemination of skills for the facilitation of mental health care in the district. Their training will also focus on managerial, supervisory and leadership skills. The trained team will in turn conduct the training program for the doctors and other paramedical workers like nurses, multi-purpose workers and pharmacists in the district headquarters. 2. Provision of drugs: All the essential drugs should be made available at the primary health centers and the stock should be checked periodically by the DMHP team. 3. Simple recording system: Records for the registration of cases seen in the PHC should be made freely available in and these records should be checked for completeness, diagnostic errors and appropriate management plans. 4. District mental health clinic: The district mental health clinic should become functional to provide referral support to the primary health care teams and the inpatient services should be available for patients needing acute care within the district (10 beds). 5. Review- cum- training as part of visits to the periphery: Field visits are a very crucial link to the DMHP. The support provided by the DMHP team determines the level of mental health care activities. The DMHP team should provide at-least 15 working days for this work every month. 6. Monthly reporting, monitoring and feedback: The DMHP team should review the progress of mental health care every month and provide very objective feedback to the doctors. The meeting should provide an opportunity to sort out logistic difficulties and issues of cooperation with the district officials. 7. Community participation: The DMHP team should initiate efforts towards community participation for development of resources in the district (e.g. self-help groups, daycare centers and counseling centers. The following are the components of the revitalized DMHP as part of the Eleventh Five Year Plan: 1. Appointment of the Program Officer/psychiatrist in every district or training the medical officer with at least ten years’ experience to work as Program Officers after three months’ training in mental health care, training and supervisory skills or, 2. Appointment of the district family welfare officer to work with the psychiatrist after three months’ training in mental health care. 3. Provision of 10 beds for acute care at the district hospital. 4. A vehicle will be provided for the DMHP team to enable field visits by the psychiatrist and the district family welfare officer to the primary health centers and primary health units in the district and Taluk level hospitals. Funds for the hire of a vehicle will be made available instead of providing a vehicle for the exclusive use by the DMHP team.
  • 105. Chapter 6: District Mental Health Programme  5. Availability of all essential drugs in every primary health center and primary health unit. The essential drugs include Risperidone, chlorpromazine, imipramine, phenobarbitone, diphenyl hydantion, trihexyphenidyl, diazepam and injection diazepam, chlorpromazine and fluphenazine. 6. The district hospital will have more advanced drugs like Risperidone, Lithium carbonate, and Sodium valproate, Carbamazepine and injectible Chlorpromazine and Haloperidol. This is in addition to the essential drugs to facilitate a higher level of care for patients referred from the primary health care institutions. 7. IEC activities in the entire district. 8. Health promotion using a life skills approach in the schools. 9. Training program for medical officers and the paramedical staff at the district headquarters by the psychiatrist and the Program Officer as the case may be. 10. Monitoring, support and supervision–visits to the PHC/ PHU by the psychiatrist or the Programme Officer as the case may be, at least once a month. A monthly review of the mental health programme at the district level, compilation of the information about the number of cases registered, the number of cases on regular treatment, the number of cases needing home care by health workers, the number of cases of patients who have recovered, the number of cases of patients who have migrated or expired. MID-COURSE EVALUATION OF THE DMHPs A team of experts from NIMHANS evaluated the DMHP being carried out in 27 districts in 2003. The evaluation report (NIMHANS, 2003) concluded that programs were functioning at different levels of efficiency contributing to different levels of outcome. Many of the DMHPs in most states had shown satisfactory progress at various stages of implementation. Where the program had been successful, the objectives of decentralizing mental health services from the cities to the district level, from the mental hospitals to the medical college hospital and the partial integration of mental health services with general health had been achieved,, the possibility of early detection of mental illness in the community had been enhanced, the distances that patients and families had to travel had been reduced, and there were indications to suggest that the case-load of mental hospitals where the programs were being implemented was declining. It attributed the success of the program to the motivation 69 and commitment of the nodal officer and the program staff, the interest and support of the administrative staff and the senior state health authorities. The report also expressed concern about the lack of any meaningful work in a few districts. It emphasized the need for an effective central support and monitoring mechanism. It highlighted that funds were not a constraint, but accessing funds was. FINDINGS AND THE RECOMMENDATIONS OF THE EVALUATION OF THE FUNCTIONING OF DMHP IN INDIA: EVALUATION BY THE MINISTRY OF HEALTH AND FAMILY WELFARE, GOVT OF INDIA, 2009 Findings • One-third of the districts under the Ninth Plan have utilized over 99 percent, one-third utilized 63 to 91 percent, and the rest have utilized 37 to 47 percent of the total amounts they received. This is mainly due to administrative delay, difficulty in the recruitment and retaining of qualified mental health professionals, low utilization in training and IEC components. • In case of the Tenth Plan districts, most of the districts had received only the first instalme