Community Mental Health
in India
Community Mental Health
in India
Editors
BS Chavan
Professor and Head
Department of Psychiatry
Government Medical College ...
®

  Jaypee Brothers Medical Publishers (P) Ltd.
Headquarters
Jaypee Brothers Medical Publishers (P) Ltd
4838/24, Ansari R...
About the Editors
BS Chavan is presently Professor and Head, Department of Psychiatry at Government Medical College and Ho...
vi  Community Mental Health in India

She has participated in 5 workshops on development of Clinical Practice Guidelines o...
Contributors
Munish Aggarwal
Senior Resident
Department of Psychiatry
Postgraduate Institute of Medical
Education and Rese...
viii  Community Mental Health in India
BS Chavan
Professor and Head
Department of Psychiatry
Government Medical College an...
Contributors 
Nitin Gupta
honorary senior lecturer
Staffordshire University
Formerly Consultant Psychiatrist
South Staffor...
x  Community Mental Health in India
Brian Kelly
Professor of Psychiatry
Faculty of Medicine
University of Newcastle
Austra...
Contributors 
S Haque Nizamie
Professor
Department of Psychiatry
Director, Central Institute of Psychiatry
Ranchi, Jharkha...
xii  Community Mental Health in India
Ammara Shabbir
Research Associate
Fountain House
Lahore, Pakistan

Dr Sood
Former Pr...
Foreword
Traveller, there is no path; paths are made by walking (An Australian Aboriginal Saying).
The progress of psychia...
xiv  Community Mental Health in India

	 I have gone through the contents of Community Mental Health in India and I am ver...
Foreword
One in four people will at some time in his life requires mental health care. Only two percent of the government ...
Preface
THE ROAD LESS TRAVELED

To date, an Indian book written by scholars in the field of contemporary community mental ...
xviii  Community Mental Health in India

were experts in the field of community mental health, preventive and social medic...
Preface 

xix

growing sporadically, probably being more individual-driven than system-driven. Thus, the book is an attemp...
xx  Community Mental Health in India

contributed to both national and international literature in advancing our understan...
Preface 

xxi

and District Mental Health Programme (DMHP), we did recognize that this was a ‘necessary evil’ as these two...
xxii  Community Mental Health in India

	 It was clearly felt by us that we cannot talk about the mantra of ‘delivering me...
Preface 

xxiii

professionals. Evidence to back, this is detailed through a sustained clinical ethnography in a north Ind...
Acknowledgments
Acknowledging the people and forces behind this book is an onerous yet pleasant task, as there have been c...
xxvi  Community Mental Health in India
Acknowledgments for reprints
Chapter 49

The authors gratefully acknowledge permiss...
Contents
Section I: An Introduction to Community Mental Health
	 1.	 The Relevance of Community Psychiatry in India..........
xxviii  Community Mental Health in India
Family in Management of Psychiatric Illnesses 82 • Changes in Traditional Indian ...
Contents 

xxix

• Implementation of the Act 173 • Awareness of the Act 174 • Certification of Disability 174 • United Nat...
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  1. 1. Community Mental Health in India
  2. 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. 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: jaypee@jaypeebrothers.com 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: info@jpmedpub.com Email: cservice@jphmedical.com Jaypee Brothers Medical Publishers (P) Ltd 17/1-B Babar Road, Block-B, Shaymali Mohammadpur, Dhaka-1207 Bangladesh Mobile: +08801912003485 Email: jaypeedhaka@gmail.com Jaypee Brothers Medical Publishers (P) Ltd Shorakhute, Kathmandu Nepal Phone: +00977-9841528578 Email: jaypee.nepal@gmail.com Website: www.jaypeebrothers.com Website: www.jaypeedigital.com © 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: jaypee@jaypeebrothers.com 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. 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. 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. 6. Contributors Munish Aggarwal Senior Resident Department of Psychiatry Postgraduate Institute of Medical Education and Research Chandigarh, India Email: drmunish2028@gmail.com 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: docniraj@gmail.com Jasmin Arneja Junior Resident Department of Psychiatry Government Medical College and Hospital Chandigarh, India Email: jasmin.arneja@gmail.com Priti Arun Professor Department of Psychiatry Government Medical College and Hospital Chandigarh, India Email: drpritiarun@gmail.com 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: Dinesh.Arya@hnehealth.nsw.gov.au Ajit Avasthi Professor Department of Psychiatry Postgraduate Institute of Medical Education and Research Chandigarh, India Email: drajitavasthi@yahoo.co.in Vikas Bhatia Associate Professor Department of Community Medicine Government Medical College and Hospital Chandigarh, India Email: drbhatiav@yahoo.com 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: dr.manik.bhise@gmail.com Debasish Basu Professor Drug De-addiction and Treatment Center Department of Psychiatry Postgraduate Institute of Medical Education and Research Chandigarh, India Email: db_sm2002@yahoo.com 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: pbbehere@gmail.com Rachna Bhargava Assistant Professor Department of Psychology Delhi University, North Campus New Delhi, India Email: rachnabhargava@gmail.com Rakesh K Chadda Professor Department of Psychiatry All India Institute of Medical Sciences New Delhi, India Email: drrakeshchadda@gmail.com 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. 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: drchavanbs@yahoo.com 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: samyrdalwai@gmail.com 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: Cheng_LEE@imh.com.sg Bhargavi V Davar Center for Advocacy in Mental Health A 4-38, Ujwal Park Housing Society NIBM Road, Kondhwa Khurd Pune, Maharashtra, India Email: camhpune@gmail.com 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: arabinda.chowdhury@btinternet.com Cheah Yee Chuang Senior Consultant Psychiatrist (Community and Rehabilitation) Hospital Bahagia Ulu Kinta Tanjung Rambutan 31250 Perak Darul Ridzuan, Malaysia Email: yeechuangcheah@yahoo.com 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: koushik.sinha.deb@gmail.com Anju Dhawan Additional Professor National Drug Dependence Treatment Centre And Department of Psychiatry All India Institute of Medical Sciences New Delhi, India Email: anjudh@hotmail.com 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: mirjam.d@thebanyan.org Abhiruchi Galhotra Assistant Professor Department of Community Medicine Government Medical College and Hospital Chandigarh, India Email: abhiruchigalhotra@yahoo.com BN Gangadhar Professor Department of Psychiatry National Institute of Mental Health and Neurosciences Bengaluru, Karnataka, India Email: kalyanybg@yahoo.com Rohit Garg Senior Research Associate Department of Psychiatry Government Medical College and Hospital Chandigarh, India Email: drrohitgarg@hotmail.com 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: navendugaur@yahoo.com  Vandana Gopikumar The Banyan Academy of Leadership in Mental Health (BALM) 6th Main Road ERI Scheme Mogappair West Chennai, Tamil Nadu, India Email: vandana.gopikumar@thebanyan.org Arunima Gupta Associate Professor Department of Psychology Maharshi Dayanand University Rohtak, Haryana, India. Email: arunimargupta@yahoo.com Divya Gupta National Advocacy and Campaign Analyst United Nations Millennium Campaign New Delhi, India Email: divyagupta2@gmail.com
  8. 8. Contributors  Nitin Gupta honorary senior lecturer Staffordshire University Formerly Consultant Psychiatrist South Staffordshire and Shropshire NHS F ­ oundation Trust United Kingdom Email: nitingupta659@yahoo.co.in 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: rajivguptain2003@yahoo.co.in 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: Mohan.Isaac@uwa.edu.au 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: s.jadhav@ucl.ac.uk 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: sumeet.jain@ed.ac.uk 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: rcjiloha@hotmail.com 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: dr.joseph.leong@gmail.com Anirudh Kala Clinical Director Mind Plus Clinic Ludhiana, Punjab, India Email: anirudhkala@gmail.com 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: kar.nilamadhab@yahoo.com Mohammad Zia Ul Haq Katshu PhD Student School of Psychology and Wolfson Centre for Cognitive Neurosciences University of Wales Bangor United Kingdom Email: pspd29@bangor.ac.uk Kunal Kala Consultant Psychiatrist Mind Plus Clinic Ludhiana, Punjab, India Email: kunalkala@gmail.com 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: jagdish.kaur@nic.in Roy Abraham Kallivayalil Professor and Head Department of Psychiatry Pushpagiri Institute of Medical Sciences Tiruvalla, Kerala, India Email: roykalli@gmail.com Paramleen Kaur Ex-Assistant Professor Department of Psychiatry Government Medical College and Hospital Chandigarh India Email: paramleenkaur@gmail.com
  9. 9. x  Community Mental Health in India Brian Kelly Professor of Psychiatry Faculty of Medicine University of Newcastle Australia Email: Brian.Kelly@newcastle.edu.au Hemant Singh Keshwal Course Coordinator and Member Expert Committee RCI Regional Institute for Mentally Handicapped Chandigarh India Email: hemantkeshwal@gmail.com Raumish Masud Khan Assistant Professor Department of Applied Psychology Kinnaird College for Women Lahore Pakistan Emai: raumishmasudkhan@gmail.com Sudhir Kumar Khandelwal Professor Department of Psychiatry All India Institute of Medical Sciences New Delhi India Email: sudhir_aiims@yahoo.co.uk 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: dr.rajeshkumar@gmail.com Sunder Lall Professor Department of Community Medicine Adesh Institute of Medical Sciences and Research Bathinda, Punjab, India Email: docvikas79@gmail.com 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: santoshl_28@yahoo.co.in Dinesh Kumar Assistant Professor Department of Community Medicine Dr Rajendera Prasad Government Medical College Kangra Himachal Pradesh, India E-mail: dinesh9809@gmail.com 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: savita.pgi@gmail.com Jayan Mendis Director and Consultant Psychiatrist National Institute of Mental Health (NIMH) Sri Lanka Email: drjmendis@yahoo.com Keerti Menon Principal and Clinical Psychologist Community Health Team-Psychological Therapies Hertfordshire Partnership Foundation NHS Trust Watford, United Kingdom Email: menondk@ntlworld.com 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: smurthy030@gmail.com Naresh Nebhinani Senior Resident Department of Psychiatry Postgraduate Institute of Medical Education and Research Chandigarh, India Email: drnaresh_pgi@yahoo.com Elizabeth Negi Independent Consultant and Social Scientist Guindy, Chennai Tamil Nadu, India Email: efnegi@gmail.com
  10. 10. Contributors  S Haque Nizamie Professor Department of Psychiatry Director, Central Institute of Psychiatry Ranchi, Jharkhand, India Email: sh.nizamie@gmail.com Antti Pakaslahti Adjunct Professor of Transcultural Psychiatry School of Health Sciences University of Tampere Finland Email: pakantti@gmail.com 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: incarnapune@gmail.com Suravi Patra Senior Resident Department of Psychiatry Government Medical College and Hospital Chandigarh, India Email: patrasuravi@gmail.com Raman Deep Pattanayak Senior Research Associate Department of Psychiatry All India Institute of Medical Sciences New Delhi, India Email: drramandeep@gmail.com Reeta Peshawaria Lead Consultant and Clinical Psychologist Tertiary Assessment and Treatment Unit and Specialist Residential Services Harperbury Hospital Hertfordshire United Kingdom Email: r_peshawaria@hotmail.com Samir Kumar Praharaj Assistant Professor Department of Psychiatry Kasturba Medical College Manipal, Karnataka, India Email: samirpsyche@yahoo.co.in Chhaya Sambharya Prasad Developmental Pediatrician Regional Institute for Mentally Handicapped Chandigarh, India Email: chhaya_sam@yahoo.co.in 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: drlokraj@hotmail.com Sneha Rajaram Freelance Writer Pune, Maharashtra India Email: sneha.rajaram@gmail.com xi Abhijit Rozatkar Ex Senior Resident Department of Psychiatry Government Medical College and Hospital Chandigarh, India Email: abhijeet_havoc@yahoo.com 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: drrahul.saha19@gmail.com 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: drsajipg@yahoo.com Alok Sarin Senior Fellow Nehru Memorial Museum and Library Senior Consultant and Psychiatrist Sitaram Bhartia Institute New Delhi, India Email: aloksarin@gmail.com Somnath Sengupta Consultant General Psychiatry Institute of Mental Health/Woodbridge Hospital Buangkok Green Medical Park Buangkok view, Singapore Email: ssengupta2003@gmail.com
  11. 11. xii  Community Mental Health in India Ammara Shabbir Research Associate Fountain House Lahore, Pakistan Dr Sood Former President Prayatan Chandigarh, India Email: dr_sood@rediffmail.com KS Shaji Professor and Head Department of Psychiatry Government Medical College Thrissur, Kerala, India Email: drshajiks@gmail.com Jagannathan Srinivasaraghavan Professor Emeritus Department of Psychiatry Southern Illinois University School of Medicine Consultant Psychiatrist Veterans Affairs Medical Center Marion, Illinois, USA Email: jagvan@gmail.com Pratap Sharan Professor Department of Psychiatry All India Institute of Medical Sciences New Delhi, India Email: pratapsharan@yahoo.com 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: ajeetsidana@hotmail.com Dato’ Suarn Singh Senior Consultant Forensic Psychiatrist Ministry of Health Malaysia Hospital Bahagia Ulu Kinta Perak Darul Ridzuan, Malaysia Email: suarnsingh@yahoo.co.uk Suman K Sinha Assistant Professor Department of Psychiatry Lady Hardinge Medical College   New Delhi, India Email: drsumansinha@gmail.com A Shyam Sundar Assistant Professor Department of Psychiatry National Institute of Mental Health and Neurosciences Bengaluru, Karnataka, India Email: a.shyamsundar@gmail.com 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: scarf@vsnl.com 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: jitendra.trivedi@gmail.com Umamaheswari V Junior Resident Department of Psychiatry Postgraduate Institute of Medical Education and Research Chandigarh India Email: uma2k2@gmail.com 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: vijoyv@frontier.com 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: wignn@yahoo.co.in 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. 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. 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. 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. 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. 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. 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. 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. 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. ac.uk/mentalhealth/research/suicide/prevention/nci/), 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. 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. 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. 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. 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. 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. 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. 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

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