Community mental health in
India- way ahead
Dr K.V.Kishore Kumar
Psychiatrist
2
Magnitude of mental disorders
• 10-15% of adult population affected
• 20% of patients seeking primary health
care have o...
World Health Survey 2003 – Karnataka
• A national sample of 10,000 individuals were
surveyed as part of WHS 2003
• States ...
Burden of mental disorders
6%
6%
4%
3%
3%
6%
7%
5%
13%
3%
10%
4%
3%
12% Cardiovascular diseases
Diabetes
Malignant neoplas...
5
Burden of disease
% attributed to mental and behavioural disorders
of total DALYs lost world-wide
• 1990 10 %
• 2000 12....
Global estimates
340 million Depression
45 million Schizophrenia
91 million Alcohol use disorders
15 million Drug use diso...
Global recommendations
• Integrate mental health in primary care
• Educate communities – mental disorders
• Ensure availab...
1950 - Amritsar – Family involvement
1960 - GHPU’s
1969 - Mudaliar committee recommendation on mental health
1970 - Integr...
9
Community-based care
benefits
• Services close to home
• Focus on disabilities as well as symptoms
• Focus on the indivi...
10
Depression
Up to 60% of patients recover
Substance Abuse
Up to 60% reduction in drug use
Epilepsy
Up to 73% of patients...
11
Poor utilisation of services
example from Australia 1997
Tab le 3 .1 Utili za tion of pro fessiona l se rvice s for m e...
Cost of care
753.27
997.41
352.34
476.37
395.03
451.07
1554.66
1357.95
1278.58 1294.32
962.09
1001.95
1075.69
1016.72
884....
Leading cause of years lived with disability
• Unipolar depression = 11.9%
• Hearing loss adult onset = 4.6
• Iron def ana...
Needs of persons with mental disorders
NMHP- 1982
1. Availability and
accessibility of minimal
MH services for all
2. Application of
knowledge to general
health ...
Approaches:
1. Diffusion of mental health skills
2. Task distribution
3. Equity
4. Integration of services
5. Linkage with...
Long-Stay
Facilities
&
Specialist Services
Community
Mental
Health
Services
Psychiatric
Services in
General
Hospitals
Ment...
Some important insights
• Community care is possible
• Economical and effective
• Non mental health professional can partn...
IEC-Manual for Health workers
IEC-Manual for medical officers
Ten features of mental disorder- Flip charts and
posters
Interactive computer-based video
training modules (6 CDs)
Institutional response to mental health
problems.
• Mental Health Problems are large in magnitude
• Challenge of mental he...
Community care in India-DMHP
• 123 DMHP as part of 10th 5 year plan.
• DMHP will extended to all the district in the
count...
Mental Disorders and poverty
Mental health gap action program
• WHO launched 2008
• Program to reduce treatment
gap
• Up Scaling of services
• Asserts ...
Changing paradigm in mental health
• Technical – political response
• Exclusion – inclusion
• Individual to public health ...
Gaps in mental health
• Promotion and prevention
• Access to quality care
• Policy and financing
• Human rights
• Values a...
Institutional response- continued
• Man power resource development –
increase in the number of psychiatrist by
substantial...
• Deinstitutionalization (Italy, 1978)
• Care in the community
• Partnership with consumers
• Partnership with families
• ...
Psychiatric beds and professional
Psych beds World S-E- Asia India
Total 1.69 0.33 0.25
MH 1.16 0.27 0.2
GH 0.33 0.03 0.05...
Barriers to care
• Though cost effective treatments exist
• Serious mental illness is not recognized
• Benefits of treatme...
Evaluation
Barriers in DMHP
 Administrative Barriers
 Lack of clarity in guidelines
 Lack of manpower resources
 Motiv...
Extension of DMHP
• 1996-1997 = 4 Districts
• 1997-1998= 7 Districts
• 1998-1999= 5 Districts
• 1999-2000= 4 Districts
• 2...
MENTAL HEALTH
- NEW UNDERSTANDING
- NEW HOPE
WORLD HEALTH REPORT 2001
1. Provide treatment in primary care
2. Make psychotropic medicines available
3. Provide care in the community
4. Educate ...
6. Establish National Policies, Legislation
7. Develop human resources
8. Link with other sectors
9. Monitor community men...
LOOKING AHEAD
CHALLENGES
1. Very uneven distribution of resources
across states / UTs.
2. Low human resources for mental
h...
• Build on community resources
• Community tolerance
• Family commitment
• Limited barriers for professional work
• Partne...
Conclusions
• Mental Health Problems are common and
universal
• There is no health care without mental
health care
• Menta...
Conclusions- continued
• Strengthening medical colleges and
development of regional institutes of
mental health is crucial...
Conclusions- continued
• Empowering families to strengthen partnership
with service providers.
• Investing on data base of...
Community mental health in India -way ahead
Community mental health in India -way ahead
Community mental health in India -way ahead
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Community mental health in India -way ahead

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Community mental health in India -way ahead

  1. 1. Community mental health in India- way ahead Dr K.V.Kishore Kumar Psychiatrist
  2. 2. 2 Magnitude of mental disorders • 10-15% of adult population affected • 20% of patients seeking primary health care have one or more mental disorders, though not recognised • One in four families have at least one member with a behavioural or mental disorder at any point in time. C H A P T E R T W O © 2001
  3. 3. World Health Survey 2003 – Karnataka • A national sample of 10,000 individuals were surveyed as part of WHS 2003 • States selected were Assam, West Bengal, Rajasthan, Karnataka and Maharasthra. • Sample size of Karnataka was 1300 • 9% of the sample were diagnosed as depression • Psychosis was < 1%
  4. 4. Burden of mental disorders 6% 6% 4% 3% 3% 6% 7% 5% 13% 3% 10% 4% 3% 12% Cardiovascular diseases Diabetes Malignant neoplasms Digestive diseases Neuropsychiatric disorders Other NCDs Injuries Other CD causes Maternal conditions Malaria Childhood diseases Tuberculosis Diarrhoeal diseases Perinatal conditions HIV/AIDS Respiratory infections Respiratory diseases Nutritional deficiencies Sense organ disorders Diseases of the genitourinary systemMusculoskeletal diseases Congenital abnormalities
  5. 5. 5 Burden of disease % attributed to mental and behavioural disorders of total DALYs lost world-wide • 1990 10 % • 2000 12.3 % • 2020 (projected) 15 % C H A P T E R T W O © 2001
  6. 6. Global estimates 340 million Depression 45 million Schizophrenia 91 million Alcohol use disorders 15 million Drug use disorders 50 million Epilepsy 29 million Dementia 8.77 lakh people complete suicide every year One out every four seeking help have mental /behavioral / neurological- most of them untreated or undiagnosed
  7. 7. Global recommendations • Integrate mental health in primary care • Educate communities – mental disorders • Ensure availability of psychotropics • Involve families communities and groups • Establish policy, program and legislation at national level. • Provide and develop human resource for mental health • Intersectoral linkages for mental health care • Promote research and evidence
  8. 8. 1950 - Amritsar – Family involvement 1960 - GHPU’s 1969 - Mudaliar committee recommendation on mental health 1970 - Integration of mental health care with primary health care 1974 - Srivatsava committee recommendation on community level volunteer 1975 - Launch of community mental health services 1985 - Bellary DMHP 1985 – NDPS act 1987 – Mental health act 1990 - NGO’s 1992 - Rehabilitation council of India act 1995- Disability act 1997 -Quality assurance in mental health care 1999- mental health identified as priority for the WHO 1999 – National trust act 2001- World health report 2003- world health survey 2003 – evaluation of DMHP 2007 – UNCRPD 2007-08 – Up-scaling DMHP to 123 Districts‘ 2011-12 – mental health policy initiatives 2013 – Union Cabinet clears mental health care bill Important Milestones of Mental Health Care in India
  9. 9. 9 Community-based care benefits • Services close to home • Focus on disabilities as well as symptoms • Focus on the individual • Wide range of services • Ambulatory rather than static services • Partnership with carers • Better quality of life for ill persons • Prevents inappropriate admissions C H A P T E R T H R E E © 2001
  10. 10. 10 Depression Up to 60% of patients recover Substance Abuse Up to 60% reduction in drug use Epilepsy Up to 73% of patients live free from seizures Schizophrenia Up to 77% of patients live without relapses Effectiveness of Treatment © 2001 C H A P T E R T H R E E FromTables3.2and3.4 © 2001
  11. 11. 11 Poor utilisation of services example from Australia 1997 Tab le 3 .1 Utili za tion of pro fessiona l se rvice s for m en tal prob lems , Aus trali a, 1997 Co nsult at ions for m ent al pro bl em s No dis or der Any dis or der > 3 dis or ders % % % Gene ral pr actition er on ly a 2.2 13 .2 18 .1 M ental he alth pro fessiona l on ly b 0.5 2.4 3.9 Othe r healt hp rof ession alon ly c 1.0 4.0 5.7 Co m bina tion of hea lt h profe ssiona ls 1.0 15 .0 36 .4 Any hea lt hp rofessi ona l d 4.6 34 .6 64 .0 a Refers t o pers ons w ho had at least one consultation with a general p ractitioner i n the previo us 12 mo nths b ut did not c onsult any other type of h eal th professional. b Refers t o pers ons w ho had at least one consultation with a m ental health professional (psychiatrist/psychologist/m ental hea lth team ) in the previous 1 2 m onths but did n ot consult any other Table3.1 C H A P T E R T H R E E © 2001
  12. 12. Cost of care 753.27 997.41 352.34 476.37 395.03 451.07 1554.66 1357.95 1278.58 1294.32 962.09 1001.95 1075.69 1016.72 884.81 295.28280.54299.75279.07 76.9 1.6317.416.72 83.93 12.41 1556.69 1505.5 1182.76 0 200 400 600 800 1000 1200 1400 1600 1800 Bas eline 3 m onths 6 m onths 9 m onths 12 m onths 15 m onths 18 m onths CostinRupees Service Travel & tim e Fam ily Total
  13. 13. Leading cause of years lived with disability • Unipolar depression = 11.9% • Hearing loss adult onset = 4.6 • Iron def anaemia = 4.5 • Chronic obstructive airway disease = 3.3 • Alcohol use disorders = 3.1 • Osteoarthritis =3.0 • Schizophrenia =2.8 • Injury =2.8 • BPAD =2.5 • Asthma =2.1
  14. 14. Needs of persons with mental disorders
  15. 15. NMHP- 1982 1. Availability and accessibility of minimal MH services for all 2. Application of knowledge to general health care and social development 3. Stimulate Community participation
  16. 16. Approaches: 1. Diffusion of mental health skills 2. Task distribution 3. Equity 4. Integration of services 5. Linkage with community development National Mental Health Programme (1982
  17. 17. Long-Stay Facilities & Specialist Services Community Mental Health Services Psychiatric Services in General Hospitals Mental Health Services Through PHC Informal Community Care Self Care highhigh lowlow highhigh lowlow COSTSCOSTSFREQUENCYFREQUENCY OF NEEDOF NEED Optimal mix of different mental health servicesOptimal mix of different mental health services (WHO 2003(WHO 2003)) QUANTITIY OF SERVICES NEEDEDQUANTITIY OF SERVICES NEEDED
  18. 18. Some important insights • Community care is possible • Economical and effective • Non mental health professional can partner with mental health professionals to deliver such a care. • Community accepts the approach to care • Ineffective implementation is due to systemic, professionals and inadequate use of resources.
  19. 19. IEC-Manual for Health workers
  20. 20. IEC-Manual for medical officers
  21. 21. Ten features of mental disorder- Flip charts and posters
  22. 22. Interactive computer-based video training modules (6 CDs)
  23. 23. Institutional response to mental health problems. • Mental Health Problems are large in magnitude • Challenge of mental health care is essentially collective responsibility of the Government, Civil society and Non- governmental voluntary agencies • Community based approach to mental health care is critical to reach the masses • Integrating mental health care into general health care is the key strategy
  24. 24. Community care in India-DMHP • 123 DMHP as part of 10th 5 year plan. • DMHP will extended to all the district in the country in the 11th plan period period. • A sum of 1089 crores will allocated for the mental health program • Current approaches to provide community care through DMHP uses restrategized methods
  25. 25. Mental Disorders and poverty
  26. 26. Mental health gap action program • WHO launched 2008 • Program to reduce treatment gap • Up Scaling of services • Asserts that with proper care, psychosocial assistance and medication, tens of millions could be treated for depression, schizophren ia, and epilepsy, prevented from suicide and begin to lead normal lives– even where resources are scarce.
  27. 27. Changing paradigm in mental health • Technical – political response • Exclusion – inclusion • Individual to public health approach • Hospitalization – Ambulatory to primary care • Individual action to team work • Hospital – community
  28. 28. Gaps in mental health • Promotion and prevention • Access to quality care • Policy and financing • Human rights • Values and Knowledge
  29. 29. Institutional response- continued • Man power resource development – increase in the number of psychiatrist by substantial increase in PG training centres • Innovative approaches to fill the void- training public health personnel to provide mental health care at PHC level and to manage mental health care programs at district level.
  30. 30. • Deinstitutionalization (Italy, 1978) • Care in the community • Partnership with consumers • Partnership with families • Human rights International Developments
  31. 31. Psychiatric beds and professional Psych beds World S-E- Asia India Total 1.69 0.33 0.25 MH 1.16 0.27 0.2 GH 0.33 0.03 0.05 Others 0.20 0.03 0.01 Psychiatrists 1.20 0.20 0.08 NS 0.20 0.03 0.06 P Nurses 2.0 0.10 0.05 Psychologist 0.60 0.03 0.03 SW 0.40 0.04 0.03 Beds/10T Professional One lakh
  32. 32. Barriers to care • Though cost effective treatments exist • Serious mental illness is not recognized • Benefits of treatment not well understood • Policy makers, insurance companies, health and labour policies, General public all discriminate between physical and mental disorders • LAMIC allocate less 1% health expenditure to mental health • Consequently, community care, policy, legislation and treatment does not get the priority they deserve
  33. 33. Evaluation Barriers in DMHP  Administrative Barriers  Lack of clarity in guidelines  Lack of manpower resources  Motivational barriers  General Issues
  34. 34. Extension of DMHP • 1996-1997 = 4 Districts • 1997-1998= 7 Districts • 1998-1999= 5 Districts • 1999-2000= 4 Districts • 2000-2001= 7 Districts • 2003-2004= 22 Districts • 2005-2006=94 Districts • 2007-2012=123 Districts
  35. 35. MENTAL HEALTH - NEW UNDERSTANDING - NEW HOPE WORLD HEALTH REPORT 2001
  36. 36. 1. Provide treatment in primary care 2. Make psychotropic medicines available 3. Provide care in the community 4. Educate the public 5. Involve communities, families and consumers RECOMMENDATIONS OF WHR 2001
  37. 37. 6. Establish National Policies, Legislation 7. Develop human resources 8. Link with other sectors 9. Monitor community mental health 10. Support more research WHR 2001 – RECOMMENDATIONS
  38. 38. LOOKING AHEAD CHALLENGES 1. Very uneven distribution of resources across states / UTs. 2. Low human resources for mental health care 3. Poor UG training in Psychiatry 4. Lack of welfare programmes 5. Public ignorance 6. Growth of private sector
  39. 39. • Build on community resources • Community tolerance • Family commitment • Limited barriers for professional work • Partnerships with wide variety of community resources • Integration of services • Using technology to improve access to care OPPORTUNITIES
  40. 40. Conclusions • Mental Health Problems are common and universal • There is no health care without mental health care • Mental Disorders are disabling and burdensome • Effective and safe interventions are available in the country • Integrating mental health care with general health services is an important strategy
  41. 41. Conclusions- continued • Strengthening medical colleges and development of regional institutes of mental health is crucial for increase in mental health manpower resource • Considering and implementing innovative approaches to fill the void in manpower is an important short term measure. • Development of telemedicine facilities to disseminate knowledge , skills is of parmount importance
  42. 42. Conclusions- continued • Empowering families to strengthen partnership with service providers. • Investing on data base of people with mental health problems to facilitate accurate estimation of treatment gap. • Intensification of IEC activities • Research to understand outcomes of interventions. • Upgrading resource material so as to incorporate recent developments • Professional commitment to incorporate research evidence into service delivery.
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