4. A state of well-being in which
the individual realizes his or her
own abilities, can cope with the
normal stresses of life, can work
productively and fruitfully, and is
able to make a contribution to his
or her community
A state of well-being in which
the individual realizes his or her
own abilities, can cope with the
normal stresses of life, can work
productively and fruitfully, and is
able to make a contribution to his
or her community
1. Feels comfortable about
himself
2. Feels right towards others
3. Is able to meet demands of
life
Three main characteristics of
mentally healthy person:
5. A “syndrome” with three
correlated but distinct
factors
Emotional
well-being
Psychological well-
being
Social
well-being
Individual’s satisfaction
& positive affect with
their “life overall”
Self acceptance
Positive relation with others
Personal growth
Purpose in life
Environmental mastery
Autonomy
Social cohesion
Social actualization
Social integration
Social acceptance
Social contribution
10. Keye’s Complete State Model (CSM)
Optimal mental health
Low
mental
illness
Minimal mental health
Serious
mental
illness
High
level of
mental
well-
being
No
mental
illness
diagnosis
Low
level of
mental
well-
being
No
mental
illness
diagnosis
low
level of
mental
well-
being
Serious
mental
illness
diagnosis
High
level of
mental
well-
being
Serious
mental
illness
diagnosis
Flourishing
Complete
mental health
Languishing
Incomplete
mental health
Floundering
Complete
mental illness
Struggling
Incomplete
mental illness
14. Deinstitutionalization:
Replacement of federal mental
hospitals for community mental
health services
First International Congress of
Mental Health was organized in
London by the British National
Association for Mental Hygiene
from 16 to 21 August, 1948
International Committee on
Mental Hygiene later superseded by
World Federation of Mental Health
Recent trend has been the addition of the qualifier public to either
mental health or to psychiatry, as it can be seen in a WHO document
entitled Public mental health
Modern community mental health
services started to grow and become
influential
1977: NIMH initiated its Community Support
Program (C.S.P.) with goal to shift the focus from
psychiatric institutions and the services they offer to
networks of support for individual clients
16. Pre-Colonial India
1700s: Development of lunatic asylums
in Calcutta, Madras, Bombay
Colonial
India
More custodial, less curative
1745: First mental hospital 1933: First psychiatric
outpatient service at
RG. Kar
Post
Independence
• Involving the family members of the patient
• Mental hospitals in India were modified by
developing training facilities, expanding outpatient
and community services, and also downsizing the
inpatient units
20th Century
• Took initiatives in community mental health
services (earliest rural Mental Health Clinic, 1967)
• 1st training program for PHC:1978-79
• Integration of mental health services with general
health services 1946: All India
Institute of Mental
Health (NIMHANS)
• Development and expansion of the GHPUs
• Community mental health outreach services started
all over the country
• 1st mental health camp organized in 1972 in Mysore
• Launching of NMHP of India in 1982 & DMHP
17. Recent
trends:
• Increasing role of voluntary organizations: an
important development in community psychiatry
• 2011: Mobile telepsychiatry unit commissioned by
SCARF
21. “ Why treat people only to
send them back to the
conditions that made them
sick in the first place?”
22.
23. One or two of these symptoms alone can’t predict a
mental illness but may indicate a need for further
evaluation
24.
25. Two widely established systems for
classifying mental disorders:
Global health agency
Single national
professional association
Global, multidisciplinary
and multilingual
Psychiatrists, psychologists
Approved by WHA Approved by APA board
Free and open resource for
public health benefit
Intellectual property of
APA
Considered to be less
accurate More accurate
26. Chapter V ( F00-F99)
Organic, including symptomatic mental disorders
F00-F09
Mental and behavioural disorders due to psychoactive substance use
F10-F19
Schizophrenia, schizotypal and delusional disorders
F20-F29
Mood [affective] disorders
F30-F39
Neurotic, stress-related and somatoform disorders
F40-F48
Behavioural syndromes associated with physiological
disturbances and physical factors
F50-F59
Disorders of adult personality and behaviour
F60-F69
Mental retardation
F70-F79
Disorders of psychological development
F80-F89
Behavioural and emotional disorders with onset usually occurring in
childhood and adolescence
F90-F98
Mental disorder, not otherwise specified
F99
28. Two broad types:
&
Major illness
(PSYCHOSIS)
Minor illness
(NEUROSIS)
1. Schizophrenia
2. Manic depressive psychosis
3. Paranoia
1. Neurosis
2. Personality & character
disorders
29. Factors Psychosis Neurosis
Causal factor
Genetic factors
more important
Stressful life events
more important
Contact with reality Lost Not lost
Personality changes Present Absent
Judgement &
reasoning
Impaired Intact
Hallucinations/
delusions
Marked symptoms Not
30. Outline
• What is mental health?
• Why is it important?
• Who are affected?
• How to promote it?
34. Chronic
Mental health disorders & NCDs often
coexist
Overlap of risk factors
Collaborative care & potential for joint
action
Integrating mental health with other
NCDs?
37. Disorders
Share of global population with disorder
(2017)
[difference across countries]
Any mental health disorder 10.7%
Depression 3.4% [2-6%]
Anxiety disorders 3.8% [2.5-7%]
Bipolar disorders 0.6% [0.3-1.2%]
Eating disorders 0.2% [0.1-1%]
Schizophrenia 0.3% [0.2-0.4%]
Alcohol use disorder 1.4% [0.5-5%]
Drug use (excluding alcohol) 0.9% [0.4-3.5%]
38. Share of population with mental health & substance use
disorders, 2017
Around 1-in-7
people (15%)
have ≥1 mental
or substance
use disorders
Share of Mental & substance use disorder in total
disease burden
Account for 5 %
of global disease
burden but this
reaches up to 10
percent in several
countries
39. Prevalence of mental disorders, India (Weighted Percent)
CMDs are closely linked to both causation and
consequences of several NCDs, thereby contributing to a
significantly increased health burden
NMHS 2016
44. Treatment gaps for mental disorder still
remains high
76% and 85% of people in LMIC receive no
treatment for their disorder
45. Global statistics on mental
health are poorly defined,
measured, and understood
Treatment
Gap
Data
quality
Health
setting
factors
Patient
factors
Social
stigma
• Mental Health Programs in India are a low priority on the public
health agenda
• Lack of defined state level action plan
• HMIS do not prioritise mental health
• Paucity of human resources
• Minimal collaboration
• Lack of awareness
• Affordability
• Health seeking behaviour
Total budget
available for
mental health was
< 1% in most of
the states
Total mental
health
expenditure per
person : 4INR
• Budget for
DMHP: 0.44%
(2010) to 0.06%
(2020)
• Government’s
total expenditure
on mental health
of total
government
health
expenditure:
1.30%
Mental health specialist human resources in NMHS
States
•According to MOHFW, SMHSA-An appraisal
Manpower Requirement Current scenario
Psychiatrist 13,000 3000
Clinical psychologist 20,000 1000
Psychiatric social
workers
35,000 900
Psychiatric nurse 30,000 1500
50. Economic
Impact
•Contribute to
economic output
losses of $2.5-8.5
trillion globally, a
figure which is
projected to
nearly double by
2030
.
•Health care costs
alone do not
account for the full
economic costs of
mental illnesses
•Indirect costs are
more than direct
costs with regards
to mental illness Families had to spend nearly INR
1000- 1500/ month
51. Impact
Social
• Unemployment
• Broken families
• Poverty
• Educational loss
• Homelessness
• Chronic disability
• Emotional burden
on family
• Productivity at
work
• Social exclusion
Loss of
productivity
Absenteeis
Presenteeism
“Hidde
n
Cost”
53. Impact
Crime
Are violence
and mental
illness
synonymous,
connected, or
coincidental
phenomena?
Public perception
Lack of awareness and
resources in handling these
individuals
More prone to violence if
they do not receive adequate
treatment
• Most important & independent risk
factor for criminality and violence
among individuals with mental
illness is a long-term substance use
disorder
• In major psychiatric illness, presence
of comorbid substance use disorder,
leads to four-fold increase in the
risk of committing a crime or
violence
54. Impact
Suicide
• Close to 800 000
people die due to
suicide every year of
these 135,000 (17%)
are residents of India
• It is the 3rd leading
cause of death in
15-19 yrs
Mental illness is
present at the time of
suicide 27% to more
than 90% of the time
65. Nearly 80% of persons suffering
from mental disorders, had not
received any treatment despite the
presence of illness for more than
12 months
Due to the stigma associated with
mental illness, a lack of awareness,
and limited access to professional
help, only 10-12% of the 200 million
sufferers in India will seek help
66.
67. “Get
over it”
You’re
faking it
Don’t
make a
big deal
out of it
You are
doing this
for
attention
Just try
&
exercise
Other
people have
so much
worse
What does
mental health
stigma sound
like?
Public stigma
Internal stigma
Perceived stigma
Label avoidance
Stigma by association
Structural stigma
Health practitioner stigma
71. 20 Years Ago Today, 28 Chained Mentally Ill
People Burned To Death In Tamil Nadu & Nobody
ERWADI TRAGEDY
72. And now? Case pending. THIS – not Erwadi – is the greater
tragedy of mental health in India…stigma, apathy, a lack of
understanding and disregard for human dignity..all
compounding the huge lack of resources
85. Outline
• What is mental health?
• Why is it important?
• Who are affected?
• How to promote it?
86. What Are Human Rights?
• Rights inherented to all human beings, regardless of race, sex, nationality,
ethnicity, language, religion, or any other status
• It includes the right to life and liberty, freedom from slavery and torture,
freedom of opinion and expression, the right to work and education, and
many more
• Everyone is entitled to these rights, without discrimination
87. Universal Declaration of Human Rights
United Nations
representatives from
all regions of the
world formally
adopted the
Universal
Declaration of
Human Rights on
December 10, 1948
88. Human rights of Mentally ill
“All persons with a mental illness or who are being treated
as such persons, shall be treated with humanity and respect
for the inherent dignity of the human person…..there shall
be no discrimination on the ground of mental illness….”
89. Mental Health Acts In
India
Pre-
independence
Indian Lunatic
Asylum Act of 1858
Indian Lunancy Act
of 1912
Post-
independence
Mental Health Act
of1987
Mental Health Care
Bill of 2013
Mental Health Care
Act of 2017
90. INDIAN LUNACY ACT, 1912
• An Act to consolidate and amend the law relating to Lunacy
• Offensive terminologies were used:
Asylum
Lunatic person
Criminal lunatic
91. T H E M E N T A L HE A L T H A C T , 1 9 8 7
• “An Act to consolidate and amend the law relating to the
treatment and care of mentally ill persons, to make better
provision with respect to their property and affairs and for
matters connected therewith or incidental thereto.”
• It was passed on 22nd May 1987 and came in force with effect
from April 1, 1993 in all the states and UTs
92. Mentally ill persons to be treated without violation of human rights
(1) No mentally ill person shall be subjected during treatment to any
indignity (whether physical or mental) or cruelty
(2) No mentally ill person under treatment shall be used for purposes of
research, unless-
(i) such research is of direct benefit to him for purposes of diagnosis or
treatment; or
(ii) such person, being a voluntary patient, has given his consent in
writing or where such person (whether or not a voluntary patient) is
incompetent
93. by reason of minority or otherwise, to give valid consent, the guardian or
other person competent to give consent on his behalf, has given his
consent in writing for such research
3) Subject to any rules made in this behalf under section 94 for the
purpose of preventing vexatious or defamatory communications or
communications prejudicial to the treatment or mentally ill persons, no
letters or other communications sent by or to a mentally ill persons
under treatment shall be intercepted, detained or destroyed
94. Mental Health Care Bill 2013
To provide for mental health care and services for
persons with mental illness and to protect, promote
and fulfil the rights of such persons during delivery
of mental health care and services and for matters
connected therewith or incidental thereto
95. The Mental Healthcare Act, 2017
• The Mental Health Care Act 2017 was passed on 7
April 2017 and came into force from 29 May 2018
• It ensures that every person with a ‘mental illness’
has access to mental healthcare services
• It guarantees the right to affordable, good quality and
geographically accessible mental health services
96. • Central or state governments must provide for or fund these
services, which should be accessible irrespective of one’s gender,
sex, sexual orientation, religion, culture, caste, social or political
beliefs, class or ability
• The Act also specifies how the admission, treatment and release
of persons (including minors) in mental healthcare
establishments should be carried out
97. THE NARCOTIC DRUGS AND PSYCHOTROPIC
SUBSTANCES ACT, 1985
An Act to consolidate and amend the law relating to narcotic drugs, to
make stringent provisions for the control and regulation of operations
relating to narcotic drugs and psychotropic substances, to provide for
the forfeiture of property derived from, or used in, illicit traffic in
narcotic drugs and psychotropic substances, to implement the
provisions of the International Conventions on Narcotic Drugs and
Psychotropic Substances and for matters connected therewith
98. PERSONS WITH DISABILITY ACT
(EQUAL OPPORTUNITIES, PROTECTION OF
RIGHTS AND FULL PARTICIPATION), 1995
It was passed by Lok sabha in 12th December 1995
and came into enforcement on 7th February 1996
99. • It is an international human rights treaty of the United Nations intended to
protect the rights and dignity of persons with disabilities
• Parties to the Convention are required to promote, protect, and ensure the full
enjoyment of human rights by persons with disabilities and ensure that persons
with disabilities enjoy full equality under the law
100. • Mental health is fundamental to our collective and
individual ability as humans to think, emote, interact with
each other, earn a living and enjoy life
• On this basis, the promotion, protection and restoration
of mental health can be regarded as a vital concern of
individuals, communities and societies throughout the world
101.
102. • Specific ways to promote mental health include:
Early childhood interventions
Support to children
Socio-economic empowerment of women
Social support for elderly populations
Programmes targeted at vulnerable people, including minorities,
indigenous people, migrants and people affected by conflicts and
disasters
103. Mental health promotional activities in schools
Mental health interventions at work
Housing policies
Violence prevention programmes
Community development programmes
104. Poverty reduction and social protection for the poor
Anti-discrimination laws and campaigns
Promotion of the rights, opportunities and care of
individuals with mental disorders
105.
106. *Improving the social environment, and promotion of
the social, emotional and physical well-being of all
people
*Working for better living conditions and improved
health and welfare resources in the community
*Early diagnosis and provision of treatment facilities
and effective community resources
*“Family based" health services
*Reduce the duration of mental illness and thus reduce
the stresses they create for the family and the
community
*To prevent further break-down and disruption
P
R
E
V
E
N
T
I
V
E
A
S
P
E
C
T
S
107. 41%
12%
7%
7%
7%
10%
9%
9% Mental health awareness/
anti-stigma/human rights
protection
Suicide prevention
Violence prevention
Early childhood
development/stimulation
Mental health promotion and prevention programmes
108. 59%
34% 35% 35%
67%
33%
46% 46%
0%
10%
20%
30%
40%
50%
60%
70%
80%
Main types of government and social support provided for person with disability, globally percentages
112. INTEGRATED MENTAL HEALTH SERVICES
INTO PRIMARY HEALTH CARE
Improving HR
capacity
More
comprehensive
care/ follow up
Reduced economic
burden of diseases
Better
productivity
Better social integration
and successful
rehabilitation
Better Human Rights
protection
Better Mental and
general health
outcomes
Better treatment
rates and follow
up
Better accessibility of
Mental Health
Services
Better
prevention &
detection
Reduced stigma
&
discrimination
114. Layer 4
Layer 3
Layer 2
Layer 1
Specialised care
Focussed care
Family and
community
support
Social
considerations in
basic services and
security
Universal
preventive
interventions
Selective
preventive
interventions
Indicated
preventive
interventions
Management
DEVELOPMENT
HUMANITARIAN
PYRAMID OF MHPSS INTERVENTIONS
116. National Mental Health Program (NMHP)
• The Government of India launched the NMHP in 1982,
keeping in view the heavy burden of mental illness in the
community, and the absolute inadequacy of mental health
care infrastructure in the country to deal with it
• The District Mental Health Program was added to the
Program in 1996
117. • The Program was re-strategized in 2003 to include
two schemes
i. Modernization of State Mental Hospitals
ii. Up-gradation of Psychiatric Wings of Medical
Colleges/General Hospitals
• The Manpower development scheme (Scheme-A & B)
became part of the Program in 2009
118. Scheme A: Centers of Excellence
in Mental Health
Up- gradation of 10 existing mental
hospitals/ institutes/ Med Colleges
to start/ strengthen courses in
psychiatry, clinical psychology,
psychiatric social work &
psychiatric nursing
Scheme B. PG Training
Departments of Mental Health
facilities
Government Medical Colleges/
Government Mental Hospitals will
be supported for starting /
increasing intake of PG courses in
Mental Health
119.
120. Treatment of Mentally ill
Rehabilitation
Prevention and promotion of positive
mental health
COMPONENTS
121. AIMS
Prevention and
treatment of
mental and
neurological
disorders and
their associated
disabilities
Use of mental
health technology
to improve
general health
services
Application of
mental health
principles in total
national
development to
improve quality
of life
122. To ensure the availability and
accessibility of minimum
mental healthcare for all in the
foreseeable future
To encourage the application of
mental health knowledge in
general healthcare and in social
development
To promote community
participation in the mental
health service development
To enhance human resource in
mental health sub-specialties
OBJECTIVES
123. Integration mental health with primary health care
through the NMHP
Provision of tertiary care institutions for treatment of
mental disorders
District Mental Health Programme
Research and training in Mental Health Programme
Psychiatric unit and Psychiatric hospital
STRATEGIES
124. Specific approaches
Diffusion of mental
health skills to the
periphery of health
services
Equitable and
balanced
distribution of
resources
Appropriate
appointment of
tasks
Integration of basic
mental health care
with general health
services
Linkage with
community
development
125. District
Level
Activities
Mental Health
Services
Mental Health
Help Line
Residential/ Long-term
Residential Continuing
Care Centre
Public – Private
Partnership Model
Day Care Centre
Mental Health
Services
At CHC/PHC
District Mental
Health Programme
National Mental Health Programme (NMHP )
126. DISTRICT MENTAL HEALTH PROGRAM (DMHP)
• On the basis of “Bellary model”, DMPH was launched in 1996 in 4
districts under NMHP
• Team of workers for DMHP
Psychiatrist
Clinical Psychologist
Psychiatric Social worker
Psychiatry/Community Nurse
Program Manager
Program/Case Registry Assistant
Record Keeper
127. OBJECTIVES:
• To provide sustainable basic mental health services to the
community and to integrate these services with other health
services
• Early detection and treatment of patients within the community
itself
• To see that patients and their relatives do not have to travel long
distances to go to hospitals or nursing homes in cities
128. • To take pressure off mental hospitals
• To reduce the stigma of mental illness
through public awareness
• To treat and rehabilitate mental patients
within the community
129. Strategies:
Service
provision
• Provision
of mental
health
outpatient
& in-
patient
mental
health
services
• 10 bedded
inpatient
facility
Out-reach
components
• Satellite
clinics: 4
satellite
clinics per
month at
CHCs/ PHCs
• Targeted
Interventions:
Life skills
education &
counseling in
schools, work
place stress
management,
and suicide
prevention
services
Sensitization
and training
• District &
sub-
district
levels
Awareness
camp
• Awareness
regarding
mental
illnesses and
related
stigma
through
involvement
of local
faith
healers,
teachers,
leaders etc
Community
participation
• Linkages with
Self-help
groups, family
and caregiver
groups &
NGOs
• Sensitization
of
enforcement
officials
regarding
legal
provisions for
effective
implementatio
n of Mental
Health Act
130. Central Level National levels hospital.
Example, NIMHANS, Bengaluru
State Level Hospital State level Hospitals
Institute of Mental Health,
Dharwad, Karnataka, Tamil Nadu
National Mental Health Programme
District Level General Hospitals Psychiatric Units
District Mental Health Programme
Local Level Primary Health Centres
Community Mental Health Centres
Sub-centres
131. Mental health services
• The mental health services comprise:
i. Early diagnosis and treatment
ii. Rehabilitation
iii. Group and individual psychotherapy
iv. Mental health education
v. Use of modern psychoactive drugs
vi. After-care services
132. Services available at PHCs:
Outpatient services
Counseling services in accessing social care
benefits
Pro-active case findings and mental health
promotion activities
• Manpower: Community Health Workers (Two)
133. Services available CHCs:
Outpatient services & inpatient services for
emergency psychiatry patients
Counseling services
• Manpower:
Medical Officer
Clinical Psychologist or Psychiatric Social Worker
134. Day Care Centre
• Provides rehabilitation and recovery services to persons with
mental illness so that the initial intervention with drug &
psychotherapy is followed up and relapse is prevented
• Helps in enhancing the skills of the family/caregiver in
providing better support care
• Provides opportunity for people recovering from mental
illness for successful community living
135. PPP Model Activities
• There is a provision for the state governments to
execute activities related with mental health in
partnership with Non-Government
Organizations/Agencies as per the guidelines of the
NHM in this regard
• Financial support @ Rs. 5 lakhs per NGO
136. Residential/ Long Term Residential Continuing Care
Centre
• Chronically mentally ill individuals, who have achieved stability
with respect to their symptoms & have not been able to return to
their families and are currently residents of the mental hospitals,
will be shifted to these centers
• Structured program which will be executed with the help of
multidisciplinary team consisting of psychologists, social
workers, nurses, occupational therapists, vocational trainers and
support staff
137. Mental Health Helpline
• A country wide 24 hours dedicated help-line to provide information
to public on mental health resources, emergency situation and crisis
management, information pertaining to destitute mentally ill patients,
registration of complaints on Human Rights Violation of mentally ill
and assistance on medico-legal issues
• Linked with district hospitals, medical college/hospitals, mental
hospitals, private mental health facilities, NGOs and all other mental
health service providers of the state
138.
139.
140. Support to Central and State Mental Health Authorities
Central Mental Health Authority (CMHA) & State
Mental Health Authority (SMHA) are meant for
regulation & co-ordination of mental health services
under the central & state governments respectively
141. Central Mental Health Team
• A Central Mental Health Team would supervise and
implement the programme and provide support to the
Central Mental Health Authority
• Team would consist of one Consultant (Mental
Health), one Consultant (Public Health) and two
Research Associates
142. • It aims to improve the effectiveness and efficiency of the mental
health service and ensure more equitable delivery by enabling
managers and service providers to make more informed decisions
for improving the quality of care
ANALYSIS
dissemination USES
COLLECTION
Mental health information system (MHIS)
143. Central IEC (information education and communication)
• The central level dedicated website provides information on
mental health resources, activities, plans, policy and programmes
• Extensive mass media activities at district and sub-district level
• TV /Radio programs and innovative media campaigns on mental
health in vernacular languages through local channels and other
media
144. Training/Workshops
• Trainings will be provided to master trainers from each
state/UT who shall further train DMHP team and other
staff working in the field of mental health
• Trainings will be standardized and delivered at identified
centres
• The standardized training manuals are being formulated
and circulated to all stakeholders
145. Monitoring & Evaluation
• Standard formats for recording and reporting have been
developed and circulated
• Used by medical colleges/institutes (under Manpower
Development Scheme), District, CHC and PHC
• Continuous evaluation of the activities of the program
148. Research & Survey
• For carrying out research & survey in different
regions of the country in the field of mental health
• Help in understanding regional needs and framing
plan and strategies in future for various parts of the
country
149. Limitations of NMHP
i. The program emphasized more on curative components rather
than the preventive and promotive components
ii. Role of support of families in the treatment of the patient was
not given due importance
iii. The administrative structure of the program was not clearly
outlined
150.
151. mhGAP
Mental Health Gap Action Programme
• To reinforce the commitment of governments,
international organizations, and other
stakeholders to increase the allocation of
financial and HR for care of MNS disorders
• To achieve much higher coverage with
key interventions in the countries with
low and lower middle incomes that
have a large proportion of the global
burden of MNS disorders
152. COMPREHENSIVE MENTAL HEALTH ACTION PLAN
2013-2020
VISION: A world in which mental health is valued, promoted and
protected, mental disorders are prevented and persons affected by
these disorders are able to exercise the full range of human rights
and right to access a high quality and culturally appropriate health
and social care in a timely way to promote recovery, all in order to
attain the highest possible level of health and participate fully in
society and at work free from stigmatization and discrimination
153. GOAL: To promote mental well being, prevent
mental disorders, provide care, enhance recovery,
promote human rights and reduce mortality,
morbidity and disability for persons with mental
disorders
154. OBJECTIVES:
i. To strengthen effective leadership and governance for mental
health
ii. To provide comprehensive integrated and responsive mental
health and social care services in community based settings
iii. To implement strategies for promotion and prevention in mental
health
iv. To strengthen information systems, evidence and research for
mental health
155. “The world is accepting the concept
of universal health coverage. Mental
health must be an integral part of
UHC. Nobody should be denied
access to mental health care
because she or he is poor or lives in
a remote place.”
156.
157. • Individual psychological help for adults impaired by distress in
communities exposed to adversity
• Simplified, scalable interventions as “low-intensity psychological
interventions”, in that their delivery requires a less intense level of
specialist human resource use
158. • People with and without previous training in mental
health care can effectively deliver low-intensity
versions of CBT and IPT as long as they are trained
and supervised
• Also, people experiencing severe levels of
depression can benefit from low-intensity
interventions
159.
160. Conclusion
• What is mental health?
• Why is it important?
• Who are affected?
• How to promote it?
161. • World Health Organization. Mental Disorders [Internet]. Geneva: World Health Organization
[cited 2021 Feb 12]. 4 p. Available from: https://www.who.int/news-room/fact-
sheets/detail/mental-disorders.
• World Health Organization. Depression [Internet]. Geneva: World Health Organization 2019 [cited
2021 Feb 16]. 3 p. Available from: https://www.who.int/news-room/fact-
sheets/detail/depression.
• Keyes CL. The mental health continuum: From languishing to flourishing in life. Journal of health
and social behavior. 2002 Jun 1:207-22.
• Bertolote J. The roots of the concept of mental health. World Psychiatry. 2008 Jun;7(2):113.
• Chadda RK, Patra BN, Gupta N. Recent developments in community mental health: Relevance and
relationship with the mental health care bill. Indian Journal of Social Psychiatry. 2015 Apr
1;31(2):153.
• Lund C, Brooke-Sumner C, Baingana F, Baron EC, Breuer E, Chandra P, Haushofer J, Herrman H,
Jordans M, Kieling C, Medina-Mora ME. Social determinants of mental disorders and the
Sustainable Development Goals: a systematic review of reviews. The Lancet Psychiatry. 2018 Apr
1;5(4):357-69.
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• Sagar R, Dandona R, Gururaj G, Dhaliwal RS, Singh A, Ferrari A, Dua T, Ganguli A, Varghese M,
Chakma JK, Kumar GA. The burden of mental disorders across the states of India: the Global Burden
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mental health-an Indian perspective. Archives of Mental Health. 2012 Jul 1;13(2):80-.
• Chisholm D, Sweeny K, Sheehan P, et al. Scaling up treatment of depression and anxiety: a global
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There have been at least three conceptions of health throughout human history. The pathogenic approach views health as the absence of disability, disease, and premature death. The salutogenic approach views health as the presence of positive states of human capacities and functioning in cognition, affect, and behavior. The third approach is the complete state model, which derives from the ancient word for health as being hale, meaning whole. This approach is exemplified in WHO def of health.
WHO
three core components of this definition are (1) well-being, (2) effective functioning of an individual, and (3) effective functioning for a community
So rather than being about ‘what’s the problem?’ it’s really about ‘what’s going well?‘
3: 1. he feels reasonably secure and adequate. He neither underestimates noR overestimates his own ability. Accepts his shortcomings and has self-respect.
2. He is able to be interested in others & to love them. Has friendships that are lasting and satisfying. He is able to be part of a group without being submerged by it. Able to like and trust others. Takes responsibility for his neighbors and his fellowmen.
3. Able to think for himself & take his own decisions. Sets reasonable goals for himself & shoulders his daily responsibility. Not bowled over by his own emotions, fear, anger, love or guilt.
MH has been operationalized salutogenically under rubric of subjective well- being or in evaluation of QOL.
Measures of emotional well-being often identify an individual’s satisfaction or positive affect with “life overall,” but rarely with facets .
Subjective well-being is a scientific term that is commonly used to denote the ‘happy or good life’. It comprises of an affective component (high positive affect and low negative affect) and a cognitive component (satisfaction with life).
The dimensions of psychological well-being are intra-personal reflections of an individual’s adjustment to and outlook on their life.
six elements make up what she calls psychological well-being (Ryff 1989; Ryff and Keyes 1995). Each of them is important in the striving to become a better person and to realize one’s potential
Keyes conceptual analysis indicates that social well-being consists of five dimensions describing a person who is functioning optimally in society
syndrome: a set of symptoms that occur together.
John W. Travis is an American author and medical practitioner. ,(residency in preventive medicine at Johns Hopkins Bloomberg School of Public Health, which included a Masters in Public Health)
Illness-Wellness Continuum is a graphical illustration of a wellbeing concept first proposed by Travis in 1972
It proposes that wellbeing includes mental and emotional health, as well as the presence or absence of illness.
Travis began developing his Continuum in 1972 and it was first published in 1975 in the Wellness Inventory. Since then the concept has been applied to fields such as medicine,nursing, counseling, physical therapy, public health, and organizational development
concept focuses on building well-being through responsibility, emotional control, deep insight, and mindful, holistic awareness
Illness-Wellness Continuum runs on three key concepts of well-being:
Wellness is a process; it is always moving up and down, right, and left. Moving from one paradigm to another does not signify personal achievement or shortcoming, it is a natural process we all go through at some point in life.
Presence of illness does not imply the absence of wellness and vice versa. They differ in degree and do not follow an all-or-none principle.
At any point, we have the potential to push ourselves from illness to wellness.
Illness-Wellness Continuum has been viewed as promoting preventive treatment, which improves wellbeing before an individual presents with signs or symptoms of illness, as well as educating people to be aware of and avoid risk factors, in order to protect against pathology and premature death.[
Department of National Defence Canadian Armed Forces developed the Mental Health Continuum (MHC) model to demonstrate that an individual’s mental health status ranges on a continuum
Mental health continuum model projects the human mind on a continuous linear perspective
model focuses on six major areas—mood, attitude and performance, sleep, physical symptoms, social behavior, and alcohol and gambling—each of which identifies specific mental conditions and challenges along the continuum.
intended to serve as a self-reflection and self-monitoring tool
MHC model may not truly reflect the relationships between MI & MH
BETTER TO THINK THEM AS SEPARATE ENTITIES WORKING INDEPENDENTLY
Are all ind without mental disorders leading equally productive and healthy lives?
MHPP is based on dual continuum model that MH & MI belong to two separate but correlated dimensions/ concepts & are not two opposite ends of the same spectrum
Many names: dual factor model of MH, two continua model, CSM
Describes complete mental health as a state in which an ind has both high level of ell being & low level of mental illness.
IMPLICATIONS:
Absence of MI does not imply presence of MH
Presence of MI, does not imply absence of MH
Ind can be categorized by their recent MI status and acc to level of MH : lanh, moderate, flourishing.
FROM STUDIES: ind who are flourishing function better than mod who in turn better than lang. any diag less than flourishing were associated with greater levels of dysfunction in termsof work reductions, health limitations & psychosocial functioning.
A critical message of Keyes’ work is that maintenance and protection of positive mental health, and not just alleviation of mental distress, is necessary to achieve a mentally healthy population.
this model demonstrates how those with many attributes of mental health (emotional, psychological, and social well-being) can still have varying degrees of mental illness – and how even those with high levels of mental illness can have many attributes of mental health .
languishing vs. flourishing model of mental health became significantly popular after the multiple success of its application across different parts of the world
1977: 650 CMH centres built to cover 43% of pop & serve 1.9 mil ind in yr and length of tt decreased from 6m to 23 days.
CSP: Tto provide funds to communities to set up a comprehensive mental health service & supports to help mentally ill pts integrate successfully in society.
Public mh comes in line with the concept of mh as movement rather than a discipline. Corresponding to application of psych to grps, comm, societies rather than on ind basis.
In India, no mental hospital was closed unlike in the West, where it was a common phenomenon in the second half of the last century.
Developing small size locally relevant community based psychiatric care facilities such as day care centres, vocational training centres, sheltered workshops, half way homes, & long stay homes. Community based mental health services currently offered by multiple settings in primary carre as extension clinics under DMPH, DH, GHPU, PRIVATE
SCARFl schizo research foundation
Advanced model of triangle of epid:
Agent: cause of ds, {causative factors}
Host: organism that harbours the disease {grps or pop & their characteristics}
Env: those surroundings & conditions external to human that cause or allow disease transmission {env behav, culture, physiological factors, ecological elements}.
Time: severity of illness in relation to how long person is infected
nmhs: prev of mental disorders was higher among males (13.9% vs 7.5%)
13-17 yrs: 7.3% (9mil)
Mental disorders are stronly socially determined: direct influence on prev, severity. Mh tt alone
developed a novel conceptual framework that summarised the major social determinants of mental health disorders and linked them with the SDGs.
Bronfenbrenner’s ecological approach,10 proximal factors
refer to people, objects, or events in the immediate
external environment with which the individual interacts
that increase or reduce risk of mental disorders. Distal
factors refer to the broader structural arrangements or
trends in society which exert their influence on mental
disorders in populations, frequently mediated by proximal
factors. This framework seeks to capture the importance
of an ecological approach10 and the complex
multidimensional way in which social determinants
interact with key genetic determinants to affect mental
disorders
Social capital is "the networks of relationships among people who live and work in a particular society, enabling that society to function effectively".[1] It involves the effective functioning of social groups through interpersonal relationships, a shared sense of identity, a shared understanding, shared norms, shared values, trust, cooperation, and reciprocity.
In this context SDGs have the potential to reduce burden of mental disordersat pop level by addressing their upstream social determinants. For this reduction to occur, greater clarity is needed on which social determinants to target & how they are alignd with SDGs.
SDGs have the potential to reduce the
burden of mental disorders at the population level by
addressing their upstream social determinants.
symptoms below should not be due to recent substance use or another medical condition
Stages are just progressions of any disease
It gives doctors an idea of how aggressive they need to be with the treatments that they prescribe.
idea behind “B4Stage4” is that we need to identify mental illnesses before they reaches Stage 4—just like physical illnesses. In fact, half of all lifetime mental illnesses begin by age 14, so we should insist on screening children and youth.
Intervening as early as possible preserves opportunities for education, employment, social supports, housing – and brain power! It also costs less than the all-too-common revolving door of incarceration, hospitalization, and homelessness, which are stage 4 indicators.
A survey of 205 psychiatrists, from 66 different countries across all continents, found that ICD-10 was more frequently used and more valued in clinical practice and training, while the DSM-IV was more frequently used in clinical practice in the United States and Canada, and was more valued for research,
- INTENT TO JOIN APA & WHO collaborative efforts has been to develop common research base for revision of both SM-5 & ICD-11. DSM-ICD harmonization coordinating grp was organized early in development process under direction of STEVEN HYMAN, chair of WHO’s international advisory grp for revison of icd-10 mental and behavioural disorders and DSM-5 task force member.
a type of mental illness characterized by distortions in thinking, perception, emotions, language, sense of self and behaviou
Noncommunicable diseases (NCDs) kill 41 million people each year, equivalent to 71% of all deaths globally. (who)
15 million people die from a NCD between the ages of 30 and 69 years; over 85% of these "premature" deaths occur in low- and middle-income countries. (WHO)
At a global level, 7 of the 10 leading causes of deaths in 2019 were noncommunicable diseases. These seven causes accounted for 44% of all deaths or 80% of the top 10. However, all noncommunicable diseases together accounted for 74% of deaths globally in 2019.
Deaths from noncommunicable diseases are on the rise.
2009: Epidemiological studies have found significant associations—within and across countries— between cardiovascular diseases and common mental disorders.
In the World Mental Health Surveys, odds ratios for the association of heart disease with mental disorders were 2.1 for mood disorders, 2.2 for anxiety disorders, and 1.4 for alcohol misuse or dependence across countries.
Dose-response ass between inc no. of mental disorders & heart ds & strng ass between early onset CMD with adult hrt ds.
2016: meta analysis found links between diabetes and mental disorders, including schizophrenia, bipolar disorder, depression, and post-traumatic stress disorder
CA & ptsd, anxiety, dep
Mood, anxiety, substance abuse: asthma [WMH]
MULTIMORBIDITY OF PHYSICAL & MENTAL DISORDERS – 1/3 cases of dep and anxiety, 4/5 cases of hrt ds.
Causal mech from ind to societal level have a role in birectional relation between key risk factors and both ncds and mental illness
Multicausal mech : integrated approach
Evidence, RCTs (2015) of collaborative care,shows that integrated care for mental disorders can improve outcomes in cardiovascular disorder, diabetes, and other conditions
IHME: INST OF HEALTH METRICS AND EVALUATION is an independent global health research center at the University of Washington. (Dr. Christopher J.L. Murray) provides rigorous and comparable measurement of the world's most important health problems and evaluates the strategies used to address them. IHME makes this information freely available so that policymakers have the evidence they need to make informed decisions about how to allocate resources to best improve population health.
Cmd: dep, anxiety and subs abuse
1 in 20 ppl in india suffer from dep with weighed prevalence for life time was 5.2%
Severe mental disorders > 1% in manipur and wb
prevalence of tobacco use disorder (moderate and high dependence) and alcohol use disorder (dependence and harmful use / alcohol abuse) was 20.9% and 4.6%, respectively.
In the context of the
bidirectional relationship between mental
health and SUDs and their demonstrated role
as causative factors for non-communicable
disorders, the high prevalence of SUDs in
India is of serious concern.
overall current prevalence
estimate was 10.6% in the total surveyed
population, significant variations in overall
morbidity are seen across the different
surveyed states, ranging from 5.8% in
Assam to 14.1 % in Manipur
ACC TO LANCET PSYCHIATRY 2020, BURDEN OF MENTAL DISORDERS PUBLICHED IN DEC,2019:
45.7 mil ppl : dep
44.9 mil : anxiety
PREVALENCE: IDID- 4.5%
DEP- 3.3%
ANX-3.3%
CONDUCT- 0.8%
Most of those identified, had not sought care
or were not able to access appropriate care
despite seeking. Multiple factors ranging
from lack of awareness, to affordability of
care, which varied between rural and urban
areas, appear to critically influence these
wide treatment gaps.
Without the availability of objective tests for mental disorders, capturing precise estimates of these disorders in population based surveys has always a been a challenge, globally
Mental health policy for manipur is lacking
No separate budget for mental health and funds are very irregular
Lack of manpower
Lots of social stigma: health camp organized in senapati (no psychiatrist) in 2018.. Due to stigma only 10 pt came
It is the gap between how pervasive mental disorders are and lack of resources/treatment/care for those living with these conditions
Indirect costs are more than direct sots.
Costs of care: like medication, clinic visits fees, hospitalization, diagnostic services, residential care, community servies, rehab and transportation are direct cost
Indirect costs are values of resources lost as a result of illness. Indirect costs include costs due to reduced supply of labour (unemployment), reduced educational attainment, expenses for social supports, costs ass with conseq like chronic disability, homelessness, crime, suicide, homicide, caregiver burden, value of family , medical complications of mi , early mortality, subs use, emotional burden.
Mh & socio-economic development appear to go hand in hand. Investing in mh is therefore investing for development.
costs of care (like medication, clinic visits (fees), hospitalization, diagnostic services, residential care, community services, rehabilitation and non-medical costs like transportation for treatment and care) are direct costs. These are the value of resources used in the treatment of disease.
Median monthly expenditure ranges between 1000 to 2500 rs
In addition to los of productivity due to absenteeism (100% loss) there are additional losses at workplace. Employees came to work but still there is loss of productivity due to low performance (presenteeism) . This is more hidden cost.
Low stress & frustration tolerance, sleeplessness, poor concentration, poor communication skills at work make them dangerous to themselves and others.
Nmhs- ¾ with severe mental disorder experience significant disability in work, social & family life.
proportion of disability proportion was relatively higher among individuals with bipolar affective disorders (63 - 59%), major depressive disorder (67%-70.0%) and psychotic disorders (53-59%)
In any given quarter, family member had missed 10-20 working days to take care of mentally ill persons
popular belief is that people with mental illness are more prone to commit acts of violence and aggression.
The public perception of psychiatric patients as dangerous individuals is often rooted in the portrayal of criminals in the media as “crazy” individuals. A large body of data suggests otherwise. People with mental illness are more likely to be a victim of violent crime than the perpetrator.[1] This bias extends all the way to the criminal justice system, where persons with mental illness get treated as criminals, arrested, charged, and jailed for a longer time in jail compared to the general population
Crime comit : untreated profound illness (homicide), delusions, command hallucinations, sud, unemployment, homelessness, cognitive impairment
79% of global suicides occur in low- and middle-income countries
2016: india: Suicide was the most common cause of death in both the age groups of 15–29 years and 15–39 years
Suicide occurs throughout the lifespan and was the second leading cause of death among 15-29 year-olds globally in 2016
India's suicide rate per 100,000 people compared to other countries, according to the World Health Organization, Geneva.] claims China, Russia, United States, Japan, and South Korea are the biggest contributors to the absolute number of suicides in the world. Värnik claims India's adjusted annual suicide rate is 10.5 per 100,000, while the suicide rate for the world as a whole is 11.6 per 100,000.
Acc to nmhs, nearly 1% of pop reported high suicidal risk half of which reported having co-occuring mental illness
Comorb of physical and mental disorders is ass with greater disability and unemployment. Not additive effect but synergistic. In other studies (2015), multimorbidity has been associated with lower quality care, worse health outcomes, and increased medical expenditure.
Physical inactivity and poor diet are also risk factors for both NCDs and mental disorders, and NCDs and mental
disorders may further exacerbate these issues
bipolar mood disorders have high mortality rates ranging from 35% higher to twice as high as the general population. • There is a 1.8 times higher risk of dying associated with depression –WHO
NMHS
Live Love Laugh Foundation (TLLLF) is a charity that aims to create awareness of mental illness and reduce the stigma associated with it, with a particular focus on stress, anxiety and depression.
The Foundation commissioned How India Perceives Mental Health: TLLLF National Survey Report 2018 to help gauge India’s mental health landscape with the objective of exploring perceptions surrounding mental health and mental illness in India. The study further explores the level of sensitivity, attitudes towards mental health, and the level of stigma associated it.
The study took place across eight cities in India over a span of 5 five months and involved 3,556 respondents.
Reasons:
Inaccurate or misleading media representations
lack of understanding or fear
Health care providers stigma
Institutional stigma, is more systemic, involving policies of government and private organizations that intentionally or unintentionally limit opportunities for people with mental illness. Examples include lower funding for mental illness research or fewer mental health services relative to other health care
Worsening of symptoms
Fear of judgement
Institutional stigma
Help seeking dec
Barrier to treatment seeking
Access to work, marriage & education
Deprived opportunities
Bullying, physical violence or harassment
Huge burden of mental morbidity
Affects care givers
Treatment gap
Efforts required to supports pt’s informed decision & avoid others to make subsitute decisions. Mental disorder alone without impaired capacity does not justify involuntary treatment, which can be considered a misuse. Substituted decision making to be replaced by supported decision making.
Coercive treatment use can only be justified when a pt’s capacity to consent is substantially impaired and severe danger to health or life cannot be prevented by less intrusive means. In this case withholding tt can violate principal of justice. In case of dangers to others, social exclusion nd loss of freedom can justify coercive tt.
Human Rights Watch found evidence of shackling across 60 countries across Asia, Africa, Europe, the Middle East, and the Americas:
In China, about 100,000 people are shackled or locked in cages in Hebei province alone, near Beijing. In Indonesia, 57,000 people with mental health conditions have been in pasung (shackles) at least once in their lives. In India, thousands of people with mental health conditions were found chained like cattle in the state of Uttar Pradesh.
Afghanistan, Burkina Faso, Cambodia, Ghana, Indonesia, Kenya, Liberia, Mexico, Mozambique, Nigeria, Sierra Leone, Palestine, Russia, the self-declared independent state of Somaliland, South Sudan, and Yemen.
found people with real or perceived psychosocial disabilities are arbitrarily detained against their will in homes, state-run or private institutions, and traditional or religious healing centers.
-unicef
Oxford: mh conseq of covid crises including suicidal behav are likely to be present for long time and peak later than the actual pandemic.
social isolation, anxiety, fear of contageon, uncertainty, chronic stress, economic diffi
Multiple cases of covid related suicides in usa,uk,germany,italy, bangla,india due to – unemployment, social isolation , uncertainty
96.2% of recovered covid pt had ptsd
89% countries reported in survey that mh and psych support is part of their covid-19 reponse plans, only 17% of those have full additional funding for covering these activities
Emergency interventions: ppl with prolonged seizures, severe subst use withdrawal, delitium
Over 60% reported disruption of services for vulnerable ppl
Although >80% hic deployed telemed, teletherapy.. <50% of lic
In manipur- anxiety was most common seen in 50 yr male..
In all districts except kamjong with ukhrul lacks psychological support team of covid-19
7:30 everyday 1 min prior – 1.5 min radio jingle related to mental health
Counselling via phone
- universal, selective or indicated approach
Tt targets those with MI, risk reduction targets those with vulnetrability to MI , MH promotion targets those with good MH or less than optimal MH that is all the members of a pop. Therefore MH promotion is amenable to public health approach & is complement rather than alternative to tt.
MHPSS
One person in five (22%) living in an area affected by conflict is estimated to have depression, anxiety, post-traumatic stress disorder, bipolar disorder or schizophrenia.
{WHO}
Social problems:
pre-existing: e.g. poverty and discrimination of marginalized groups;
emergency-induced: e.g. family separation, lack of safety, loss of livelihoods, disrupted social networks, and low trust and resources; and
humanitarian response-induced: e.g. overcrowding, lack of privacy, and undermining of community or traditional support.
Mental health problems:
pre-existing: e.g. mental disorders such as depression, schizophrenia or harmful use of alcohol;
emergency-induced: e.g. grief, acute stress reactions, harmful use of alcohol and drugs, and depression and anxiety, including post-traumatic stress disorder; and
humanitarian response-induced: e.g. anxiety due to a lack of information about food distribution or about how to obtain basic services.
United nations high commissioner for refugees - is a UN agency mandated to aid and protect refugees, forcibly displaced communities, and stateless people, and to assist in their voluntary repatriation, local integration or resettlement to a third country. It is headquartered in Geneva, Switzerland
14 December 1950;
Between 2015 and 2050, the proportion of the world’s population over 60 years will nearly double, from 12% to 22%. (900 million to 2 billion people)
Mental health and well-being are as important in older age as at any other time of life.
Mental and neurological disorders among older adults account for 6.6% of the total disability (DALYs) for this age group.
15% of adults aged 60 and over suffer from a mental disorder.
most common mental and neurological disorders in this age group are dementia and depression, which affect approximately 5% and 7% of the world’s older population
MH promotion seeks to elevate levels of positive MH & protect against its loss.
Promotion involves actions that involve creating an env that supports mh that respects & protect sbasic civil, political, socio-economic and cultural rights.
UN
30 ARTICLES
Recover better stand up for human rights
UN 1991
8 chapters, 100 sections English lunacy Act IV of 1912
Act 1890
Psychiatric hosp-
Mentally ill person
Mentally ill prisioner
10 CHAPTERS, 98 SECTIONS
136 CLAUSES IN 16 CHAPTERS
16TH Sept
the global disability rights movement enabling a shift from viewing persons with disabilities as objects of charity, medical treatment and social protection towards viewing them as full and equal members of society, with human rights
ANTI ANXIETY-BENZDPINE-CLONAZEPAM
STIMULANTS-ADHD, AMOHETAMINE
ANTI PSYCHOTICS-TYPICAL AND ATYPICAL
MOOD STABILIZERS
COGNITIVE BEHAVIORAL THERAPY
INTERPERSONAL THERAPY
PSYCHODYANAMIC, PAST EXPERIENCE IMPACTING CURRENT
FAMILY THERAPY
GROUP THERAPY
ONLINE THERAPY
CREATIVE ART THERAPY
PLAY THERAPY
Guidance for countries on how to organize services for mental health
Mental health psychosocial support
First aid,parent education,peer support group
No risk-awareness
Some risk
Prob but disease not
Identified cases
Prev of mental health2per 1k pop,10k beds and 30 institutions
1962, no stat on MH, high no of pt, treatment was limited
1974 community health volunter scheme, service to 1k pop manage MH prob
1975 nimhans and raipur-community mental health unit
2 national workshops in 1981-82
2000 in Manipur,
349 MO, 482 Nurses and paramedics are trained since 2018
Treatment may also include psychotherapy (also called “talk therapy”) and brain stimulation therapies (less common).
50K/CENTRE/MONTH
75K/CENTRE/MONTH
purpose of gathering data, but also for enabling decision-making in all aspects of the mental health system
7th October 2013
TEDROS ADHANOM,DG
VISION WHERE ALL PEOPLE AND COMMUNITIES HAVE ACESS TO QUAlity health services where and when they need without financial hardship
