Mental health

1. MENTAL HEALTH IN INDIA

2. The birds of worry and care fly
over your head, this you can
not change, but they build nests
in your hair, this you can
prevent.

3. HISTORY OF MENTAL HEALTH
 Ancient Hindu scriptures like ‘Ramayana’ and
‘Mahabharata’ contain fictional descriptions of
depression and anxiety states.
 Mental disorders were generally thought to
reflect abstract entities, supernatural agents, or
witchcraft.
 “Charaka Samhita” part of the Hindu Ayurveda,
saw ill health as resulting from an imbalance
among three kinds of bodily fluids or forces
(doshas).

4.  Different personality types were also described,
with different propensities to worries or
difficulties.
 Suggested causes included inappropriate diet;
disrespect towards the gods, teachers or others;
mental shock due to excessive fear or joy; and
faulty bodily activity.
HISTORY OF MENTAL HEALTH

5.  In the 20th century, the work of
Sigmond Freud led to the concept that
it is possible to admit and treat all
types of mentally ill patients
HISTORY OF MENTAL HEALTH

6.  Mental Health is far more than the absence
of mental illness and has to do with many
aspects of our lives including:
• How we feel about ourselves
• How we feel about others
• How we are able to meet the demands of life

7. Behaviour
Mood or
Feeling
Thinking
Perception
Higher
Functions
Functions of
the Mind

8.  Mental health is defined ‘as the capacity in
an individual to form a harmonious relation
with others and to participate in or contribute
constructively to change in the social
environment’.
 “Mentally ill person” is a person who is in
need of treatment by reason of any mental
disorder other than mental retardation
DEFINITIONS

9.  Mental Disorder - Clinically recognisable
set of symptoms or behaviour associated in
most cases with distress and with
interference with personal functions. Social
deviance or conflict alone without personal
dysfunction is not considered as mental
disorder
WHO, 1992
DEFINITIONS

10.  Depression - intense feeling of sadness,
loneliness, despair, lack of confidence and
lack of pleasure.
 Delusions - fixed beliefs which are held
firmly on inadequate grounds.
 Obsession - persistent recurrent
thoughts, images or impulses.
DEFINITIONS

11.  Illusion - misperception of an external stimulus.
 Hallucination - perception in the absence of a
stimulus
 Amnesia - partial or total inability to recall past
experiences
 Schizophrenia - serious functional psychotic
condition manifests in the form of delusions,
hallucinations, irrelevant speech and grossly
abnormal behaviour.
DEFINITIONS

12.  Mania - elevated mood, grandiosity and
excessive talk.
 Neurotic disorder - anxiety which is
considerably more than that of a normal
person.
DEFINITIONS

13. MENTAL STRESS
“The Stress Response”
 This is the sum total of body reaction,
both physiological and psychological, in
response to a “stressor” i.e, an event
occurring outside the body in the
external environment.
 It is the stress response which leads to
various “Stress Symptoms” or “Stress
diseases”.

14.  Environmental
Toxins, Heat, Cold
 Psychological
Threats to Self Esteem, Depression
 Sociological
Unemployment, Death of a loved one
 Philosophical
Purpose of life
Regardless of the stressor, body’s reaction will
be the same.
TYPES OF STRESSORS

15. Headache
Skin rashes
Lowered
Immunity Heart disease
Hypertension
Stomach and Intestinal
disorders
Sexual
dysfunction
Backache
The Physical Toll of stress
• Many ailments of the stomach,
intestinal tract, skin
• Headaches & Backaches
• Sexual Problems
Have been
linked to
stress.

16. ICD-10 CLASSIFICATION OF
MENTAL AND BEHAVIOURAL
DISORDERS
 Organic including symptomatic , mental
disorders eg. Dementia in Alzheimer’s,
Delirium
 Psychoactive substance abuse
 Schizophrenia, schizotypal and Delusional
disorders
 Mood (Affective disorders)
 Neurotic, stress related and somatoform
disorders
 Behavioural syndromes associated with
physiological disturbances and physical
factors

17.  Disorders of adult personality and
behaviour
 Mental retardation
 Disorders of psychological development
 Behaviour and emotional disorders with
onset usually occuring in childhood and
adolescence
 Unspecified mental disorder
ICD-10 CLASSIFICATION
(Contd)

18. CLASSIFICATION
 Major illnesses
 Schizophrenia
 Manic Depressive Psychosis
 Paranoia
 Minor illnesses
 Neurosis
 Personality and Character disorders

19. MAGNITUDE OF THE PROBLEM

20. GLOBAL
Overall , around 450 million people suffer from
Neuropsychiatric disorders worldwide
 154 million people suffer from depression
 25 million people from schizophrenia;
 91 million people are affected by alcohol use disorders
 15 million by drug use disorders.
 50 million people suffer from epilepsy
 24 million from Alzheimer and other dementias
 DALYs lost
 6.8% in 1990 projected to be 15% in 2020
 WHO estimates -2002

21. DISORDER WORLD S. ASIAN REGION
DALYs per
million
population
% of total
disease
burden
DALYs per
million
population
% of total
disease
burden
SCHIZOPHRENIA 1,894 0.76 2,087 0.71
BIPOLAR
DISORDER
1,583 0.63 1,612 0.55
DEPRESSION 8,431 3.37 10,507 3.57
PANIC DISORDER 740 0.30 757 0.26
World Health organization. WHO global Burden of Disease 2001
Estimates recalculated by World bank.

22.  1 out of every 4 indls have mental
disorder.
 On average about 800,000 people
commit suicide every year, 86% of them
in low- and middle-income countries.
 More than half of the people who kill
themselves are aged between 15 and
44.
WHO estimates -2002

23. WORLD HEALTH DAY - 2001
“STOP EXCLUSION
DARE TO CARE”

24. TEN RECOMMENDATIONS
 Provide treatment for
mental disorders in
primary care
 Ensure wider accessibility
to essential psychotropic
drugs
 Provide care in the
community
 Educate the public
 Involve communities,
families and consumers
 Establish national policies,
programmes and legislation
on mental health
 Develop human resources
 Link with other sectors
 Monitor community mental
health
 Support relevant research.

25.  10 October is observed as the World Mental
Health Day since 1992
 This year’s theme is ‘Advocacy for global
mental health: scaling up services
through citizen advocacy and action'.

26.  More than 75% of people suffering from mental
disorders in the developing world receive no
treatment or care.
The Lancet Global Mental Health Group (2007) Scale up services for
mental disorders: a call for action. The Lancet, 370:1241-52

27.  A new WHO programme launched on World Mental
Health Day 2008 “Mental health Gap Action
Programme (mhGAP): Scaling up care for mental,
neurological and substance use disorders”
 It highlights the huge treatment gap for a number
of mental, neurological and substance use
disorders.
 The programme, asserts that with proper care,
psychosocial assistance and medication, many
could be treated even where resources are scarce

28. INDIA
 Estimated Prevalence -
58.2/1000
 15 Million people suffering from mental
disorders in India.

29. The major psychiatric conditions contributing to
morbidity:
 Neuroses - 20.7 per 1000
 Affective Disorders (including Mania,
Maniac Depression and Depression ) - 12.3 per 1000
 Mental retardation - 6.9 per 1000
 Schizophrenia - 2.7 per 1000.
Source : Reddy MV, Chandrasekhar CR. Prevalence of mental and behavioural disorders in
India : a meta-analysis. Ind J Psychiat 1998 ; 40 : 149 – 57.

30.  There are a number of theories or models
seeking to explain the causes of mental
disorder
 The most common view is that disorders
tend to result from genetic vulnerabilities
and environmental stressors combining to
cause patterns of dysfunction
AETIOLOGY OF MENTAL ILL
HEALTH

31.  Genetic factors
 Monozygotic - 33-78%
 Dizygotic - 8-28%
 First degree relatives - 10%
 Organic conditions-tumors, metabolic,
endocrinal, neurological, chronic diseases
AETIOLOGY

32. AETIOLOGY
 Other environmental factors
 Toxic substances - Hg, Mn, Pb, Tin
 Psychotropic drugs
 Nutritional
 Mineral eg iodine
 Infective agents
 Traumatic
 radiation

33.  Individual characteristics
 This includes cognitive or neurocognitive
factors
• The way a person perceives, thinks or feels
about certain things
• Overall personality, temperament or coping
style
AETIOLOGY

34.  Life events, stresses and relationships
 Maltreatment in childhood
 Post traumatic stress disorder
 Parental divorce
 Marital discord
 Socio-path causes
 Poverty,
 Unemployment
 Lack of social cohesion
 Migration, homelessness
 Socioeconomic position
AETIOLOGY

35. DELIVERY OF MENTAL HEALTH
SERVICES IN INDIA
o State supported mental
hospitals :- Large
hospitals in India include
those at Agra, Bareilly
and Ranchi and
NIMHANS at Bangalore.
o Private Psychiatric
Hospitals
o Psychiatric services as
a part of general
hospitals, as District
hospitals.
o Private Practice based
psychiatric consultation /
treatment
o Mental health services
at the primary care level,
through trained
paramedical workers.
o Preventive & Promotive
Mental Health care
services as a part of
Vertical Mental Health
Programs at the national
/ state level.

36. NATIONAL MENTAL HEALTH PROGRAMME

37.  Envisages a primary
health care based
approach supported
by specialist services
and referrals

38. National Mental Health Programme launched in
1982
The Mental Health Act 1987 repeals Indian
Lunacy Act 1912 and Lunacy Act, 1977
(Jammu & Kashmir) and extends to whole of
India.

39. AIM
 Prevention & treatment of mental and
neurological disorders and associated
disabilities
 Use of mental health technology to improve
general health services.
 Application of mental health principles in
national dev to improve quality of life.

40. 
 Sustainable basic MHS and integration
 Early diagnosis and treatment
 Domiciliary mental health care
 IEC ,Community edn to reduce stigma
 To treat & rehabilitate in family setting
 Operation research for implementation
COMPONENTS

41.  Proper recognition and treatment of mental
disorders to reduce morbidity
 Trg of MPW to deal with psychiatric emergencies,
maintenance of treatment, counselling etc

42.  At PHC
 Mental diagnosis through flow charts
 Epidemiological surveillance
 Planning and implementation of the programme
 Specialist at every district hospital

43.  Mental hospital and teaching psychiatric
units
 Strengthening of department of
psychiatry in medical colleges (under
which 70 medical colleges have been
covered)
 Modernisation of mental hospitals (under
which 23 mental hospitals have been
funded)

44.  A sum of Rs. 70 crore has been
earmarked for implementation of the
National Mental Health Programme
during the year 2007-08.

45. REGULATORY BODIES
 Central Mental Health Authority
 State Mental Health Authority
 National Human Rights Commission

46. PREVENTIVE MEASURES
PRIMARY PREVENTION
 Personality development
 Life skills education
 Youth welfare
 Workplace env
 Family life
 Social welfare
 Social security
 Job
 Education

47. SECONDARY PREVENTION
 Early diagnosis and treatment
 Recognition of common signs & symptoms
 Deviation from normal - eating,working,
speaking
 Sleep disturbances
 Excess smoking, drinking
 Irritability, tension,emotional instability
 Progressive tiredness, weakness, wt loss
PREVENTIVE MEASURES

48. TREATMENT
 Medicines
 Antipsychotics
 Antidepressants
 Anxiolytics
 Mood stabilisers
 Drugs used for dementia
PREVENTIVE MEASURES

49. TREATMENT
 ECT
 Psychotherapy
 Psychoanalytic, behaviour, cognitive,
group
 Social cultural therapies
 Music, art, yoga, meditation, sports
PREVENTIVE MEASURES

50. TERTIARY PREVENTION
 Rehabilitation
 Half way home
 Deaddiction centre
 Suicide prev centre
 Industrial therapy centre
 Vocational trg centre
 Self help gps
 Day care pgmme
PREVENTIVE MEASURES

51. MENTAL HEALTH PROGRAMME
IN ARMED FORCES

52. MENTAL HEALTH ARMED FORCES
 Increased stress during wartime
 Peculiarity of mental life
 Break in period : 1 - 3 yrs
 Career planning period : 7-12 yrs
 Established period
 Situations causing breakdown
 Fear & conflict
 Morale
 Sense of guilt
 Predisposing hereditary
 Inadequate trg etc

53.  A Mental Health Programme for the Armed
Forces (in the form of booklet dt 04 Sep
2008) has been prepared by a board of
officers headed by the Senior Consultant
(Medicine)
 Policy formulated in view of the increasing
trend in suicides and other stress related
disorders

54. HOSP ADMISSION RATE/1000
Service Year Psychosis Neurosis All
Forms
Army 2005 0.96 2.58 3.54
2006 0.96 2.40 3.42
Navy 2005 4.14 1.49 5.63
2006 4.45 1.94 6.39
Air Force 2005 0.88 0.49 1.37
2006 0.83 0.34 1.17

55. Service Army Navy Air Force
1996 3.85 3.66 1.73
1997 3.70 3.41 1.53
1998 3.75 4.26 1.63
1999 2.72 4.88 1.60
2000 1.71 4.44 0.92
2001 1.84 3.15 1.32
2002 3.38 2.80 1.06
2003 3.11 3.16 1.13
2004 3.38 4.81 1.43
2005 3.54 5.63 1.37
Av of 10 Yrs 3.09 4.02 1.37
2006 3.42 6.39 1.17
DECADAL TREND IN HOSP ADM FOR PSYCHIATRIC
DISORDERS (Rate per 1000)

56. MENTAL DISORDERS AS A CAUSE OF
INVALIDEMENT (RATE PER 1000)
2005 2006
Army 0.31 0.22
Navy 0.38 0.5
Air Force 0.85 0.15

57. SUICIDES IN ARMY : 2006
COMMANDS NO OF SUICIDES PER 1000
Southern Comd 1 5 0.05
Eastern Comd 0 2 0.01
Western Comd 1 5 0.06
Central Comd 0 8 0.03
Northern Comd 3 3 0.08
Army Trg Comd - -
TOTAL 7 3 0.06
SUICIDES IN ARMY-2006

58. MEMBERS
 Prof and HOD (Psychiatry), AFMC, Pune
 Sr Adv Psychiatry, BH, Delhi Cantt
 Sr Adv Psychiatry, INHS Asvini, Mumbai
 Dir Medical Services (Army, Navy, Air
Force)
 Scientist ‘E’, DIPR, Delhi
 Scientist ‘E’, AFMC, Pune
 The Dir AFMS (Health) is the member
secretary

59.  To promote mental health
 To prevent mental morbidity
 To facilitate early diagnosis and
management
 To minimize disability and ensure
effective rehabilitation
AIM

60.  27 psychiatric centers in military hospitals
 Services provided by medical specialist
where a Psychiatrist is not posted
 MO’s/RMO’s play a crucial role at unit levels
 Defence Institute of Psychological Research
looks into the research activities
EXISTING MENTAL HEALTH CARE
DELIVERY SYSTEM

61. AREAS OF CONCERN
 Improvement in environmental and
social support
 Need for developing an ambience
 Sensitisation of commanders at all levels
 Inadequate pay and allowances
 Inadequate family accomodation
 Need for emphasisig on issues of mental
health
 Shortage of mental health manpower
 Adoption of healthy lifestyles

62. RECOMMENDATIONS
Promotion of mental health is primarily a
command function
 General recommendations
 Specific recommendations

63. GENERAL
 Immediate promotional measures
 Immediate preventive measures
 Long term measures

64. IMMEDIATE PROMOTIONAL MEASURES
 Health edn of soldiers
 Adoption of healthy lifestyles
 Effective utilisation of manpower
 Deployment needs to be met
judiciously

65. IMMEDIATE PREVENTIVE MEASURES
 Junior leaders to ensure better interaction
with men at their place of deployment
 Regular and frequent spells of leave
especially if deployed in sensitive /stressful
environment
 Ensure prompt redressal of grievances
 Interview and med examination of all
personnel returning from leave

66. LONG TERM MEASURES
 Restructuring of the training curriculum
 Enhancing leadership qualities in Officer’s and
JCO’s
 Provision of adequate married family
accomodation
 Better educational avenues and assured
admissions to children of service personnel
 Assistance by the civil authorities
 Enhancement of the pay and allowances

67. SPECIFIC
 Education on Mental Health issues
 Training
 Medical personnel
 Nonmedical personnel
 Centre of Excellance
 Staffing and facilities at psychiatric centers
 Inpatient psychiatric facilities for lady officers
 Additonal recruitment of mental health professionals
 Involvement of RMO’s and AWWA / NWWA / AFWWA

68. HEALTH EDUCATION
 One day interactive session to be held at
all Command HQ of all three services
 One day interactive session for Officer’s
once in six months at Div/Indep
Bde/eqivalent level in Navy and Air force
 Lectures by AMA/Psychologists/junior
leadres and counsellers once a month at
unit level for tps and families

69. MENTAL HLTH TRG (MED)
 TRAINING OF MEDICAL PERSONNEL.
 Mental health issues already incorporate in
AMC courses for Officer's to be periodically
reviewed and updated
 Training courses of all nursing technicians
to have mental health issues in the
curriculum
 Advance course training curriculum for
psychiatrists to be reviewed periodically
and updated

70.  All units to have trained counselors /mentors
(02 per major unit and 01 per minor unit)
•Curriculum of religious teachers and NCO’s
at AEC to include a four week course
•Training centers for recruits to have capsule
on mental health issues
•Training academies to incorporate mental
health issues in their curriculum
MENTAL HLTH TRG (NON MED)

71. MENTAL HEALTH PROGRAMME
ADVISORY, IMPLEMENTATION-CUM-
REVIEW COMMITTEE
 Headed by DGHS (AF)
 Members
 Sr Consultant (Med)
 Sr Advisor (Psychiatry), BH, Delhi
Cantt
 Dir Health Of the three Services
 Dir AFMS (Health) – Coordinator of
Mental Health Programme of Armed
Forces

72.  Guidelines in the “Reference For Psychiatric
Examination, Diagnosis, Treatment and Disposal of
Service Presonnel and their families suffering from
psychiatric disorders” as given in DGAFMS Medical
Memorandum171/2002
MANAGEMENT OF PSYCHIATRIC
DISORDERS

73. Recovered cases of psychotic disorders
To be observed in temp LMC for two years / 96
weeks with maintenance medication
If maintaining satisfactory remission, placed in S2
perm for two years without medication (provided the
clinical condition is well stabilized and AFMSF-10 is
favorable)
Treatment instituted
Upgradation to S1 may be considered thereafter
CATEGORISATION AND DISPOSAL

74.  The observation period may be further extended
for two years in S2 perm
 Cases of Bipolar/recurrent depressive disorders
who require long term prophylactic therapy may
be considered for retention in S2 perm for
longer periods
 Sick leave
 Grant of comparatively longer S/L may be
considered
CATEGORISATION AND DISPOSAL

75. INVALIDMENT
• All cases of Mental retardation
• All cases of Dementia
• Alcohol and Drug Dependence cases
• Cases motivated enough to be kept under
surviellance for a period of at least one year
before upgradation to S1
• All cases suffering a recurrence after
upgradation to S1 to be invalided out

76. • All cases of major psychiatric disorders that have not
responded well to treatment and turned to a chronic
nature
• All cases of neurotic and somatoform disorders that
have become chronic
• Cases with less than two years of service and where
chronicity is likely
• Other mental disorders due to brain damage,
dysfunction or physical disease which are unlikely to
improve
INVALIDMENT

77.  All recovered cases of delirium
 Other mental disorders due to brain damage,
dysfunction or physical disease and amnesic
syndromes likely to remit and unlikely to interfere in
sheltered appointments
 All recovered cases of acute and transient Psychotic
Disorders
 All cases of Psychotic Disorders, with good response
to treatment may be retained
RETENTION

78.  All individuals who had suffered from Psychiatric
disorders with less than two years of service
 All cases of stress related disorders
 All Neurotic and somatoform disorders
Retention of specific cases may be recommended by the
psychiatrist depending on the merit of such cases
RETENTION

79.  Patient will be counselled and persuaded
 If suffering from a minor psychiatric illness
which may lead to harm to the patient or others,
he will institute necessary treatment and inform
CO of the hosp
 In other cases, consequences of refusal would
be explained to the patient and written statement
obtained from the patient thereafter
REFUSAL OF TREATMENT

80.  Psychiatric patients not capable of looking
after themselves will be discharged to their
homes directly with two escorts
 In case further treatment required, the kin of
the patient will be accordingly advised by
the OC Hosp for follow up at nearest Govt
Hospital
FINAL DISPOSAL OF PSYCHIATRIC
PATIENTS INVALIDED OUT OF SERVICE

81. AMENDMENT TO DGAFMS MEDICAL
MEMORANDUM NO 171
 AFMS-10 need not be initiated whenever
the patient is referred /admitted for
psychiatric investigation
 However, it can be asked for by the
cncerned specialist, if he deems the
necessity for the same

82.  The CO must outline briefly
 The usual nature of the person
 The nature of abnormal changes noted by
him or cmmunicated to him
 His own personal impression on the
matter
 AFMS-10 shall be a confidential
document
AMENDMENT TO DGAFMS
MEDICAL MEMORANDUM NO 171