community psychiatry nimhans, public mental health program

1. Community mental health in
India- way ahead
Dr K.V.Kishore Kumar
Psychiatrist

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.
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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. 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
Burden of disease
% attributed to mental and behavioural disorders
of total DALYs lost world-wide
• 1990 10 %
• 2000 12.3 %
• 2020 (projected) 15 %
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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. 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. 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
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
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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
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FromTables3.2and3.4
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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
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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. 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. Needs of persons with mental disorders

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. 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. 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. 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. IEC-Manual for Health workers

20. IEC-Manual for medical officers

21. Ten features of mental disorder- Flip charts and
posters

22. Interactive computer-based video
training modules (6 CDs)

24. 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

25. 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

26. Mental Disorders and poverty

27. 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.

28. 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

29. Gaps in mental health
• Promotion and prevention
• Access to quality care
• Policy and financing
• Human rights
• Values and Knowledge

30. 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.

31. • Deinstitutionalization (Italy, 1978)
• Care in the community
• Partnership with consumers
• Partnership with families
• Human rights
International Developments

34. 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

35. 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

36. Evaluation
Barriers in DMHP
 Administrative Barriers
 Lack of clarity in guidelines
 Lack of manpower resources
 Motivational barriers
 General Issues

37. 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

38. MENTAL HEALTH
- NEW UNDERSTANDING
- NEW HOPE
WORLD HEALTH REPORT 2001

39. 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

40. 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

41. 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

42. • 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

43. 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

44. 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

45. 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.