1. An Analysis of the Mental Health Challenges
in the State of Kerala, India
Presented to: Dr Manoj Mohanan and Dr Joanna (Asia) Maselko
6th April 2011
SUSAN CHEN
Duke University
1
4. Morbidity rate for Kerala is double the national average.
Inadequacy of past epidemiological and community based
surveys in India.
Kerala suicide rate is 2.5 times the national average.
National Average:
10.9 per 100,000
Suicide Rate per 100,000:
Less than 10
10-20
20-30
30+
4
6. Community Workers Community Centers Hospitals / Colleges
Private / Private /
Private
Cooperative Cooperative
Centers* Hospitals*
Community Health Mental Health
Anganwadi
Centers Centers*
General /
Public
DMHP Clinics* District / Taluk
ASHA Hospitals*
Primary Care Medical
Centers Colleges*
*Provide some level of psychiatry, social
services, counseling and psychiatric drugs.
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8. State Government of Kerala -
Minister for Health And Social Welfare
Kerala State Mental
Health Authority
District Panchayaths
District Panchayaths
Block Panchayaths
Block Panchayaths
(Community Health Centres and Taluk
(Community Health Centres and Taluk
Hospitals)
Hospitals)
Village Panchayaths
Village Panchayaths
(Primary Care Centers)
(Primary Care Centers)
8
9. Anga
nwa /
ASHA di / RSBY School
CHIS Health
NGOs Program
/
ISIS
KR ACE
SP
DMHP
DMHP
HM
IS
Assw
A waa a
s
IMHA Kiriaa sa
K r nn m
NS a
Scch am
S hee e
me
m
KMSC
11. 1. Prevalence of Mental Illness 5. Mental Health
Governance
Department of
Research Structure Health – KSMHA
Private /
Private / Cooperative
Cooperative
6. Local Centers
Mental Health Hospitals
Initiatives
3. Mental
Health Care
System Community Health Mental Health
Centers Centers
Anganwadi
DMHP Clinics General / District /
Taluk Hospitals
ASHA
2. Contextual
Environment
4. Mental
Health Care Primary Care Centers Medical Colleges
Professionals
7. Global Mental Health Initiatives
12. 1. Establish statewide governance structure.
2. Undertake rigorous population studies.
3. Launch statewide community awareness and life-skills
campaign.
4. Increase the number of local psychiatric resources and
enhance mental health education programs.
5. Implement a stepped care model.
6. Enhance support to family care givers.
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13. Maximize effectiveness of prevention, identification,
diagnosis and treatment interventions targeting mental
illness.
Maximize public access to mental health services.
Minimize costs to the public and State of Kerala
associated with improving mental health services.
Minimize time required to improve mental health
services.
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14. • Reports to Kerala Health Minister.
• Sets Kerala mental health policies and regulations.
• Coordinates and monitors initiatives.
• KMHSA enforces regulations.
• Quarterly meeting between Medical
Colleges, Mental Health and District
Hospitals.
• Reports to State Level Coordinator.
• Leverages social media and
mobile technology to highlight
public concerns and promote
accountability.
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18. Community Workers Community Centers Hospitals / Colleges
Private / Private /
Private
Cooperative Cooperative
Centers* Hospitals*
Mental Health
Anganwadi Community Health Centers*
Centers*
General /
Public
District / Taluk
ASHA
Primary Care Hospitals*
Centers* Medical
Colleges*
*Provide some level of psychiatry, social
services, counseling and psychiatric drugs.
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20. State Level Coordinator & KSMHA
1. Establish Statewide
Governance Structure
Mental Health Advisory
Mental Health Advisory
Public Focus Group
Public Focus Group Research
Research Committee
Committee
2. Undertake State-
wide Population
Studies
Private /
Private / Cooperative Cooperative
Centers Hospitals
Anganwadi Mental Health
Centers
Community Health
Centers
3. Community General / District /
Awareness and Life- ASHA
Taluk Hospitals
Skills Campaign
Primary Care Centers
6. Support Family
Care Medical Colleges
5. Implement
Stepped Care
Model 4. Enhance Available
Medical Resources
23. Implementation Outline
Aggregate
2012 2013 2014
Statewide Governance
Population Studies
Community Awareness
Enhance Medical Resources
Stepped Care
Family Care
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24. Aggregate Analysis
Action Steps
Enhance Capabilities
Expand Technology Research
Resources Non-MH Investment Grants
Anganwadi ASHA Teachers
Prof.
1. Establish Statewide
X X
Governance Structure
2. Undertake Statewide
X
Population Studies
3. Launch Community
Awareness and Life Skills X X X
Campaign
4. Enhance Available
X X X X
Medical Resources
5. Implement Stepped Care
X X X X X
Model
6. Support Family Care X
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25. Aggregate Analysis
Cost and Benefit Analysis
(Rupees)
Projections of Benefits
Productivity Per Capita Saved (Half Impact) 1,658,335,815
Estimate of Available Funds
Allopathy Un-utilized budget (Based on 2007/08) 273,500,000
2011-12 Kerala Budget Extract
School Health Program 1,000,000
ASHA Allowance 111,500,000
DMHP 2,000,000
PHC & CHC 9,000,000
Hospitals 40,000,000
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WHO conservatively estimated in 2008 that Kerala had a mental disorder prevalence of 58 per 1000 population and a severe mental disorder prevalence of 10-20 per 1000 population. However there is a limit to relative measures. The diversity of education, health facilities and public information on illness and remedies across India make relative morbidity rates unreliable. There is however a limitation in validating absolute numbers. Epidemiological studies over the last forty years in India have tended to focus only on general psychiatric morbidity in small-to-medium populations, with often varying selection and identification criteria and inappropriate statistical procedures. Only one longitudinal study for all mental disorders has ever been conducted in India. However in 2009 Kerala also recorded the fourth highest suicide rate in comparison to all other Indian states that was two and a half times the national average. This emphasizes the need for greater attention towards mental health in Kerala by its next elected State General Assembly.
Kerala ’s contextual environment continues to impose a greater biological, social and psychological strain upon its population. The rapid urban development in Kerala is placing more stress on society, precipitated by social isolation, insecurity, dissolution of family relations and cultural conflicts (Prakash 2008). The per capita consumption of alcohol is consequently the highest in Kerala (KSMHA 2011). There is growing unemployment in real sectors like agriculture and industry and increasing inequalities in income and land distribution (Raman 2010). Women continue to be treated as subordinates in terms of work participation, gender equality and freedom of expression (Raman 2010). Often poorly educated young men obtain the most lucrative jobs in Gulf countries and marry more educated Kerala women. The unequal education between couples often leads to domestic problems and violence and results in long periods of absence where the wife must take full responsibility for the family (Mitra 2007). Kerala has the highest divorce rate of any other Indian state (KSMHA 2011). Indebtedness and poverty levels are increasing, health status indicators are reversing and there is a growing incidence of vector-borne diseases (Raman 2010). Kerala ’s environmental damage threatens the quality of life and has reduced its resource base, with only 10% of its natural forests remaining (Paravil 2000). Kerala ’s population is also aging at a rapid pace, which is anticipated to increase the number of dementia cases (Mathurananth 2009).
