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Community Mental Health in India: Past Present and Future

Presentee: Tanaya Roychowdhury Discussant: Priya Puri Chair Person: Mr. Kamlesh Kr. Sahu Assistant Professor, PSW Date: 14/05/2012

Introduction
Community mental health (CMH) has been the major mental health policy and treatment initiative of more than five decade. It emerged in the early 1960s as an alternative to treatment in centralized state mental hospitals, calling for a decentralized, non-coercive system that promoted patients right to selfdetermination within collectivist recovery settings (Berlim et al., 2003). The World Health Organization states that community mental health services are more accessible and effective, lessen social exclusion, and are likely to have less possibility for the neglect and violations of human rights that were often encountered in mental hospitals. However, WHO notes that in many countries, the closing of mental hospitals has not been accompanied by the development of community services, leaving a service vacuum with far too many not receiving any care (WHO, 2007). Community mental health is a decentralized pattern of mental health, mental health care, or other services for people with mental illnesses. Community-based care is designed to supplement and decrease the need for more costly inpatient mental health care delivered in hospitals. Community mental health care may be more accessible and responsive to local needs because it is based in a variety of community settings rather than aggregating and isolating patients and patient care in central hospitals. Community mental health assessment, which has grown into a science called psychiatric epidemiology, is a field of research measuring rates of mental disorder upon which mental health care systems can be developed and evaluated. In other words, it is a treatment philosophy based on the social model of psychiatric care that advocates that a comprehensive range of mental health services be readily accessible to all members of the community (Mosby's Medical Dictionary, 8th edition). Principles of Community Mental Health 1) Addressing population-based needs in ways that are accessible and acceptable 2) Building on the goals and strengths of people who experience mental illnesses 3) Promoting a wide network of supports, services, and resources of adequate capacity; and 4) Emphasizing services that are both evidence based and recovery-oriented (Thornicroft et. al., 2011) Components of Community Mental Health: Identifying a grass root level organization, essentially socio-developmental in their objectives, either for the population as a whole or for the disabled in the community. Training community volunteer workers in the identification and referral of persons with mental disorders using audio-visual aids and interaction through role play. Operating periodic mental health clinics in the community to provide medical care to the identified mentally ill. Increasing awareness of mental health problems in the population, using public friendly methods like face to face talks, street theatre, folk dance and drama. Training the community workers to implement simple psychosocial rehabilitation measures, particularly the mobilization of locally available resources. Networking with other medical and social service organization for the purpose of rehabilitation. Establishing family and community support, group for people with schizophrenia and other chronic mental illnesses. (Thara and Padmavati, 2007)

Historical Background of CMH The care of patients with mental illness has undergone major changes over the last two centuries. In the 19th century, large asylums were built throughout industrialized countries to provide care for patients with mental illness. Conditions in these asylums worsened during the 20th century in Western countries. Originally based on principles of moral treatment, they were often situated in rural areas or on the outskirts of cities. Following human rights and financial concerns, a deinstitutionalization movement led to the closing down of many asylums (Fakhourya, & Priebea, 2007). Mental Health Movements There have been various mental health revolutions. Pinel led the first, bringing humane concern for the mentally ill; Mental Hygiene was the second, the third revolution, Community Mental Health. Over time, public mental health care in the U.S. has been a shifting terrain. In their classic periodization of its major cycles of reform, The first cycle of reform, in the early nineteenth century, introduced moral treatment and the asylum; the second cycle, in the early twentieth century, was associated with the mental hygiene movement and the psychopathic hospital; and the third cycle, in the mid-twentieth century, was spawned by the community mental health movement and the community mental health center (Morrissey, J.P., & Goldman, H.H., 1984; 1986). Historical reform movements in mental health treatment in the United States
Reform Movement Moral Treatment Mental Hygiene Community Mental Health Community Support Psychosocial rehabilitation Consumer movement Evidence-based practice Era 1800 1850 1890 1920 1955 1970 1975 present 1960 90 1990 present 1998 present Setting Asylum Mental hospital or clinic Community mental health centre Communities Centres Consumer organizations Community Focus of Reform Humane, restorative treatment Prevention, scientific orientation Deinstitutionalization, social integration Mental illness as a social welfare problem (e.g. treatment housing, employment) Limitations of medical model and recognition of central role of rehabilitation Recovery as a guiding concept in the design of programme Use of the evidence in all stages of service provision

(Morrissey, J.P., & Goldman, H.H., 1984; 1986). Worldwide Development The development of community care movements in the world can be roughly divided into 3 stages: 1. Pre-community era 2. From deinstitutionalisation to community care 3. Community care or post deinstitutionalisation Pre-community era Strictly speaking, the focus of community care occurred long before the de-institutionalisation movement. The first general hospital clinic for psychiatric outpatients was established at St. Thomas Hospital in 1890. In 1930, the Mental Treatment Act gave local authorities the power to arrange outpatients which led to a serious increase in no. of outpatients clinics with at least 216 outpatients clinics by 1942(Blacker, 1946). In the US, concepts and practice of community care was actually originated from Cliff Beers book A mind that found itself (Beers, 1908) and his establishment of National Association of Mental Hygiene in 1909. This was followed by mental hygiene movement stressing early detection and prevention of mental illness (Archen & Greenberg, 1982) that further led to the establishment of child guidance clinics for maladjusted children and also stimulated establishment of adult outpatient clients after World war I(Felix, 1957).

From deinstitutionalisation to community care The increasingly worsening condition of the asylums caught the attention of the UK Parliament in 1950s. This led to a strong deinstitutionalisation movement simply by discharging mental patients into the community. Thereby, a dominating community care movement developed from 1960s to 1980s in psychiatric outpatients service. The intervention of psychoactive drugs, such as chlorpromazine, also speeded up community care movement. 1953: 3rd expert committee on Mental Health of WHO produced a new report that offered a new model for the development of mental health service. It suggested inclusion of inpatient, outpatient, day care, domiciliary care, hostel and other related community services. 1959: Passing of new mental Health Act that legalised informal admission of mental patients. 1962: Powell Policy proposed community care and comprehensive district hospitals for mental patients. 1980: Publishing of a paper Psychiatric Rehabilitation in the 1980s was published. This paper highlighted needs of adult chronic patients. Parallelly in 1946 in US the National Mental act was passed that led to formation of national institute of Mental Health in 1949. 1963: Community Mental Health act was passed in that year. It recommended construction of mental health centres in each catchment area. 1975: Public Law 94-63 was passed where Congress recognised success of community care movement in mental health services. (Kam-Shing Yip, 1996) Community care or post deinstitutionalisation After deinstitutionalization that modern community mental health services started to grow and become influential. In 1955, the Mental Health Study Act was passed. After passing of this Act, the U.S. Congress called for an objective, thorough, nationwide analysis and reevaluation of the human and economic problems of mental health. For the next four years this Commission made recommendations to establish community mental health centers across the country. In 1963 the Community Mental Health Centers Act was passed. Immediately after that the community mental health revolution was started. This Act contributed further to deinstitutionalization by moving mental patients into their least restrictive environments. During 1984 to 1985 practice of community care was also criticised. A study found out that 42 states had no consensus in the support of chronic mental patients being treated outside institutions. (James, 1987). Many problems were pointed out about implementation of community care. In UK also, practice of community care was also criticised. (KamShing Yip, 1996) The Declaration of Alma Ata- to achieve Health for All by 2000 by universal provision of primary health care (1978): The famous Health for All by 2000 slogan was born in a major international conference on primary health care organized in 1978 by the WHO and UNICEF in Alma-Ata in the then Soviet Union (now Almaty, capital of Kazakhstan) and primary health care was declared the bedrock of health care provision globally. It urged all governments, health and development agencies, and the world community to protect and promote the health of all the people of the world. According to the AlmaAta declaration, primary health care is "essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community through their full participation and at a cost that the community and the country can afford to maintain at every stage of their development in the spirit of self-determination" (Declaration of Alma-Ata 1978).19 Primary health care was essentially an approach to the provision of basic health services (Isaac, 2011).

History of community mental health from the Indian perspective The late Dr. R.L. Kapur who has written extensively on community mental health, began the story of community psychiatry with Dr. Vidya Sagar who, as early as in the 1950s, involved family members of patients admitted into Amritsar Mental Hospital. This experiment not only reaped rich benefits but also initiated a major movement of involving families in the care process. Now family wards are located in several institutions like NIMHANS, CMC, Vellore and the IMH, Chennai. (Thara, Rameshkumar and
Mohan, 2010).

Bhore committee (1946): It recommended the importance of manpower development in the field of mental health. It is this recommendation that made the Govt. of India establishes the All India Institute of Mental Health in 1954, at Bangalore. This is the first centre where postgraduate training in Psychiatry, Clinical Psychology and Psychiatric Nursing was started. The Bhore Committee also recommended: a) the creation of mental health organization as part of the establishment under the Director General of health services at the centre and at the provisional Directors of Health services, b) improvement of the existing 17 mental hospitals and the establishment of 5 new institutions in the first 5 years and 5 more in the next 5 years, c) Provision of facilities for training in mental health work for medical men in India and abroad and for ancillary personnel in India. This was followed by the Mudaliar committee in 1962. Mudaliar Committee (1962): This committee known as the Health Survey and Planning Committee, headed by Dr. A.L. Mudaliar, was appointed to assess the performance in mental health sector since the submission of Bhore Committee report. Its recommendations were as follows-General recommendations regarding preventive and curative field. The recommendations for prevention suggested provision of mental health services at pre-primary and secondary schools by the employment of not only of psychiatrists and psychiatric social worker but also of trained school counsellors; marital guidance and psychiatric clinics in all teaching and other major district hospitals. While some of the recommendations for the curative field are inpatient and outpatient departments at lay hospitals, Independent psychiatric clinics, and Institution for mental defectives. They promoted training in the area of training of mental health personnel, orientation in mental hygiene of pediatricians, school teachers, nurses and administrators, orientation in mental health for all medical and health personnel. They also encouraged research in the area of causes of mental diseases and disorders, factors which promote mental health, personal and educational problems of children, malnutrition, suicide and crime. Srivastava Committee (1974): The purpose of this committee was to suggest policy approaches to achieve better health care in the country. One of the most important recommendations of the committee was to develop community health volunteer scheme. As part of this scheme, community health volunteers have been recommended an intensive training of 3 months which includes the component of mental health. (Proceedings of The Indo-US Symposium on Community Mental Health, 1992, pg.2425) Raipur Rani in Hariyana: These committees were followed by another major step in Community Mental Health Care which was the experiment carried out in Raipur Rani. The Chandigarh program, carried out at the Raipur Rani Block of Ambala District of Haryana (1975-1982), was part of a WHO project titled Strategies for Extending Mental Health Care. Efforts were directed to develop a system of priority selection to train the existing primary health care personnel to carry out basic mental care tasks and to involve the community through public education and formation of Mental Health Association. 60,000 population of PHC block was selected for work. Over the course of 6 years, the levels and limits for mental health care work at primary health care level were outlined. The results demonstrated that, there are significant numbers of mentally ill living in the rural areas needing urgent treatment and they were not receiving any help. Further, it was demonstrated that it was possible for the different categories of primary health personnel to carry out a limited range of mental health activities with the support of the medical officers. It was also shown that it was possible to involve the community in a meaningful manner. (Murthy et al., 2005)

Sakalwara at Karnataka: Simultaneously a project was carried out at Bangalore by Community Psychiatry unit, National Institute of Mental Health and Neuro Science (NIMHANS) Bangalore from 1975. In a series of planned studies and training programmes, it was noted that, it was possible to define clear tasks for doctors and health workers working in PHC system and provide training to them. Separate manuals for the multipurpose workers (MPWs) in Kannada and the medical officers in English were developed based on the experience of the many years of fieldwork. Majority of the above rural mental health programmes were carried out from the Sakalwara Centre in Anekal Taluk. In addition, the Solur PHC set up was also involved in the application of the knowledge gained. These experiences have shown the urgent need for taking mental health care to villages and the vital role the multipurpose workers and medical officers can play in providing basic mental health care. (Murthy et al., 2005) National Mental Health Programme: The major breakthrough occurred in 1975 when the Raipur Rani and Shakalwara experiments were being carried out, when a new initiative to integrate mental health with general health services, also referred to as community psychiatry initiative, was identified as the approach to develop mental health service. The draft of the NMHP, written by an expert drafting committee which consisted of some of the leading, senior psychiatrists in India then was reviewed and revised in two national workshops attended by a large number of mental health professionals and other stakeholders during 1981-82, before its final adoption by the Central Council of Health and Family Welfare (CCHFW) in August 1982. In the backdrop of these events the National Mental Health Programme (NMHP) was formulated in 1982 to develop a national level initiative for mental health care. The objectives of NMHP were: (a) To ensure the availability and accessibility of minimum mental healthcare for all in the foreseeable future, particularly to the most vulnerable and underprivileged sections of the population (b) To encourage the application of mental health knowledge in general healthcare and in social development (c) To promote community participation in the mental health service development and to stimulate efforts towards self-help in the community. (Murthy, 2010) District Mental Health Programme: Realizing that the NMHP was not likely to be implemented on a larger scale without demonstration of its feasibility in larger populations, the National Institute of Mental Health and Neuro Sciences developed a programme to operationalize and implement the NMHP in a district. Bellary district with a population of about 20 lakhs, located about 350 kms away from Bangalore was chosen for the pilot development of a district level mental health programme. This project was undertaken with the active support of the directorate of health and family welfare services, government of Karnataka and the Bellary district administration. Currently 127 districts are covered by this programme. The central idea is the integration of mental health care with general health care, through decentralisation of services, deprofessionalisation of services and community involvement. The DMHP had the following objectives: 1. To provide sustainable basic mental health services to the community and to integrate these services with other health services. 2. Early detection and treatment of patients within the community itself. 3. To see those patients and their relatives do not have to travel long distances to go to hospitals or nursing homes in the cities. 4. To take pressure off the mental hospitals. 5. To reduce the stigma attached towards mental illness through change of attitude and public education. 6. To treat and rehabilitate mental patients discharged from the mental hospitals within the community. The essentials of the DMHP were:

1. A decentralised training programme for the existing health personnel on essentials of mental health care at the district level; 2. Provision of mental health care in all general health facilities; 3. Involvement of all categories of health and welfare personnel in mental health care; 4. Provision of essential psychiatric drugs at all health facilities; 5. A simple record keeping; 6. Mechanism to monitor the work of primary health care personnel in the provision of mental health care, 7. A mental health team at the district level, for training of personnel, 8. Referral support 9. Supervision of the mental health programme and 10. Administrative support of local government and Health Department (Murthy, 2010)

Challenges for mental health care in India


Large unmet need for mental healthcare in the community Poor understanding of psychological distress as requiring medical intervention in the general population Limited acceptance of modern medical care for mental disorders among the general population Limitations in the availability of mental health services (professionals and facilities) in the public health services Poor utilization of available services by the ill population and their families Problems in recovery and reintegration of persons with mental illnesses Lack of institutionalized mechanisms for organization of mental healthcare (Murthy, 2011)

National Human Rights Commissions (1999):


In order to deal with the above mentioned challenges, the National Human Rights Commission (NHRC), very early after its inception, was asked by the Supreme Court to monitor the mental hospitals at Agra, Gwalior and Ranchi. Subsequently, on its own initiative, the NHRC commissioned a project to review the mental health situation in the country particularly in the mental hospitals. The project publication has been lauded as a landmark report and brought attention to the neglected area of mental health. The NHRC has taken up several issues related to hospital and community mental health care. The commission and its representatives have made several visits to many of the hospitals in the country. It has initiated dialogue with State authorities and constantly reviews the ground situation to make sure that its recommendations on the quality assurance in mental health are implemented both in letter and spirit. (Nagaraja and Murthy, 2008). This was followed by National Mental Health Policy in 2001. National Mental Health Policy (2001): The National Mental Health Policy outlines the prioritized agenda for extending within a pragmatic time-frame basic mental health care facilities to all sections of the population across the country by the year 2020. The tactical vehicle for implementing the said policy will be the refocused National Mental Health Programme, initially formulated in 1982, with five key thrust areas The District Mental Health Programme (DMHP), redesigned around a Nodal Institution which in most instances will be the Zonal Medical College. Strengthening the Medical Colleges with a view to develop psychiatric manpower (HRD), improve psychiatric treatment facilities at the secondary level and to promote the development of general hospital psychiatry in order to reduce and eventually to eliminate to a large extent the need for big mental hospitals with a huge proportion of long-stay patients. Streamlining and modernization of Mental Hospitals to transform them from the present mainly custodial mode to tertiary care centers of excellence with a dynamic social orientation for

providing leadership to research and development (R&D) in the field of community mental health. Strengthening of Central and State Mental Health Authorities in order that they may effectively fulfill their role of monitoring ongoing Mental Health Programmes, determining priorities at the ventral / state level and promoting intersectoral collaboration and linkages with other national programmes.

Manpower development schemes in mental health for the 11th 5-year plan (2007-2012) To address the shortage of qualified mental health professionals it was thought necessary to have dedicated manpower development schemes in addition to continuing with the community care approach adopted under DMHP. These schemes are aimed at increasing the PG training capacity in the mental health specialties of psychiatry, clinical psychology, PSW and psychiatric nursing. To support the expansion of DMHP and implement Manpower Development Schemes the government allocated more funds for NMHP during the 11th 5-year plan period. The schemes approved for addressing the Manpower concerns in mental health are as follows: o Manpower development schemes in mental health for the 11th 5-year plan o 11 Centers of excellence in mental health o Scheme for manpower development in mental health o Modernization of state-run mental hospitals o Upgradation of psychiatric wings of Government Medical Colleges/General Hospitals Current scenario of community mental Health in India NMHP 2011: at present, the national mental health programme in India has the following features: 1. District mental health programme as already being carried out. 2. IEC Activities: Innovative IEC strategies involving Electronic/ Print/local media at Central level to reduce stigma attached to mental illness and increase awareness regarding available treatment and health care facilities. 3. Monitoring & Evaluation 4. Training and research (Ministry of Health & Family Welfare, 2011). Matrix of all activities at various Health Facilities under National Mental Health Programme (NMHP) 2011 Health Facility/ Geographical area/ Sl. No. Proposed Activities 1 2
Catering Population Village

Sub Centre/ 5000 population 20 Sub Centre under 1 Community Health Centre (CHC) PHC/ 30000 population 66 PHC under 1 District (Avg. population 20 lac) CHC/ 100000 population 20 CHC under 1 District (Avg. population 20 lac)

1. IEC Activities 2. Referral to PHC Estimated Case Load : 300 (60 per 1000 population) 1. IEC Activities 2. Referral to PHC Estimated Case Load: 120000 (60 per 1000 population) in a district. 1. Early Identification & Treatment 2. Referral to District Hospital 3. IEC Activities 4. Training of school teachers by master trainers for LSE

(Ministry of Health & Family Welfare, 2011).

District Mental Health Programme (DMHP) 2011 The existing and additional components for the DMHP are as follows:

Existing Activities of 123 DMHPs Early Identification and Treatment of Mental Illness near patients doorsteps Training of Health and Community Workers for 3 years only IEC activities at district level

6 member DMHP team for 10th plan districts, 11 member DMHP team for 9th plan districts

Additional Activities of 123 DMHPs for 11th Plan Period Life Skills Education and Counselling in Schools, College Counselling Services, Work Place Stress Management Training of Health and Community Workers for all years Dedicated Monitoring team, Essential participation of Community based organisations, more effective Integration of DMHP in the district health system Revised to seven member team for implementing DMHP

Proposed activities for the DMHP 2011: (In 123 Districts) 1. Brief survey for situation analysis, identification of partners and planning a road map. 2. Engagement of DMHP Team. 3. Training of DMHP Team. 4. Early detection and treatment of Severe Mental Disorders (SMD) 5. Referral support for PHC/ CHC in managing mental disorders. 6. Training of doctors and health staff of PHC/ CHC 7. IEC activities and screening camps. 8. Training of Master Trainers for LSE in schools. 9. Training of teachers for college counseling services. 10. Outsourcing and supervising District counseling centre and suicide prevention helpline 11. Workplace Stress Management workshops. 12. Maintenance of website. 13. Referral of complicated cases to tertiary centers. 14. Monitoring & Implementation of DMHP (Ministry of Health & Family Welfare, 2011). Current scenario of CMHP in private sector: Non Government Organizations: As the government funded projects for the development of CMH were in progress, simultaneously, the private sector was also active in the form of NGOs. Non-Governmental Organizations (NGOs) are institutions, recognized by governments as non-profit or welfare oriented, which play a key role as advocates, service providers, activists and researchers on a range of issues pertaining to human and social development. The growing role of non-governmental organizations (NGOs) which provide services for suicide prevention, disaster care and school health programmes, in which non-specialists and volunteers play an important role, has tremendous importance for India as NGOs can bridge the gap of human resources. The paucity of treatment facilities and psychiatrists in the Government sector has widened the treatment gap in mental health. Non-governmental organizations (NGOs) have played a significant role in the last few decades in not only helping bridge this gap, but also by creating low cost replicable models of care. NGOs are active in a wide array of areas such as child mental health, schizophrenia and psychotic conditions, drug and alcohol abuse, dementia etc. Their activities have included treatment, rehabilitation, community care, research, training and capacity building, awareness and lobbying. (Patel and Thara, 2003). NGOs have been strongly committed to extending care into community (Patel and Thara, 2003). Several community mental health programs have been reported in various parts of the country

(Nadkarni, 1997). These programs operated by the voluntary agencies and NGOs were demonstrated as feasible and cost effective (Chatterjee et.al. 2003). Factors affecting community outreach programmes of NGOs: o Community acceptance- sustenance of any community program lies in its acceptance by the community, particularly in mental health service and delivery, shrouded in long-standing myths and conceptions regarding causation and manifestations. Involving lay community people has increased the acceptance. o Management strategies: pharmacotherapy of mental illness, particularly severe mental disorders, has brought about a reduction in the disturbing manifestation such as violent behaviour and socially unacceptable conduct. With adequate supervised orientation and follow up program in the use of anti-psychotic drugs, it is possible to involve the community health workers in the treatment of mental disorder (Thara and Srinivasa, 2004). o An important method in community outreach for the mentally ill has been the home based intervention program offered at NGOs such as SCARF. Many people are non-compliant due to distance and cost constraints. The families of the mentally ill are also being involved. o Networking: this has been an important strategy, allowing for a multi-dimensional care and rehabilitation process in the community care for the mentally ill. Networking promotes the effective use of locally existing community rehabilitation alternative. o Sustainability: the challenge has been in identifying ways of continuity care for the patients, particularly, the resources for provisions of medicines, since this forms a major expenditure in the program operation. One strategy is to link up with government funded programs. Some NGOs are also providing telemedicine services in order to bridge the gap due to limited manpower and distance. The major activities of NGOs are as follows: o Treatment-care and rehabilitation o Community based activities and prevention o Research and training o Advocacy and empowerment (Thara and Padmavati, 2007) Names of some NGOs: 1. SCARF(Chennai) 2. ARDSI- Alzheimers and Related Disorders Society of India(Cochin) 3. Sangath Society (Goa) 4. Umeed and Research Society(Mumbai) 5. Manas(WB) 6. Anjali (WB) 7. Antara (WB) 8. Ishwer Sangkalpa (WB) 9. MPA-Medico Pastoral Association (Bangalore) 10. RFS 11. SNEHA (Chennai) 12. Saarthak 13. Chaitanya 14. Bonyon (Chennai) 15. Pabu Trust The strengths and weaknesses of NGOs are: Strengthso Working in partnerships o Innovations in practice o Transparency in administration

Weaknesseso Sustainability o Accountability o Limited scope

DISCUSSION:
Need for community mental health: The mental health in the community encompasses a wide variety of needs. These include: 1. serious mental disorders in the community; 2. Persons with Acute conditions; 3. Persons with long-standing(chronic) mental disorders; 4. Mental disorders in primary health care; 5. Mental health of women; 6. Children and adolescents- school going and out of school; 7. Special groups like refugees, survivors of disasters, 8. Persons attempting suicide; 9. Public mental health education; 10. Persons in institutional settings; 11. Prevention of mental disorders and 12. Promotion of mental health (Srinivasa Murthy et al 2004, Thara et al, 2008) The inspiration for the community mental health movement in India comes from three sources (Srinivasa & Burns, 1992) Realization in Western countries that the treatment of mentally ill patients in mental hospitals might be counterproductive. In the 1960s, Kennedy administration launched the American version of the community mental health programme (Gruenberg, 1967) Realization that institution-based psychiatry through trained professionals can be very expensive and that, countries like India will not have the sufficient manpower and facilities to deliver services through conventional methods, for many years. Happy discovery in other poor countries, that para-professionals and non-professionals could, after undergoing simple and short innovative training, deliver reasonably adequate mental healthcare (Haworth, 1969; Schmidt, 1967; Swift, 1972). Historical Development of Mental Health services in India pre-independence: Until the arrival of the Europeans in the 18th and 19th centuries, there were no separate services for the mentally ill the traditional Indian medical systems such as Ayurveda or Unani, recognised various types of mental illness. Methods of yoga and meditation also played a significant role. In traditional Indian practice, mind and body were not treated separately. Given below is a Historical overview of the mental health services in India before independence. The pre-independence scenario of mental health services can be divided into 4 stages:

Establishment of Lunatic Asylums (17841857):

1787: the 1st reference to a mental hospital in Calcutta under the tenure of Lord Cornvallis (1786-1793) 1794: establishment of mental hospital in Kilapauk (Madras). 1795: establishment of a mental hospital in Monghyr (Bihar) which was mainly meant for soldiers. 1817: sergeant Bredmore tried to improve the conditions of mental patients in Calcutta which had facilities for 50-60 European patients living in clean surroundings. Until the early part of the nineteenth century, mental asylums were located only at the major cities of that period like Madras, Bombay and Calcutta. These asylums were primarily custodial in nature and mostly catered to the British and the Indian sepoys employed by the British. It appeared that the East India Companys administration concerned itself only with its own countrymen and their Indian employees. The large masses of the local population were mostly left unattended and uncared for. The mentally ill from the general population were taken care of by the local communities and by traditional Indian medicine doctors, qualified in ayurveda and unani medicine. At this point it is important to mention about the treatment available in the mental hospitals at that time. The Calcutta (1856) and Dulland (1857) reports stated that although mechanical restraints remained, chains and manacles were reserved for extremely violent patients. A majority of the patients were of lower class and labour was used as a mode of therapy. Growth of Mental Asylums (18581904): 1858: passing of Lunacy Act which detailed the procedures for establishment of the mental hospitals for admitting patients. 1860-1870: during this time, the Gheel system was used as a therapy in Dacca. For those whom it was felt safe, arrangements were made to live in the home of responsible persons where medical officers of the mental hospitals checked them. This method was a financial success, but the fear of being blamed remained among the hosts. Thereby, the treatment conditions were unsatisfactoryand inhumane. By 1874, there were at least six such asylums at Bhowanipore in Calcutta, Patna, Dacca, Berhampur, Dulanda (in Calcutta) and at Cuttack (Orissa). The year 1874 is also important in Indian history as Assam was separated from Bengal, and by 1876 a new asylum was opened at Tezpur to cater to the needs of the mental patients of Assam. In this phase, there was a discernible growth in the number of mental asylums, located away from the major metropolitan cities in the provinces, and the local population was also permitted to avail these facilities. However, most of these asylums were set up primarily near cantonments, where the British army units were stationed. Humanistic Approach and Early Legislation (19051919)

By 1906 it was contemplated to have a central supervision of these hospitals. The central supervision of these hospitals shifted from Inspector General of prisons to the civil surgeons of the Indian Medical service. Second historical change was the appointment of psychiatrists as full-time medical officers. Third significant development was the intent of the government in 1906 to have a central supervision by legislation of all the lunatic asylums. This resulted in the Indian Lunacy Act 1912. The other associated development at that time was the growing concern of the public about the poor and unhygienic conditions of mental hospitals. This resulted in not only the improvement of existing conditions of hospitals at that time, but also in the opening of many more new hospitals. Movement away from Mental Hospitals (19201947):

The sustained efforts of Dr Berkeley Hill and many of his colleagues not only helped to raise the standard of treatment and care at the mental hospital at Ranchi, but also persuaded the government to change the term asylum to hospital in 1920. As a part of the social awareness, initial attempts to establish direct links with the patients family were made in the form of family units. In 1930, an Association of the Medical Superintendents of Mental Hospitals was established Later in the 1940s, the emphasis was on improving the conditions of existing mental healthcare and the treatment programmes Post-Independence Era: After India attained independence, many committees came up to evaluate the status of Mental Health Service in the country. Some of the committees that came up at that time are as follows: Bhore committee (1946) Mudaliar Committee (1962) Srivastava Committee (1974) Raipur Rani project in Haryana (1975) Sakalwara at Karnataka (1975) National Mental Health Program in 1982: These projects revealed many loopholes in the mental health services in India at that time and these projects jointly impacted the formation of the National Mental Health Program in 1982. The impact of the NMHP in its initial 20 years has been mentioned below: Impact of NMHP: progress between 1982-2002Since the adoption of the NMHP, in some ways its progress can be said to be very significant. The wide variety of community care alternatives essentially coming from the voluntary sector. These initiatives have included day care centres, half-way homes, long-stay homes, suicide prevention and school mental health programmes. All of these have demonstrated that there is a felt need for alternative community care facilities, as well as the fact that they would be used by the general public when they are provided in user-friendly manner. The other major development is human resource development. At the time of the formulation of the NMHP, the number of psychiatrists was less than a 1,000 and in the last 20 years it has nearly tripled to 3,000. The public awareness which has increased enormously due to community-based mental healthcare, initiatives of voluntary organisations, trained mental health professionals working in remote areas in the private sector, as well as due to a massive effort by professionals to address the general public with modern mental health information.

Barriers to the Implementation of NMHP Poor funding Limited undergraduate training in psychiatry Inadequate mental health human resources Limited number of models and their evaluation Uneven distribution of resources across states Non-implementation of the MHA 1987

Privatisation of healthcare in the 1990s. Limitations of NMHP: 1. The programme looked good on paper, but was extremely unrealistic in its targets, especially considering the available resources of manpower and funds. Just to give an example, the cost of psychotropic drugs required for minimum mental healthcare would be three to four times the total budget of a PHC. The setting up of district hospital psychiatry units would also be very expensive. The sum of Rs 10 million was obviously sanctioned without working out the costs. 2. The approach was top down and did not take into account the ground realities. The poor functioning of the PHCs in India in general as well as the poor morale of the health inadequately would certainly be unable to absorb new targets. We seem to have learnt little from the failure of the family planning programme. 3. There was a lack of enthusiasm for the programme in the profession as a whole. Without the help and active cooperation of professionals across India, no large-scale training programme or supervision is possible. 4. There was a lack of an administrative structure to monitor the progress of the programme in a decentralised manner. District Mental Health Programme (DMHP): The District Mental Health Programme (DMHP) came as a part of the National Mental Health Programme (NMHP) started in Bellary District, current 127 districts are covered by this programme. Given below is the District Mental Health Programme (DMHP)Summary report of Chandigarh, Haryana, Himachal Pradesh and Punjab states by Murthy and Nagarajiah, (2003).

Evaluation of DMHP OBJECTIVES

(Murthy and Nagarajiah, 2003): CHANDIGARH HARYANA HIMACHAL PRADESH PUNJAB

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 the cities To take pressure off the mental hospitals

Community services but not integration with health services

Community services but not integration with health services

Community services but not integration with health services

Minimal community services but not integration with health services

yes

yes

yes

Yes-minimal

partial

partial

partial

To a very limited extent

Not applicable

Yes

Yes

Not applicable

To reduce the stigma yes attached towards mental illness through change of attitude and public education To treat and rehabilitate mental patients discharged from the mental hospitals within the community partial

yes

yes

In initial stages

no

partial

no

Barriers to DMHP: Limited development of the DMHP in its operational aspects by the Central agency Limited state level capacity to implement the DMHP Location of the DMHP with teaching centres Inadequate technical support from professionals Lack of emphasis on creating awareness in the community Lack of mental health indicators Lack of monitoring

National Human Rights Commission (1999): Findings of the NHRC Project The project team personally visited 59 facilities, including governmentrun mental hospitals (32), general hospital psychiatry units (16) and private psychiatric treatment

centres (10). In a majority of the hospitals the team observed: An archaic structure of the buildings and practices with existence of cells without any sanitary facilities, giving a prison like ambience, Poor living environments with overcrowding (bed:patient, 1:1.4), poor sanitary conditions, poor quality of food, Poor or nonexistent lab facilities, Lack of staffwith a psychiatrist patient ratio in some hospitals of 1:200 (two hospitals had no psychiatrist) and even poorer presence of psychologists and social workers, Lack of rehabilitation facilities, and Poor documentation of patient information. The NHRC project findings led to changes, both direct and indirect. In many states, sensitisation of the administration led to efforts at improving basic amenities. Financial support to many of the hospitals for structural improvements was sanctioned. During the tenure of the NHRC project, the Ministry of Health, Government of India, initiated two parallel efforts in the area of mental health: the first was to sensitise the state health secretaries, and the other was to evolve minimal standards of care in mental hospitals in consultation with medical superintendents. However, although there were positive steps, the changes were slow and sporadic, as was evident in the findings of a subsequent survey carried out by the Ministry of Health in 2002. Problems In Community Care In Developing Countries The Hierarchy of Needs Concepts of Mental Illness Professional Commitment Demand and Governmental Priorities The absence of a Social Welfare Net: The Vertical Nature of Health Programmes Scope of the Programme Other factors: - Other factors that may interfere with community care include the high levels of civil strife and violence in some societies, political instability and corruption and gender inequality . Future of Community Mental Health in India: Community psychiatry has developed in Western countries in response to a felt need. The economic development took care of physical needs and mental health became a priority. To expect strategies employed in industrialized nations to succeed in developing countries, where the ground realities differ, is nave. Combating the obstacles to progress is difficult in the short term. In the long term, if the basic needs of the populations are met, mental health care would be a priority and consequently would be adequately delivered. Possible solutions are discussed briefly below: Shifting the Focus: The immediate goal should be restricted to the identification and treatment of priority disorders (e.g. psychoses, depression & epilepsy). Focusing on achievable goals would be a useful first step in mental health care delivery. Other specific goals (e.g. life skills education, school mental health programmes, follow-up of subjects at high risk for developing mental illness) (Rahman et al., 2000) also can be included when priority illnesses are managed. Demonstrating the Economic Advantages of Managing Mental Disorders: Although studies of effectiveness have shown that treating mental disorders makes clinical and economic sense (Thornicroft et al, 1998), there is a dearth of studies on the reduction of morbidity, disability and consequent financial costs in developing countries. A recent study has demonstrated that economic analysis of mental health care programmes in low-income countries is technically feasible and can usefully inform policy and service development (Chisholm et al., 2000). There is a need to demonstrate the financial advantages of managing mental disorders in the community before governments will support such initiatives on a large scale.

Enhancing Skills During Basic Training: Although empowerment of physicians, nurses and other health workers has been emphasized and various training programmes developed (Harding et al, 1983; World Health Organization, 1984, 1990), the basic curriculum of these courses in many developing countries pays lip service to the diagnosis and management of mental disorders. The training programmes do not provide the necessary skills, nor do they transfer the confidence required to treat mental illness. These programmes are conducted in mental health facilities, using patients referred for specialist intervention, and they employ specialist perspectives. Physicians and health workers are best taught about common presentations and problems in primary care settings using strategies that are locally available and applicable (e.g. ICD-10; World Health Organization, 1996). Bridging Mental Health Issues with Existing Public Health Priorities: Adding a vertical mental health programme to the existing public health programmes has been attempted and found to be unsuccessful. The mental health component needs to be integrated into community health programmes Supporting Community Health Workers: Training courses for health workers have been conducted in many countries (Harding et al., 1983; World Health Organization, 1984). However, the health workers usually do not have support in the field, resulting in poor recognition and treatment rates for mental illness. There is a need for training programmes to be followed by the provision of regular supervision in fieldwork. This is best achieved by public health physicians and nurses trained in the management of these disorders. Partnership with the Private Health Care Systems: Most national mental health programmes employ governmental resources for health care delivery. However, resource constraints of governments prevent such programmes from reaching many sections of society. Partnership with the Traditional Health Sector: In most developing countries traditional medicine is flourishing. It caters to a large population and it manages many common mental disorders (Patel et al, 1995 Role of the Mass Media: The lack of awareness about mental illness, the role of early recognition and the need for treatment result in the absence of demand for mental health services. The mass media, especially radio and television, are especially helpful in educating illiterate populations. This will help also to reduce the stigma related to mental illness and increase the demand for mental health care. The situation in developing countries is such that any strategy used in isolation will be much less effective than a combination of approaches. All available resources should be harnessed to improve community care for mental disorders. Conclusion: In conclusion, the development of mental health services all over the world, in rich and poor countries alike, has been the product of larger social situations, specifically,the importance society has given to the rights of disadvantaged/marginalized groups. There is a need to continue the process by widening the scope of mental health interventions, increasing the involvement of all available community resources, and basing the interventions on the historical, social and cultural roots of India. This will be a continuing challenge for professionals and people in the coming years. The story of mental healthcare is an unfinished one. Much has occurred during the past 6 decades but much more needs to be done to complete the story.

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