International Review of Psychiatry, April 2005; 17(2): 103–107

Community mental health care in India

R. PADMAVATI

Schizophrenia Research Foundation, Chennai, India

Summary
Recent times are witnessing methods in the various forms of community care for the mentally ill in India. Non-governmental
organizations (NGO) play a pivotal role in filling the gap in the existing mental health services in India and the substantial
need for these services. Various strategies that have been employed in community care have attempted to utilize existing
community resources for implementation. Informal manpower resources incorporated with specialist psychiatric care and
integrated with existing health care facilities have been general strategies. While the feasibility and cost-effectiveness of the
NGO operated community outreach programs for the mentally ill have been demonstrated, various factors are seen to
influence the planning and execution of such programs. This paper elucidates some critical factors that would need to be
considered in community mental health care in India.

Introduction continue to be inadequate, in terms of manpower as

well as infrastructure, as evident from the fact that
Mental illness has been reported in ancient Indian
there are only about 3500 psychiatrists, about 1000
medical literature as early as circa 600 (Namboodhri,
each of psychologists and psychiatric social workers
1986) and accurate descriptions of psychoses can be
and around 900 psychiatric nurses in the entire
found in the medical treatise of that period. Mental
country.
illnesses have been viewed as a ‘curse’, an infliction
Several community studies have demonstrated
or a sin of the past birth, and so forth. These
that one-third of the chronic mentally ill in the
explanations have been perpetuated through genera-
community remain untreated (Padmavati, Rajkumar
tions. While the mentally ill patients do elicit
& Srinivasan, 1998). Stigma associated with mental
negative responses such as fear, disgust, pity or
illnesses, inaccessibility of mental health care and the
hostility from society, families continue to care of
traditionally prevalent causative perceptions hinder
them. Temples and other religious institutions have
the utilization of existing services. Not more than
also helped shelter these patients, who are left there
10% of those who need mental health care are
by relatives who cannot cope. Rural communities
receiving the required help with the existing services
have offered refuge to many patients who have
(Murthy, 2004). The impetus for community care of
wandered into their localities. Thus non-institutional
the mentally ill, in the framework of modern
care, a core concept of community psychiatry,
psychiatric practice has come from the veritable gap
has always been practiced in India through the
in the existing mental health services and the
ages, although this has been rather disorganised
substantial need for these services.
in structure and in function (Chandrasekhar &
Parthasarathy, 1999).
More than 20 million people in India suffer from
History of community mental health in India
various forms of mental disorders, with over 9
million suffering from severe disorders. Government Community mental health in India had its origins
run Mental Hospitals and General Hospital prior to the initiation and implementation of the
Psychiatric Units (GHPUs) provide treatment for National Mental Health Program (NMHP) for India.
most of the mentally ill. Non-governmental organi- The experiments carried out by Dr Vidya Sagar at
zations (NGOs) and private services have comple- Amritsar Mental Hospital, the establishment of the
mented this effort, but these are located primarily in GHPUs, the rural mental health programs by
urban areas. Formal mental health care systems the National Institute of Mental Health, Bangalore,

Correspondence: Dr R. Padmavati, Schizophrenia Research Foundation, Chennai, India. E-mail: raman_padma@vsnl.com

ISSN 0954–0261 print/ISSN 1369–1627 online ß 2005 Institute of Psychiatry
DOI: 10.1080/09540260500073562
104 R. Padmavati
and the other premier institute at Chandigarh are
early examples (Kapur, 2004). Community care
as an organized program was initiated in India in
the mid-1970s, beginning with experiments in
Sakhalwara in Karnataka (Chandrasekhar, Isaac &
Kapur 1981) and Raipur Rani district in Haryana
(Wig, Murthy & Harding, 1981). The National
Mental Health Program for India was a development
of the concern for alternate care programs for the
mentally ill and the initial experiences of organizing
mental health care for the needy. Based on the
principles of decentralization and destigmatization,
the program aimed at integrating mental health care
with primary care. Significant components of this
program aimed at training health care personnel at all
levels at the primary health care centres (PHC),
sensitising policy planners to mental health issues
and promoting community participation in mental
health service development. After about two decades,
critical factors identified as detriments to progress
were a uni-dimensional, top-down programme,
poor funding, inadequate human resources, uneven
distribution of resources across states and the non-
implementation of the legal processes (Goel, Agarwal,
Ichhpujani & Shrivastava, 2004; Murthy, 2004).
The strong commitment to extending care into the
community has resulted in the active involvement of
NGOs in community outreach (Patel & Thara,
2003). Several community mental health programs
have been reported in various parts of the country
(Chatterjee, Chatterjee & Jain, 2003; Nadkarni,
1997; Thara & Padmavati, 1999). These programs,
operated by the voluntary agencies and non-
governmental organizations were demonstrated as
feasible and cost-effective (Chatterjee et al., 2003;
Murthy, 1998). Presented below is one such
programme of the Schizophrenia Research
Foundation at Chennai.
Community outreach programs at SCARF
The Schizophrenia Research Foundation (SCARF,
India) is a non-profit voluntary organization in the
city of Chennai in South India. Over the past 20
years, SCARF has been involved in care, rehabilita-
tion, research, mental health education, training and
advocacy for the mentally ill. During the two
decades, SCARF has operated several community
mental health programs in urban as well as rural
areas. The components of community mental health
care have been:
(1) Training of community volunteer workers: Lay
community volunteers who have completed
their school level education are recruited and
provided training in recognition, identification
and referral of persons with mental disorders.
The participatory training program used audio-
visuals, case demonstrations and discussions,
pamphlets and so forth. The trainees are
provided basic information to identify various
categories of mental disorders identified by the
National Mental Health Program. They are also
trained in motivating persons suffering from
mental disorders to take medical treatment and
to refer them to the proposed mental health
camps in the locality. Reinforcing sessions are
held periodically to sustain knowledge gains.
(2) Establishment of a mental health clinical service
in the catchment area: Mental health camps are
organized in selected areas at periodic intervals.
A psychiatrist-psychiatric social worker team
would visit these areas. The probable cases of
mental disorders, identified by the community
workers would be evaluated at these camps and
medication initiated. These camps also serve to
sensitise the community workers in handling
day-to-day problems that may be faced by the
mentally ill persons and their families.
(3) Increasing awareness of mental health problems
in the general public: This is viewed as essential
for sensitising the general public to mental
health problems and their management.
Extensive use of folk music, dance, and drama
in rural areas, and street theatre in urban
localities has ascertained the dissemination of
information related to mental health and illness.
(4) Training the community workers to implement
simple rehabilitation measures: The focus is on
a multi-disciplinary rehabilitation program
using simple techniques, which could be
implemented by the community workers. The
key components of these programs have been
case management techniques and vocational
rehabilitation.
(5) Networking with other medical and develop-
ment organizations: Networking has emerged to
be important for resource mobilization for
community-based rehabilitation of the mentally
ill persons.
While the feasibility and cost-effectiveness of the
NGO operated community outreach programs is
documented, various factors appear to influence the
planning and execution of these programs.
The challenge
The macro level planning of community mental
health services is a challenge in any country. In India,
while the National Mental Health Program facili-
tated the foray on mental health care into the
community, effective implementation has several
hurdles. Low priority to mental health services,

inadequate funding resources, lack of awareness
about mental health issues amongst administrators
and policy makers, failure in understanding mental
health needs, and poorly organized support groups
have been major issues in the nationwide implemen-
tation of community-based mental health care
activities. Active involvement of non-governmental
organizations for the implementation of the commu-
nity mental health programs in small geographical
areas appears to be a feasible initiative for reaching
out to the mentally ill in the community. The
challenge lies in sourcing adequate fiscal support,
utilizing exiting community resources, research
documentation and dissemination of methodology.
Community acceptance
Community acceptance is a critical issue in initiating
and sustaining any community program. This is
specifically important in mental health service
delivery as mental health and illness continue to be
shrouded in longstanding myths and conceptions
regarding causation and manifestations. Involving
lay community people belonging to the locality
has promoted the acceptance of the program, both
in rural (Chatterjee et al., 2003; Thara & Padmavati,
1999) and in urban areas (Padmavati & Benjamin,
1995). Several community programs have demon-
strated the feasibility of training lay people, who have
had a minimum formal education, in identifying
mental health problems. The initiative to train them
in implementation of simple psychosocial rehabilita-
tion strategies has also proven a useful mechanism
of reaching to the mentally disabled person and
family, simple strategies aimed at re-integration of
the person back into the community.
Cultural factors
Cultural factors are fundamental to the acceptance
of any mental health care programme. While it is
critical to create an awareness of the medical model
of mental illness, change in community attributes
and attitudes can only evolve through time. In a
recent experiment, a team of mental health profes-
sionals, paraprofessionals and community volunteers
have been operating a mental health care service in
the vicinity of a temple in the state of Tamil Nadu.
The co-existence of traditional religious ritualistic
practices and adoption of a medical model on
management has proven to be successful
(Gopalakrishnan, 2004, personal communication).
Management strategies
Over the past 50–60 years, pharmacotherapy
of mental illness, particularly severe mental
Community mental health care in India 105
disorders, has brought about a reduction in the
disturbing manifestations such as violent behaviour
and socially unacceptable conduct. The problems
that have accompanied use of medication in the
community outreach programs have been the cost
of drugs and the side effects caused by typical
antipsychotics, and tricyclic antidepressants. Recent
advances have resulted in the development of
medicines producing greater visibility in improve-
ment as well as fewer side effects. The newer
medications have also resulted in the increase in
economic productivity of the ‘sick person’ thereby
ensuring the acceptance of the long-term nature of
treatment. However, the cost of medication does
continue to be a recurring problem faced by NGOs
operating such programs.
The National Mental Health Programme has
taken into account and has involved the trained
non-professional mental health workers in the
treatment of chronic mental health disorders
especially in the long-term management. Patel et al.
(2003) have opined that affordable anti-depressants
should be the treatment of choice for common
mental disorders in general health-care settings in
the community in India. With adequate supervised
orientation and follow-up programs in the use of
anti-psychotic drugs, it is possible to effectively
involve the community health workers in the
treatment of mental disorders (Thara & Srinivasan,
2004).
Domiciliary delivery of medication is an impor-
tant strategy in the management of the mentally
ill in the rural community. The NMHP has
provided for training physicians at the level of the
Primary Health Centres (PHC) in every district
and has also made available some basic medication
for the management of mental illness. However,
the reality has been medical officers at the PHC
are not often willing to take on the additional task
of managing mental health problems and psycho-
tropic drugs are very often inadequate in supply.
Persons in remote villages often find it difficult to
access treatment facilities, regularly. Therefore,
supplying medication at the doorsteps of these
patients seems to be a practical option. In
SCARF’s outreach programs, domiciliary distribu-
tion of medication has been carried out through
the community volunteers, who receive training to
follow-up on patients and report to the psychiatrist
at the clinic. It is also emphasized that patients
should follow-up at the clinic at least once in three
months. This strategy has ensured continuity of
medication for patients.
The use of depot neuroleptic medication for
patients suffering from chronic mental illnesses is
well established (Janicak, Davis, Peskorn & Ayd,
1993). The advantages of depot medications has
106 R. Padmavati
been best demonstrated in studies such as those
conducted by Johnson (1984) under conditions that
most closely resemble community clinics. In a recent
experiment at SCARF, the community psychiatrist-
social worker outreach team has been administering
depot injections for patients with schizophrenia in
the community, who cannot access a mental health
service facility with ease. Preliminary observations
indicate an improvement in clinical state and better
functioning of these patients.
Another important method in community out-
reach for the mentally ill has been the domiciliary
care programs. Patients suffering from schizophre-
nia, in an urban area were treated at home and
followed-up for six months. This group of patients
did better in clinical and social functioning that
a group of patients not receiving home treatment
(Pai, Channabassavanna & Raghuram, 1985).
Intervention at home, carried out from SCARF has
been reported to be feasible and effective in reaching
out to patients and their families (Padmavati, 2004).
The new strategies announced by NMHP has
since proposed a ‘supervised domiciliary after care
program’ (Goel et al., 2004).
The occurrence of crisis circumstances such as
relapse of psychotic symptoms, violent, difficult
behaviours and suicide attempts are not uncommon
in mental health. Management has traditionally been
focused on isolation and restraint of the patient. Is
the community mental health care system equipped
to deal with such situations? Currently operated
program planning does not offer optimum acute care
services. However, most community programmes
have established an active network with in-patient
facilities in and around the area of operation to
facilitate short-term acute care management for most
mental disorders. This seems to be the most practical
option for NGOs in view of the considerable cost
and manpower resources required to operate such
facilities.
Essentially, most community-based mental health
care in the country has been a biomedical psychiatric
service approach. However, community-based reha-
bilitation, envisaged as an important component of
the community mental health care system, neces-
sarily needs to be sensitive to social and cultural
influences. The emphasis should be on the adoption
of simple psychosocial strategies rather than struc-
tured technical approaches. The scope of vocational
rehabilitation is enormous in the large agro-rural
community in India. The onus of initiating CBR
programs for the mentally ill has largely rested with
NGOs. In conformity with the principles of the CBR
model of developing a network of lay volunteers who
are specifically trained to identify and provide first
level rehabilitative inputs, SCARF was able to
demonstrate the feasibility of implementing a CBR
program for a rural community (Thara, Islam &
Padmavati, 1998).
Networking is another important strategy, which
will allow for a multi-dimensional care and rehabil-
itation process in community care for the mentally
ill. SCARF has been actively networking with a
number of NGOs involved in social and develop-
mental activities, both in urban and rural areas.
These collaborations have been fruitful in several
ways. It has been an important approach to reach
out to a wide geographic area, with a shared econo-
mic commitment of the collaboration—a limited
resource for most NGOs. Further, networking
promotes the effective use of locally existing com-
munity rehabilitation alternatives. The collaborations
also provide opportunities for research in the field.
A number of NGOs have demonstrated the feasi-
bility of undertaking research producing adaptable
results.
Sustainability
Sources of funding to operate community mental
health programs are largely limited to time-bound
projects. This is a critical issue in the continuity
of care provided at the level of the community. Ways
of sustaining the programs need to be planned early
in the commencement of the program. Of particular
significance are the resources for provision of
medicines, since this forms a major expenditure in
the program operation.
Accountability
Most NGOs involved in mental health care do not
often have an established mechanism for monitoring
and evaluation through external sources (Patel &
Verghese, 2003). Maintaining transparency in pro-
ject operations and financial management is critical
in sustaining not just public acceptance, but also with
funding sources.
Future projections of the Global Disability
Adjusted Life years (DALY) for the year 2020,
(World Health Organization, 1999) shows that
mental disorders are projected to increase to 15%
of the global disease of burden and unipolar major
depression could be the second leading cause in the
disease burden after ischaemic heart disease. Yet,
the fact remains that the limited mental health care
services in the country is not going to increase
sufficiently to meet the growing awareness and
demand for care. The public health implications of
mental health are enormous. The onus of care largely
rests with the ‘community mental health system’.
The low priority accorded to mental health services
across the country is enough reason for the initiative

and active involvement of non-governmental
organizations. Interwoven with active community
participation and support, the initiative can sustain
the process of a successful implementation of a
community-based program, which is more socially
and culturally relevant to the mental health needs
of India.
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