1.6 CMH in India.

India represents a mixture of old and new in the area of mental health. A review of development of
mental health care in India shows different trends. There has been a shift from medical to bio-social
model. There have been slow but definite changes in the last five decades. In the pre-independence era
the approach was to build asylums which were custodial in nature. In 1946 a committee called Bhore
committee was set up which recommended expansion of services and establishment of training
institutes. All India Institute was established in 1954 for this purpose which later became NIMHANS. The
Mudaliar committee report (1962) recommended establishment of more facilities to meet the training
needs of the community. The next phase of development was setting up of General Hospital Psychiatric
units (GHPU). This meant shorter stay at hospital and quicker return to community. As early as 1950,
one Dr. Vidya sagar had pioneered community care in Amritsar mental hospital. Murthy divides the
development of mental health care in India in post independence period into four phases as follows.

1) 1947-19715: One of the earliest references to the needs of mentally ill persons is the report in the
India Medical review. It was noted that at that there were 17 mental hospitals in British India with
accommodation for 8425 patients. Most hospitals were overcrowded. In the first phase, hence, to
develop policies relating to primary health care. Beginning with Bhore committee report, mental health
has become a part of general health planning in the country. The major recommendation of Bhore
committee was for setting up of infrastructure in the rural areas with the primary health centre as the
chief focus. There was to be one unit for population of 40,000. The next review committee ( Mudaliar
committee) recommended inpatient departments in general hospitals, independent psychiatric or
mental health clinics, institutions for mental defectives, training of mental health personnel, and urged
for a change in the situation of mental hospitals.

The growth and development of GHPU in India is an important milestone. In many ways it revolutionized
mental health field. Though GHPUs were initially resented as mental hospitals coming to general
hospitals, soon it was accepted as valuable. The advantages of GHPU are:

1. they are situated right in the community and are easily accessible and approachable
2. families can easily visit and relatives can stay with patients
3. there is no stigma of mental hospitalization
4. there is no legal restriction on admission and treatment
5. proximity to other medical facilities ensure thorough physical investigatins and early detection
of associated physical problems.
Both the above centers in 1975 examined the feasibility of including mental health care as part of
general health services. It was shown that it is possible to develop simple training material to suit the
needs of PHC personnel and to train them to carry out a limited range of tasks to benefit the mentally ill
in rural areas. These efforts have also been taken up by centers in Baroda, Calcutta, Hyderabad,
Lucknow, Jaipur, Patiala, Delhi and Vellore. With regard to mental health manpower and training
facilities, the first effort was the setting up of AIIMH, Bangalore in 1954. As of 1987, there were about
1,500 psychiatrists, 400-500 clinical psychologists and about 500 psychiatric nurses in the country.

Establishment of GHPU were prompted by:

1. The existence of a large infrastructure of general health services (PHC system)

2. The approach to utilize multipurpose workers and rural doctors to provide health care
to rural people.
3. The realization of the magnitude of severe mental disorders in the community (at least
1%) and the availability of simple interventions for these conditions.
4. Experiences of community mental health care at Bangalore and Chandigarh centers.

District Psychiatric units (DPU) , though recommended were slow to develop. The situation is not too
satisfactory in this regard. To overcome shortage of services innovative procedures like involving family
members in mental health care, and use of traditional methods like Yoga have been tried.

2) 1975- 1982: This phase is the period of integration of mental health with primary health care. There
were many reasons for this. Firstly, there was a recognition that a large number were requiring mental
health services all over the country. Secondly, there were limited number of mental health
professionals. Thirdly, there was an emerging integration of all health programs from the vertical
program model to multipurpose model. Fourthly, the international development of primary health case
as the approach to organize health services was becoming accepted. Fifthly, there was recognition of
importance of early identification and treatment of illness to prevent chronicity. Finally, the goal of
continued care to mentally ill could be achieved with integration of services in general health services.
This was achieved in several ways.

One major method was training of General Practitioners (GP). A large number of professionals were
trained in basics of psychiatry and sensitized to mental health care. This was in the form of courses by
psychiatrists organized for GPs and informal discussions and private consultations. A more formal
training of GPs was begun in NIMHANS, Bangalore from 1975. An ICMR collaborative study was
undertaken to test method and material developed for training. This method enhanced the mental
health manpower in the country with comparatively minimal inputs.

Rural Psychiatric services were started on an experimental basis in Bangalore and Chandigarh and later
spread to many other states. In 1976, at NIMHANS, the first rural project was inaugurated to develop
suitable training programs for doctors and multipurpose workers from various PHC in the state of
Karnataka. PHC personnel were trained to detect and manage cases and refer what they could not
handle. A model program to cover a district with a population of 2 million was developed. Results of
such efforts showed the feasibility of integrating mental health with general health services.

There were also some national level initiatives for mental health program. One of the earliest efforts
was in the 1960s. The Mental Health Advisory Committee constituted in 1962 met in 1963,1965 and
1966 to consider the mental health needs in the country. A draft of mental health plan was prepared in
1981

3) 1982-1990 National mental health program (NMHP)

The national health program was the outcome of earlier efforts. The objectives of the program were

Ensure availability and accessibility of minimum mental health care for all , especially
underprivileged.

To encourage application of mental health knowledge in general health care

To promote community participation and stimulate self-help in community.

The specific approaches suggested for implementation of NMHP are:

Diffusion of mental health skills to the periphery of the health service system

Appropriate appointment of tasks in mental health care

Equitable and balanced territorial distribution of resources

Integration of basic mental health care with general health services

Linkages to community development.

From the time of formulation of NMHP, following initiatives have been taken up

1. Sensitization and involvement of state level program officers

2. workshops for mental health professionals
3. workshops for voluntary agencies
4. training for program mangers
5. state level workshops for health directorate personnel
6. development of models of integration of mental health into primary health care (PHC)
7. Preparation of support materials in the form of manuals, health records and health education
material
8. Training programs for teachers of undergraduate psychiatry.

These developments were the result of a large group of mental health professionals. This has resulted in
a decentralized training program for existing health professionals, provision of mental health care in all
general health facilities, involvement of all categories of health and welfare personnel in mental health
care, provision of essential psychiatric drugs at all health facilities and a simple record keeping
procedure.

4) 1990-2000: During the last decade, DMHP have been launched at the national level. The current
program envisages, a community based approach to the problem which includes

1. training of MH team at identified nodal institutes within the state

2/. Increase awareness regarding mental health problems and need for care

3.provide services for early detection and treatment in community

4. provide valuable data and experience at the level of community in the state and centre for future
planning and development.

Now DMHP have extended to most of the Indian states.

Mental health manpower development is still a challenge. There are only a handful of trained people for
the millions who need mental health care. There are about 140 medical colleges and about three
quarters have a department of psychiatry. To overcome shortages, several methods are used.
 1. involvement of families. Majority of mentally ill in India live with their families. Families have
been a part of care program for a long time. Now a days family wards help keep patients
with families and thus provide support.
2. Community involvement in managing drug and alcohol abuse and suicide prevention and
school mental health program have helped ease the shortage.
3. Public mental health education using the available media has been another method widely
used.
4. Traditional practitioners are part of the Indian scene. They have been trained and used in
community to spread awareness.

During the last decades there have been other developments. Indian Lunacy Act of 1912 was replaced
by the Mental Health Act of 1987. In 1995, The persons with disabilities act was formulated. The
national institute for the mentally handicapped was established in 1984 at Secunderabad. Yet there are
many gaps in services. It has not been possible to provide quality care to the millions of Indians. There is
a recognition that trained professionals alone will be inadequate to meet the needs for a long time to
come .The importance of developing services beyond mental health institutions (such as training a
multidisciplinary team to deliver mental health services in primary health centres) has been well
recognized. The commitment of the country to provide health services to all and the Alma Ata
Declaration of Primary Health Care have been guiding the country’s efforts at promoting mental health
of the population.

The central council of Health and Family Welfare (1982) recommended that

1. Mental Health must form an integral part of the total health program and as such should be
included in all national policies and programmes in the field of health education and social
welfare.
2. Realizing the importance of mental health in the course curriculum for various levels of health
professionals, suitable action should be taken in consultation with the appropriate authorities to
strengthen the mental health education components the planned approach is to integrate
mental health services with existing general health services.
3. The first opportunity to develop a plan of action for the NMHP was provided by the 7 th five year
plan starting from 1985, when Rs. 100 Lakhs were allocated for NMHP. A committee under the
chairmanship of Dr. G.N. Narayana Reddy, Director, NIMHANS, Bangalore, submitted its plan for
implementation of NMHP.

The efforts under NMHP include:

1. Sensitization and involvement of state level planners and administrators by small group
workshops and state level programmes.
2. Workshops for mental health professional namely, psychiatrists, clinical psychologists,
psychiatric, social workers and nurses.
3. Workshops for voluntary agencies.
4. Training programmes in public mental health for programme managers.
 5. State level workshops for the personnel of health directorates and secretariats.
6. Evaluation of the level of care provided by trained PHC personnel.
7. Development of a Model District Mental Health Programme.
8. Training programmes for teachers of basic health workers.
9. Preparation of support material in the form of manuals, records, health education materials.
10. Training programmes for teachers of undergraduate medical education.
11. Workshops for superintendents of mental hospitals and training for the staff of mental
hospitals.

In addition, during this period, the centre for advanced research for community mental health was set
up (1984- 1990) for longitudinal research in this area, at NIMHANS, Bangalore.

The NMHP for India (1982) and its implementation can be considered against the larger health service
organization. The cardinal points of health organization are decentralization, to provide services close to
the population and integration of services (including both a coordinated service and total health
coverage). The need for mental health care, Promotive, preventive and curative has become well
recognized. The most significant achievements of NMHP are the developments of models of care
suitable for 1,00,000 to 1.5 million populations. The coming years should result in greatest coverage of
the programme throughout the country.

The Future: There is a movement to develop primary care mental health programs which have proved
to be useful elsewhere. Studies of such projects show that when well integrated such programs have
several advantages.

1. patients attend for their appointments in their familiar place and attended by their known practice
staff

2. Relevant medical records are more readily available, particularly the information about treatments
they are receiving.

3. Any new prescriptions or change can be done immediately

4. Face to face contact with GP gives opportunity to discuss patient management in some detail

5. This contact is educational for GPs also

6. A proportional allocation of all the MH professional’s time to general practice is a fair way to
distribute resources
7. a new and enhanced role of CMH nurse linked to the GP assists in integration of services and
continuity of care

8. screening of referrals allows patient to be seen by the most appropriate health professional

9. The team provides a seamless service by accepting patients of common mental health disorders for
assessment yet concentrating on the care of severely mentally ill.

10. Integration reduces stigma

There may be some disadvantages:

1. mental health teams may have difficulties organizing regular clinics in the practices
2. if the practitioners are far away, as is often the case in rural districts, then a significant part of
time is spent in traveling
3. this model does not allow the flexibility to see new patients from other practices
4. most practice have limited space and time available to run clinics.

In developing countries like India, there are several problems. Information about prevalence and pattern
of mental and in rural and urban communities is lacking. The MH facilities and man power is extremely
limited. Altitudes of community are difficult to change. There is need to be innovative. Integration of MH
with general health care is one method. Using school mental health programs involving teachers and
students, service through ICDS, anganawadi, and child health programs, suicide prevention, half way
homes for mentally ill, education of family members, education of public through involving NGOs,
medical material for public education, training non professionals, sheltered workshop for mental
retarded are developed in India.

Some policies are to be formulated such as

- Formulation of alcohol –related policies

- Policy regarding working mother
- Housing problems
- Legislation regarding mental health care
- Development of services
- Support of NGOs
- Social support to elderly and so on.
CMH practice depends on multidisciplinary teams. In a CMH many people need to work together in
collaboration. Psychiatrists, psychologists, social workers work with less trained people and non
professionals. This requires an absence of strict hierarchy and flexibility of roles. It makes demands on
professionals to assume new roles, step outside the confined walls of hospitals and clinics and expand
their services.