COMMUNITY MENTAL HEALTH IN INDIA

COMMUNITY MENTAL HEALTH IN INDIA:

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A VISION BECKONING FULFILLMENT?

R. THARA
Director, Schizophrenia Research Foundation,
Chennai, India

ABSTRACT

More than 20 million persons in India need some kind of mental health
services. The divide between the demand and the resources available is huge,
leaving major parts of the country totally devoid of any mental health services.
During the last few decades, there has been a growing interest in undertaking
community mental health initiatives in India; nonetheless, such initiatives have
been largely isolated efforts. This article presents a general overview of India’s
mental health scene and discusses the many issues related to community care in
the Indian context. It then describes the experience of the Schizophrenia
Research Foundation (SCARF) in implementing community mental health
programs based upon the Community-Based Rehabilitation Model in both rural
and urban settings.

INTRODUCTION

Nearly a billion people (almost 1/6 of the world’s population) make India the
second most populous country in the world. This huge population—combined with
the country’s great geographical, religious, linguistic, and cultural diversities and
with the competing priorities of a struggling economy—make any planning in India
an unenviable task. Health planning is no exception. Because the presence of com-
municable diseases (such as tuberculosis, malaria, and more recently, the problem
of HIV-AIDs) looms large among health concerns in India, a major chunk of health
funding is allocated to address the problem. Another large chunk of funding is
directed towards family planning in order to curtail the burgeoning population. As a
result of these foci, mental health remains a low priority for health planners in India
—despite the fact that there are probably more than 20 million Indians suffering
from some kind of mental disorder.
There exists—and probably will continue to exist for at least the foresee-
able future—a fairly substantial gap between mental health care needs and the
resources allocated to them. The service provider/service seeker ratio is appalling
by any standards, and the huge, sometimes unwieldy, highly expensive state mental
hospitals usually swallow most of the scarce resources available to mental health
policy planners. Over the past few decades, however, there has been an upsurge in
interest in community mental health issues. Initiatives by both governmental and
non-governmental organizations (NGO) have delivered some mental health care to
remote parts of the country. Unfortunately, these efforts are dependent upon in-
secure funding from external sources and, as a result, tend to be time-bound and,
thus, limited in their effectiveness. Mental health issues have been a part of Indian

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culture from its earliest times and, despite these recent developments, they continue
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to be a challenge.

TRADITONAL INDIAN TREATMENTS OF MENTAL ILLNESS

Ancient Texts and Teachings

As early as 1500 BC, the Atharva Veda mentioned insanity as “unmada.”
Even in those times, physicians and surgeons were differentiated from magic do-
tors, and lived in cottages surrounded by medicinal plants. Descriptions of
disorders similar to schizophrenia and bipolar disorder are found in the Vedic texts.
Thera-peutics and Surgical Practice, an ancient textbook of Ayurvedic medicine by
Charaka and Susrutha, provides a clear description of schizophrenia. According to
Charaka, life is divided into 4 kinds: Sukha (happiness), Dukha (sorrow), Hita
(goodness) and Ahita (badness). It was stated clearly that only an expert in the field
of mental health should treat persons with mental disorders. Other traditional med-
ical systems such as Siddha were also popular in south India and recognized various
types of mental disorders (Namboodri, 1985).

Religious Treatments
From earliest times, and continuing today, places of worship have been im--
portant venues for the treatment of the mentally ill. In fact, some temples (Hindu
places of worship) and Durghas (where Muslims pray) are considered to be “spe-
cialized” centres for mental health care (Thara, Islam, & Padmavati, 1998). Per-
sons visiting these centres often operate within a magico-religious explanatory
model, wherein the locus of control is placed outside the sufferer, and the problems
associated with mental health disorders quite often are considered to be the result of
black magic, a curse, God’s wrath, or the Karma of a previous birth.
Treatments at religious centres range from observing a series of rituals (such
as bathing in the temple tank and walking around the temple) to prayers at specified
points of time during the day. Physical restraint by chaining patients to a pole or a
tree is often the practice. Small shelters to house the mentally ill have been built
around some of these centres of worship. For the most part, though, these shelters
are more exploitative than theraputic. In August of 2001, in the Yerwadi shelter in
Tamil Nadu State, 26 mentally ill persons burned to death; they were prevented
from escaping the fire by the chains on their feet. This heart-rending event has led
to a rethinking of mental health practices and services, and to some governmental
action.

THE DEVELOPMENT OF INDIA’S CONTEMPORARY

MENTAL HEALTH SYSTEM

Mental Hospitals
Ernst (1987) described the growing number of mental asylums in British India
as providing a “less conspicuous form of social control.” The city of Calcutta had
the first mental hospital in 1787, followed by Bombay and Madras (now renamed
Mumbai and Chennai respectively). There are now 37 mental hospitals, with a total
of 18,024 beds, in the country (NHRC, 1999).

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An in-depth study of India’s mental hospitals, undertaken by the National

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Human Rights Commission over a two-year period, revealed: (a) gross inadequ-
acies in all aspects of care, clinical services, and rehabilitation; (b) appalling basic
living conditions; and (c) painful violations of human rights (NHRC, 1999). These
shocking findings became an eye opener to many and, as a result, steps are now
being taken to allocate more resources to improving conditions at some of India’s
mental hospitals (NHRC, 1999).

The National Mental Health Programme

In the 1980s, the National Mental Health Programme (NMHP) was developed
to ensure that all sections of the population had minimum levels of mental health
care available and accessible to them. Based on the philosophy of decentralization
and demystification, this comprehensive program sought to integrate mental health
care with primary care. The basic thrusts of the initiative involved: (a) training
health care personnel at the primary health centres (PHC), (b) sensitizing policy
planners and bureaucrats to issues of mental health, and (c) making basic medicines
available at the PHCs. Since 1984, these changes have been operationalized in a few
states—but there are many more areas that have yet to adopt them, even in a
rudimentary fashion. It can be expected, though, that the Yerwadi fire accident
might provide some impetus for change.

General Hospital Psychiatry Units

The establishment of psychiatric units in general hospitals, which began in the
1930s and intensified in the 1960s, has led to a change in the quality of care avail-
able to mentally ill people. Currently, there are about 65 of these units, attached to
medical colleges throughout India, which provide beds for approximately 3000
patients. A number of people with minor mental morbidity or psychosomatic dis-
orders prefer to use these facilities since they are less stigmatizing than the older
asylums and shelters. However, admission to these units is voluntary, and families
have to remain with the patients.
There has been a role, albeit limited, for private psychiatric services. Those
seeking help from private practitioners (accounting for a good percentage of overall
help seekers in the cities and towns) do so for a fee, which is not covered by any of
India’s insurance plans. In the private sector, there are very few hospitals or
nursing homes specializing in psychiatric care; most admissions take place in gen-
eral settings.

Voluntary agencies and NGOs

The last two decades have witnessed a surge in the voluntary mental health
movement in India. NGOs, many of them in the southern part of the country, offer
specialized care to several groups, including: (a) the chronic mentally ill (e.g., the
Schizophrenia Research Foundation in Chennai, and the Richmond Fellowship
Society in Bangalore and Delhi); (b) the suicidal (e.g., SNEHA in Chennai); (c) the
elderly (e.g., ARDSI in Kerala, with several state chapters); (d) children (e.g.,
Sangath in Goa); and (e) alcoholics and drug addicts (e.g., TT Ranganathan Re-
search Foundation in Chennai). Self-help and support groups consisting largely of

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families of mentally ill persons also are making their presence felt in the national
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mental health scene (Patel & Thara, 2003).

Disability and After Care

It was only in 1995 that disability caused by mental illness was included in the
Indian Persons with Disabilities Act. However, after almost a decade, the mentally
disabled still do not enjoy even the meager benefits available to other disabled per-
sons. There are, for example, no social welfare schemes which offer any benefits
for the mentally ill.
Although some mental hospitals offer some vocational activities, organized
psychosocial rehabilitation (PSR) services are few and far between. Over the past
two decades, the private and NGO sectors have attempted to mend this breach and
have kept up enough pressure on policy planners to ensure that PSR is accorded
higher visibility. As a result, PSR facilities now include some half-way homes, day-
care centres, sheltered workshops, family support programs, and long-term residen-
tial facilities.
.
COMMUNITY-BASED REHABILITATION MODEL:
THE SCARF EXPERIENCE

The Schizophrenia Research Foundation (SCARF) is a non-profit voluntary

organization in the city of Chennai (formerly Madras) in south India. Since 1984,
SCARF has been engaged in care, rehabilitation, research, education, training, and
advocacy to ensure better rights for the mentally ill. Since its inception, SCARF has
operated several community out-reach programs—both in rural areas and in urban
slums. These programs were developed in accordance with the Community Based
Rehabilitation Model (CBR), which envisages the development of a network of lay
volunteers who are specially trained to identify and provide first-level rehabilitative
supports.

CBR in a Rural Area (Thiruporur)

SCARF examined the possible implementation of CBR in a rural population,
focusing on the region of Thiruporur (Thara & Padmavati, 1999). Thiruporur is
about 50 km from Chennai, covers an area of 1412 square miles, and has a popula-
tion of 110,000 living in 100 villages. Fishing, salt production, and agriculture are
the main sources of livelihood for the region’s people. The Indian Red Cross had
established a CBR program for the physically disabled in the region; SCARF decided
to piggyback on this by incorporating a mental health component. A trained band of
40 lay volunteer workers (residents of villages in the area) was already available, so
these workers only needed to be trained in the principles of detection and rehabilita-
tion of persons with psychoses, epilepsy, depression, cognitive deficiencies, and
substance abuse problems.
Parallel to this effort, workers at the primary health care network in the area
were sensitized to the medical management of these disorders, and appropriate
med-ication was made available at the Primary Health Centre. An active liaison
also was established with the traditional healing centres in the area (there was one
temple and one mosque frequented by the mentally ill for treatment), but the

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religious healing programs were not interfered with. Instead, volunteers and the
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authorities at the places of worship helped persuade patients to add medication to

their current reli-gious protocols.
A team of mental health professionals from Chennai visited the centre every
fortnight to offer, in addition to medication, simple rehabilitation as determined by
the expressed needs of the population. This rehabilitation sometimes was as simple
as distributing livestock or arranging for loans to buy fishing nets, so that the dis-
abled had both a means of supporting themselves and an experience of enhanced
self-esteem through engagement in productive activities. The team also sought to
establish functional bridges between mentally disabled people and the newly
developed CBR network. After a few initial problems, the various people within the
network came to accept one another and, within a year, the project was able to
provide substantial service to more than 600 persons with mental disorders. The
project, which was sponsored by the International Development Research Centre
(IDRC) Canada, operated for 6 years.
To assess the effectiveness of this project, a qualitative exploration of the
explanatory models held by the rural population with respect to mental disorders
was undertaken. Three groups of respondents were chosen and the sampling was
done in stages (described in Thara et al., 1998). The findings clearly demonstrated
that even an illiterate and impoverished population is sensitive to and can describe
in detail the behavioural concomitants of mental disorders: episodes of violence and
grossly abnormal behaviour caused concern within the community; a lack of
involvement in productive activity and slight oddities in behaviour were, in fact,
well tolerated by the community. Indeed, the entire community was highly
responsive to the services offered by the program. It is reasonable to suggest,
therefore, that rural areas throughout India would benefit from similarly structured
programs.

CBR in an Urban Area (Chennai)

The needs of and experiences in the urban area of Chennai (which has a popu-
lation of nearly 5 million) were, however, considerably different. An epidemiol-
ogical study of over 100,000 people in the city revealed that, though mental health
services generally were available within 3 km of their homes, nearly 15% of the
population remained untreated for psychotic disorders such as schizophrenia (Pad-
mavati, Rajkumar, & Srinivasan, 1998). One of the predominant factors accounting
for this low level of uptake was the fact that immediate and extended family
members had, over time, learned to cope with the mental illness as experienced in
their homes and to compensate for the resulting economic and other shortcomings.
Consequently, the community programs which SCARF initiated in certain areas
of the city—most notably in the slums—were established in conjunction with
existing facilities in related service areas, most of them in the voluntary sector.
With support from the World Health Organization, the project grew into a major
urban program which succeeded largely because of grassroots workers and perma-
nent health care professionals. Nonetheless, the services more commonly were ac-
cessed by those with more visible symptoms (such as seizures, cognitive defici-
encies, sporadic violence, or bizarre behaviour).
For similiar programs to be developed in other areas, however, two issues

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need to be considered: (a) Because many community-based programs are time lim-
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ited due to the constraints imposed by organizations, efforts to ensure ongoing fund-
ing need to be incorporated directly into the projects; and (b) plans for proper
evaluation need to be built into any community-based programs before they are
initiated.

CONCLUSION:
THE FUTURE OF COMMUNITY MENTAL HEALTH IN INDIA

Although several programs have demonstrated the feasibility and cost ef-
fectiveness of CBR initiatives in developing countries (Murthy, 1998), several con-
textual problems—namely the poor allocation of resources, the insensitivity of both
professionals and policy planners to the needs of the mentally disabled, and the
indifference which other medical practitioners have shown to mental health prob-
lems—have slowed down the process of improving mental health care in India.
Nonetheless, over the last few years, some progress has been made. The
National Mental Health Program advocates both the admirable philosophy of de-
centralization and the integration of mental health with primary care and, even
though it is not yet being uniformly implemented in all of India’s states, more
money is expected to be made available for its implementation, and for mental
health care in general. Further, the mushrooming of larger numbers of small- to
medium-sized initiatives in the private and voluntary sectors is also heartening.
These emerging services offer a mixture of residential and nonresidential settings,
and are encouraging the enthusiastic involvement of community members. Thus,
though things are not as they should be, the future certainly seems less bleak for
mental health care in India than it was a few decades ago, when mental health care
was synonymous with mental hospital admissions.

RÉSUMÉ

On estime qu’en Inde, plus de 20 millions de personnes ont besoin de

services de santé mentale de quelque sorte. L’écart entre la demande et les
ressources disponibles est vaste, ce qui laisse des portions importantes du pays
totalement privées de tout service de santé mentale. Même si, dans les dernières
décennies, on a observé un intérêt pour le mouvement de santé mentale
communautaire dans ce pays, les initiatives communautaires en santé mentale
ont été largement des efforts isolés. Ce texte présente un tour d’horizon général
de la scène de la santé mentale en Inde, ainsi qu’une discussion sur des ques-
tions reliées au soin communautaire dans le contexte de ce pays. Le texte décrit
ensuite l’expérience de la Fondation de la recherche sur la schizophrénie dans
son effort d’implantation de programmes tant urbains que ruraux, développés
dans le cadre du modèle de la réadaptation fondée sur la communauté.

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