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Indian Journal of Community Medicine

Vol. 27, No. 4 (2002-10 - 2002-12)

Editorial

Moving Away from Mental Institutions - Towards Community Mental Health Care

Mental disorders figure among the leading causes of disease and disability the world over. Depressive disorders are already the fourth-leading cause of the global disease burden; they are expected to rank second by 2020, behind Ischaemic heart disease1,2. Meta-analysis studies indicated high prevalence rate of mental disorders in the community (58.2 per thousand)3. Mental disorders affect one in four persons1,2.

The year 2001 was a landmark in the development of mental health services. Since the problem of mentally challenged is a global problem, WHO has chosen the theme: "Mental Health: stop exclusion - Dare to Care" during the year 2001, to focus worldwide attention on the issues related to mental health4-9. The past, in the history of mental health services has been a gloomy, but nevertheless it has taught us many lessons. Past experience of mental health built a strong myth and perception in the community and the common man perceived mental illnesses as stigma, admission in asylum or mental hospital, electric shocks and confinement in institution with sub-human conditions. The picture has changed drastically and the modern mental health care goes far beyond the institutions and in a way it is trying to restore and build confidence of common man and by changing his/her perception through educational programme. Mass media continues to focus on miserable conditions of asylums and mental hospitals and sub-human conditions of these hospitals, to draw the attention of authorities for improving these conditions. Directives of Honourable Supreme Court have made substantial contribution in the area of mental health programme.

Similarly, the derogatory Indian Lunacy Act of 1912 which was based on earlier English Lunacy Act of 1890 has been replaced by 1987 Mental Health Act with a focus to improve the quality of services/care and protect the rights of mentally ill. Mental health act has been a very important milestone in the development of modern psychiatric services in the country, hopefully, the act is made patient friendly. The State Governments took a long lead time to establish mental health authority and to implement this act.

National Mental Health Programme initiated in 1981 has ultimately come out with community based approach for sustainability of actions as also enhanced accessibility. Development of district mental health programme is a step in the right direction, but the progress and coverage is too slow to make any mark on amelioration of the problem. Nodal agency has been identified in each state to undertake in-service training programme of the Medical Officers and paramedical workers as also to provide technical support to district training programme; it adheres to prescribed manual by NIMHANS, Bangalore5,6. Two weeks training programme is being perused at the level of Medical College by the department of Psychiatry (a tertiary level of care). This decision undermines the capacity of district health agencies or district training teams developed recently as a training institution for continuing education programme of medical and paramedical personnel.

It is recognized that effective delivery of primary health care including mental health care would largely depend upon the nature of education and appropriate orientation towards community health of all categories of medical and health personnel and their capacity to function as an integrated team. Basic training curriculi of all categories should incorporate sufficient time for building essential skills of medical and paramedical personnel so that they are able to deal with the problem of mental health within the framework of primary health care. In general, we must address the issues of quality of medical education for undergraduates and specifically to the training of students in the discipline of Psychiatry, to lay firm foundation for development of mental health services at primary health care level7-9. This should be considered as real investment in development of psychiatric health services in the community.

Training of Trainers (TOT) is essential to impart need based and relevant training on the key areas of mental health and counselling. Training needs assessment and pursuing the hands on the training with case material and community should become the primary focus with trainers of medical and paramedical personnel. Medical education cell and State Institute of Health and Family Welfare can be entrusted with the task of training of trainers. National Health Policy and programme on mental health and its key strategies must be made available to the trainers. To maintain the uniform standard of training, manuals prepared by NIMHANS, Bangalore be distributed in local languages.

In-service training manual prepared by NIMHANS focuses largely on technical subjects and hospital based training, confirming an established impression that the solution to mental health problem lies in big hospitals and nothing worthwhile can be done/achieved at the community level. Substantial part of training of Medical Officers and paramedical personnel should be at the community level to focus on critical areas like role of community, institutions, family and individual to tackle mental health problems.

Focus of the training of necessity should be on the methods of interviewing and contact with the individuals and families, skills of listening to clients, assessing their needs, counselling and identification of high risk families and clients as also group meetings and dynamics besides community organization and mobilization of resources. Continuing education should be part of routine meetings. Health teams (multipurpose health workers, anganwadi workers, gram sewikas and health guides) should be trained together for better understanding of each other's role and responsibility.

Awareness generation and mental health literacy drives at the level of community through active involvement of Panchayati Raj Institutions, influential groups, non-formal leaders and other organized groups on regular basis can be most productive. Awareness generation campaign must have the support of district mental health services, Community Health Centre, Primary Health Centre and Subcentre system.

Ownership of the programme by district health orgnization and the area is essential for sustainability and endurance. If the training programme and development of strategies are evolved far away from the real situation, this may create a negative impact and generate a sense of dependency and kills local initiatives. Building district capacity for training and continuing education as also for developing services should be the real role of nodal agency.

If one looks at the basic curriculum of MBBS students and paramedicals (multipurpose health workers male and female) one finds that subject of Mental Health is covered adequately but the implementation thereof is questionable.

Even the available services for mental disorders are being poorly utilized. Nearly two third of persons with known mental disorders never seek help from health professionals and most clients utilize the services of other agencies and resort to harmful practices and keep on visiting faith healers and delay the treatment till the condition deteriorates which compels them to seek the treatment from established government institutions. Stigma, discrimination and neglect prevent care and treatment reaching people. Mental health literacy needs to be built strongly in the community to scale up the utilization of available mental health services.

In the first instance, the services and infrastructure for mental health services in public sector are inadequate and mostly confined to bigger cities and hospitals. Distt. programme of Mental Health Services has just taken off, primary health care infrastructure on the other hand is reasonably well developed and is almost universally accessible to rural and urban areas. Minimum package of mental health services for all can be best delivered through primary health care system. Preventive and promotive programme along with awareness generation can be undertaken on sustainable basis through this infrastructure.

System of Integrated Child Development Services (ICDS) which is poised for universal coverage has played a pivotal role for mother and child development in rural, urban and tribal areas. Non-formal education component and early childhood stimulation through play way activities have laid down firm physical, mental and psychological development foundation.

In a way, the institution of anganwadis has been recognized as sheet anchor in personality development of young children. This is one of the finest examples of development of positive mind and mental health. International programme developed by WHO to stimulate mother-child interactions has much more chances for success if persued actively in the family through ICDS system. This system involves families in total child development through integrated services of nutrition, health and education and relies on inter-sectoral co-ordination. NIMHANS has rightly picked up ICDS system to involve them in National Mental Health Programme through District Mental Health Services. They are being imparted 5 days training programme at distt. level. Their training would be critical, as these workers will serve as link workers between community and the formal health services system. Since anganwadi workers are locally resident voluntary workers, deeply rooted in the community they can be most effective in dissemination of knowledge on mental health programme besides identification of clients at the earliest stage of morbidity, because of their continuous contact with families. Strengthening of this institution can be most rewarding and will have high payoff effects in the long run. National Population Policy envisages enlarging the sphere of ICDS to cover school going children upto the age of 9 years. Continuous on the job training of anganwadi workers through supervisory support can further enrich the non-formal education programme. The in-service training on mental health should be undertaken by supervisors or trained Child Development Programme Officers and it should focus on child development, personality development and learning by play way activities.

Adolescent boys and girls who are the future parents need greater degree of mental health services to develop value based learning and balanced personality. Teachers training programme for balanced development of physical, mental and social faculties of school going children is essential for healthy life styles. Teachers along with parents can shape balanced personality. District Mental Health Services Programme should have incorporated this programme very strongly and entrust the responsibility of teachers training to district health teams. Though the teachers are trained during their teachers training programme on Child Psychology but they need continuous education on balanced personality development of child. District mental health programme should not lose the opportunity, as it would be a real investment in preventive, promotive and positive mental health or extended community mental health. The outreach district mental health services should embody this component of the programme on sustainable basis. WHO's "Life Skills" educational curriculum which attempts learning of wide range of skills amongst school children to improve their psycho-social competency through problem solving, critical thinking, communication, equity, tolerance, interpersonal skills, empathy and methods to cope with emotions can be made effective through school teachers and parents teachers interaction on continuous basis and much more through "child friendly schools"10.

Government or Public Mental Services is just one resource for mental health services, Private sector and Non-Governmental Organizations, as also diverse health care providers such as practitioners of Indian System of Medicine should be considered as potential resource for primary health care including mental health services. Their involvement can increase the base of accessibility of services to masses. Some of the technologies of Indian System of Medicine can be exploited for treatment of mental disorders. District programme of mental health services may be given liberty to utilize the services of these agencies. Resource mapping for primary health care, as also mental health care should not lose sight of other available organizations contributing to the care or services related to mental health programme. Partnership between government and private sector is an important area for development of mental health services programme at community level.

It is widely acclaimed that community care is more effective as well as more humane than in-patient stays in mental hospitals. It is, therefore, essential to develop mental health services in the community settings as an integral part of primary health care; to root out stigma, myths and misconceptions and discrimination against mental disorders. The World Mental Health report 2001 advocates community based mental health programmes and active involvement of families and consumers and community in the delivery of programme.

People and the community are the biggest resources available in India. Many of the problems in the area of mental health can be effectively dealt with by the people and within resources available close to them. Large-scale dissemination of knowledge and simple skills to people and health volunteers should be addressed through primary health care. Capacity of family must be built and primary health care infrastructure should support the family to build their capacity to prevent and manage the mental health problems within the available means. What people do with their lives and those of their children affects their health far more than anything that government does. Building knowledge and awareness of families can make the real difference. Health guides, anganwadi workers and health workers as also Non-Governmental Organizations (NGOs) should raise the level of awareness of people on sound mind in sound body and attainment of positive mental health, through their own actions and practices as also utilization of available services.

Operational research studies on community based mental health services are called for. We have just two models evolved long back at Chandigarh and Bangalore in 1975 which are indeed insufficient. These two models limited their approach to curative services at the community level through primary health care. District mental health programme was initiated at Bellary (Karnataka). Success of operations in programme conditions at the ground level needs to be documented further. Outcome and impact of district training programme in terms of coverage of mental health services and awareness level; of community needs to be explored through operational research studies. The task can be undertaken by nodal agency or independent institution can be entrusted this task. Built in system of monitoring and evolving parameters of mental health in the community could be another area of interest. Similarly, longitudinal follow-up of pre-school children and school children for personality development could be another worthwhile area of research. Many more interventional studies can be evaluated in adolescents in and out of schools in community settings, Delineation of role of NGOs, Panchayati Raj Institutions and partnership of public and private sector in delivery of mental health services can be throught of as an area of exploration. Working of drug de-addiction centers, their cost benefit ratio and impact should form part of community based operational research.

References:

  1. WHO Press release. WHO/30, 23 April 2002.
  2. WHO. Press release. WHO/42, 28 September 2001.
  3. Venkataswami Reddy M, Chandrashekar CR. Indian J. Psychiat. 1998; 40(2): 149-57.
  4. Kumar N. Development in Mental Health Scenario: Need to Stop exclusion - Dare to Care. ICMR Bulletin Vol 31, No. 4 April 2001 Division of Publication and Information, ICMR, New Delhi.
  5. Features of Mental Disorders - A Folder ICMR centre for advanced research on Community Mental Health. Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore (India). 1987-8.
  6. Mental Health Manual for Health Workers ICMR Centre for advanced research. NIMHANS Bangalore - 1990.
  7. Issac MK. Severe Mental Morbidity ICMR Bulletin Vol. 18, No. 12, December 1988, ICMR, New Delhi.
  8. Report of National Workshop on undergraduate Medical Education in Mental Health (sponsored by WHO) December 22-24, 1985. Edited by Dr. Mrs. S. Trivedi and Co-edited by Dr. D.K. Srinivasa - JIPMER Pondicherry India.
  9. National Mental Health Programme for India. Recommendations of the Central Council of Health and Family Welfare 1982.
  10. WHO. The World Health Report 2001 - Mental Health: New understanding New Hope.
  11. National Health Policy 2002. MOH&FW, GOI, New Delhi.

Sunder Lal, B.M. Vashisht*
Prof. & Head, Reader*
Deptt. of SPM
Pt. BDS PGIMS, Rohtak

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