2. What is mental health?
• "Health is a state of complete physical, mental and social well-being and
not merely the absence of disease or infirmity.“
• Mental health is an integral and essential component of health.
• An important consequence of this definition is that mental health is more
than just the absence of mental disorders or disabilities.
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3. • Mental health is a state of well-being in which an individual realizes his or
her own abilities, can cope with the normal stresses of life, can work
productively and is able to make a contribution to his or her community.
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4. Backround
– The World Bank report (1993) revealed that the Disability Adjusted Life Year (DALY)
loss due to neuro psychiatric disorder is much higher than diarrhea, malaria,
worm infestations and tuberculosis if taken individually.
– DALY’s loss due to mental disorders are expected to constitute 15% of global burden
of diseases by 2020(world health report 1999)
– One in four families is likely to have at least one member with a behavioral or
mental disorder (WHO 2001).
– One percent of the population suffers from severly incapacitating severe mental
disorder
– Ten percent of the population has life time risk of developing severe mental disorders.
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5. • Depression is a very common psychiatric disorder and affects 3 percent of
the population
• Studies have also reported that one in every four patients attending primary
care clinics have diagnosable mental disorder.
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6. MAJOR CATEGORY OF MENTAL DISORDER IN INDIA:
1) Mood disorder: Depression(F 32)
2) Psychotic Disorders: Schizophrenia(F20)
Acute psychotic
disorder:mania(F23)
Bipolar disorder(F31)
3) Anxiety disorders:
Panic disorders : discrete, severe anxiety attacks(F 41)
Phobias (F 40)
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7. 4) Obsessive-Compulsive Disorder
5) Generalized Anxiety Disorder( F 41.2)
6) Adjustment Disorder(F 43)
7) Substance Use Disorders – alcohol use disorder( F 10) ,
drug use disorder( F 11) , tobacco use disorder ( F 11.1)
8)Personality Disorders(F 60)
9)Organic disorders : Dementia(F 00) , Delirium ( F 05)
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8. Basic Mental health care programmes in India-
How and Where it was developed in the country
• Initial experiments in organizing basic mental health programs were at
Chandigarh and Bangalore.
• Both these centres tried to integrate mental health care at primary health
care level.
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9. Chandigarh Program:
• Was carried out in Raipur rani block, Ambala district of Haryana state
during 1975-1982
• It was a part of WHO project titled “Stratergies for extending mental health
care”
• System of priority selection to train the existing primary health care
personnel
• This experience resulted in the practical manual of Mental disorders and
Mental health education materials.
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10. Project in Banagalore
• Community psychiatry unit of department of psychiatry, NIMHANS.
• It was possible to define clear tasks for doctors and health workers
working in PHC system and provide training to them.
• Separate manuals for MPWs in kannada and the medical officers were
developed based on the experience of many years of field work.
• Carried out at Sakalavara Centre in Anekal Taluk, Solur PHC was also
involved in the application of knowledge gained.
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11. • The Government of India has launched the National Mental Health
Programme (NMHP) in 1982, with the following objectives:
1. 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;
2. To encourage the application of mental health knowledge in general healthcare and
in social development; and
3. To promote community participation in the mental health service development
and to stimulate efforts towards self-help in the community.
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12. • The central council Health and Family welfare in its meeting held on 18-
20, august 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 programs in the field of health
education and social welfare.
2. To strength the mental health education components.
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13. Strategies under national mental health
program.
1. Integration of mental health with primary health care through the
NMHP;
2. Provision of tertiary care institutions for treatment of mental disorders;
3. Eradicating stigmatization of mentally ill patients & protecting their
rights through regulatory institutions like the central mental health
authority, & state mental health authority.
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14. Components of National Mental Health
Program.
1. District Mental Health Programme (DMHP)
2. Manpower Development Schemes - Centers Of Excellence And
Setting Up/ Strengthening PG Training Departments of Mental Health
Specialities
3. Modernization Of State Run Mental Hospitals
4. Up gradation of Psychiatric Wings of Medical Colleges/General
Hospitals
5. IEC
6. Training & Research
7. Monitoring & Evaluation
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15. District mental health program
Launched under NMHP in the year 1996 (in IX Five Year Plan). The
DMHP was based on ‘Bellary Model’ with the following components:
1. Early detection & treatment.
2. Training: imparting short term training to general physicians for
diagnosis and treatment of common mental illnesses with limited
number of drugs under guidance of specialist. The Health workers are
being trained in identifyingmentally ill persons.
3. IEC: Public awareness generation.
4. Monitoring: the purpose is for simple Record Keeping.
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16. Bellary model
• Bellary model is a community based service for delivery of basic mental
health care using short term (9 days) trained MOs for diagnosis and
treatment of prevalent mental illnesses with the aid of limited no. of drugs
with support and guidance from specialist.
• Health workers are trained in identifying mentally ill.
• Grass root level IEC & simple record keeping
• Model was successfully implemented in Bellary district with help from
district adm., DHS and NIMHANS
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17. Objectives of District Mental Health
programme.
1. To provide sustainable basic mental health care services in the
community by integrating mental helath into general health care services
in primary care settings
2. Early identification and treatment
3. To see that patient and their relatives do not travel long distances to go to
hospitals.
4. To take pressure out of the mental hospitals
5. To reduce stigma attached towards mental illness
6. To treat and rehabilitate mental patients discharged from the mental
hospital within the community.
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18. Modernization of State Run Mental Hospitals
• 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
toresearch and development (R&D) in the field of community mental
health.
• As per the existing scheme to modernize the existing state-run mental
hospitals, a one-time grant with a ceiling of Rs.3.00 crores per hospital is
provided
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19. Up gradation of Psychiatric Wings of Medical
Colleges/General Hospitals
• Every medical college should ideally have a Department of Psychiatry
with minimum of three faculty members and inpatient facilities of about
30 beds as per the norms laid down by the Medical Council of
India.
• scheme for strengthening of the psychiatric wings of government
medical colleges/hospitals which provides for a one-time grant of Rs.50
lakhs for up gradation of infrastructure and equipment as per the
existing norms
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20. Manpower Development Scheme
• In order to improve the training infrastructure in mental health,
Government of India has approved the Manpower Development
Components of NMHP for XIth Five Year Plan. It has two schemes which
are as follows:
– Centers of Excellence (Scheme A)
• Under Scheme-A, at least 11 Centres of Excellence in mental health were to be
established in the IXth plan period by upgrading existing mental health
institutions/hospitals.
– Setting Up/ Strengthening PG Training Departments of Mental Health
Specialities (Scheme B) :
• Government Medical Colleges/ Hospitals are supported to start PG courses in Mental
Health or to increase the intake capacity for PG training in Mental Health
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21. IEC Activities
• NMHP has dedicated funds for IEC activities for the purpose of increasing
awareness and removal of stigma for mental illness. The funds are
allocated at central and state levels for IEC activities. An amount of Rs.
one crore is allocated for the purpose of IEC activities at central level.
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22. • Health promotion using life skills approach in the schools.
• Training program for the medical officers and the paramedical staff at the
district headquarters by the psychiatrist.
• Availability of all the essential drugs in every primary health centre.
• District hospitals will have higher drugs like olanzipine, lithium carbonate,
and carbamazepine. This is in addition to the essential drugs.
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23. NMHP during 10th five year plan
Re-strategized in 2003 based on evaluation to include:
1. Up gradation of Psychiatry wings of Govt.
Medical Colleges/ General Hospitals.
2. Modernization of State run Mental Hospitals.
3. Extension of DMHP to 100 more districts.
4. Research & Training.
5. IEC
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24. NMHP during 11th five year plan
• The district mental health programme will be extended to another 100-
districts while consolidating the same in the 100-districts covered at the
end of the 10th plan.
• Psychiatry Department of the remaining Medical Colleges will be
upgraded and the infrastructure created during the previous plan will be
reinforced
• The activities of the Central and State Mental Health Authorities will be
augmented.
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25. NMHP during 12th five year plan
• The district mental health programme will be extended to the remaining
161-districts.
• Gains made in the previous plans will be consolidated, up gradation of the
remaining 39-Medical College Psychiatry Departments will be undertaken
and 20-Mental Hospitals will be taken up for
disinvestments/reconstruction.
• Non-viable mental hospitals will be closed down or merged with general
hospitals to create general hospital psychiatry units (GHPUs).
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26. New components of District Mental Health
Programme (DMHP)
• New Components proposed in DMHP
– School Mental Health Services: Life Skills Education in Schools, Counseling Services
– College Counseling Services: Through trained teachers
– Work Place Stress Management
– Suicide Prevention Services- Counseling Center at District level, Sensitization
Workshops, IEC, Collaboration with various departments.
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27. School Mental Health Services
• Life Skills Education using standard training manuals
• Counseling services through trained teachers/ HiredCounselors
• Involvement of the NGOs
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28. College Counseling Services
• Provided by trained teachers of psychology department of the colleges
• The P .O. will organize the training at the district level in close co-ordination
with the Dept. of Collegiate Education
• The trained teachers will act as counselors and as referral and support-giving
agents in their respective colleges
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29. Workplace stress management
• Imparting skills for time management, improving coping skills,
assertiveness, relaxation techniques like Yoga, Meditation etc.
• Identify workplaces with sizeable population and organize stress
management workshops for them
• District Counseling Centre will also address this group
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30. Special Issues :
• Senior citizens suffering from severely disabling diseases such as
Alzheimer’s and other types of dementias, Parkinson’s disease, depressions
of late onset and other psycho geriatric disorders.
• Victims of child sexual abuse, marital / domestic violence, dowry related
ill –treatment, rape and Incest.
• Children and adolescents affected by problems of maladjustment or other
scholastic problems, depressions/psychosis of early onset, attention deficit
hyperactivity disorders and suicidal behavior resulting from failure in
examination or other environmental stressors.
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31. • Victims of poverty, destitution and abandonment such women thrown out
of the marital home or old and infirm parents left to fend for themselves.
• Victims of natural or man-made disasters such as cyclones, earthquakes,
famines, war, terrorism and communal/ethnic strife, with special attention
to the specific needs of children orphaned by such disasters.
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32. Key Lessons on the functioning of the DMHP
in the XIth Plan
• Large gaps exist in the coverage of the DMHP within the country.
Although the DMHP is supposed to be active in 123 districts, it was barely
functional in most districts.
• key lessons leraned can be Summarised above and these are organized in
the following themes.
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33. Lack of Public Health and Technical
Capacity:
• Technical support includes a range of inputs from establishing a mental
health information system to human resource planning to implementing
clinical management protocols.
• Non availability and amendment of guidelines without consultation or
guidance were a source of confusion
• In the absence of uniform guidelines and technical support, the objectives
of the programme were interpreted differently in different states
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34. Fragmentation of Responsibilities for Mental
Health Care:
1. Poor inter-ministerial co-ordination at the Central level:
2. Poor inter-departmental co-ordination at the State Level:
3. Poor co-ordination with NRHM: At the delivery level, there is a lack of
coordination with the NRHM which has contributed towards the
strengthening of the infrastructure in primary health care. However, in
many cases, NRHM’s agenda has not included mental health though this
was raised at Common Review Mission (CRM) meetings.
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35. Inconsistent fund flows:
• Fund flow was identified as a major barrier to the functioning of the
programme.
• Simultaneously there were many instances of under-utilization of funds
and difficulties in accessing available funding
• In most states, DMHP funds were sent to the Directorate of Medical
Education while the Directorate of Public Health or Directorate of Medical
Services were responsible for implementing the programme.
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36. Inadequate Human Resources and Training:
• Lack of appropriate and trained human resources, rigid recruitment criteria
for specialists and lack of involvement of non-specialists were identified as
significant hurdles to the implementation of the programme
• lack of training for the state nodal officers, programme officers and
psychiatrists in the implementation of the DMHP as an important barrier in
the implementation of the programme..
• very narrow understanding of a mental health professional. Most often
service delivery revolved around the medical doctor at the PHC or the
district Psychiatrist
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37. Non availability of treatments :
• Availability of psychotropic drugs has been noted as a problem in many
districts
• Internal review of the DMHP showed only 11 districts reported availability
of essential drugs and their dispensing to patients while another review
(ICMR, 2008) found that 75% of the districts faced difficulties in
maintaining regular availability.
• The review done by NIMHANS reported that the drug list for management
of mental health problems and epilepsy was too long and not based on any
scientific rationale.
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38. IEC activities:
• Reviews found lack of uniformity in IEC activities and complete lack of
technical support for IEC
• One review found only 10% of the districts utilized funds allocated for IEC
activities, 20% of the districts did not utilize funds under IEC and 70%
districts had only partially utilized the resources
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39. Lack of integration of mental health in
primary care:
• About 61% of those accessing the DMHP services, accessed the district
hospital as their first point of contact.
• The percentage of patients accessing CHCs (12.7%) and PHCs (11.5%)
were found to be low (the rest accessed sub-centre, mental hospital and
others as first point of contact)
• Even when persons with mental illness accessed the DMHP, there was no
system to ensure they received evidence based treatments (in majority of
cases treatment was restricted to drug treatment) or that they continued
treatment until recovery. Consequently, many dropped out of treatment
with the health system failing to respond appropriately.
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40. Limited Accessibility:
• The ICMR review reported that over half of the patients had to travel more
than 5 kms to access treatment services; 40% had to travel over 10 kms.
• The ICMR review showed that patients spend Rs 43.5 (min Rs 10 – max
Rs 250) on travel to the hospital to access services provided under the
DMHP.
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41. Missing links:
• . Inadequate provision of care for full range of mental illness:
– Even though the burden of alcohol and substance use disorders is a major, and
growing problem for communities across the country, there was no systematic
provision of services for affected persons.
– services for mental illness at the two extremes of life, viz. child and adolescence and
older people, were notable only for their absence.
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42. • Crisis management and in patient service
– Due to a complete lack of utilization data on inpatient services, it is difficult to
comment on whether inpatient services were utilized appropriately by the DMHP.
• Continuing care in the community:
– The DMHP does not provide any form of continuing care in the community.
Consequently,
– the DMHP has failed to address the ongoing health and social care needs of persons
with chronic and severe mental illness.
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43. • Homeless and mental illness:
– DMHP has not addressed the needs of the homeless persons with mental illness. The
needs of homeless persons with mental health issues continue to be a cause of concern
as a signifcant population of homeless people have mental health problems.
• Enthusiasm of health staff:
– existing burden of work, inadequate facilities, lack of conducive work environment,
lack of skills, incentives, and non-availability of additional resources (in particular
human resources) for counselling and social support.
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44. • Lack of involvment of users and care-givers:
– There was a near total absence of users and care-givers in the design, implementation
and monitoring of the DMHP
– There was no provision for users and care-givers to question the health system or the
staff when there were problems of non-availability of care, nonavailability of drugs or
any such problems.
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45. • Poor NGO and private sector participation:
– Unlike RCH, TB and HIV/AIDS programs, the DMHP did not see active participation
of andcollaboration with NGOs.
– There was an absence of an organised approach to engagement with civil society
actors. As a result, the bid to increase stakeholder participation failed.
• Disability certification:
– While persons with mental illness received disability certification, the coverage was
patchy and in majority of the cases, no Disability Allowance (DA) was given.
– The DA was also notsynchronous with time and not adjusted for inflation.
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46. Conclusion
• The National Mental Health Program is aimed at doing“the greatest good to the
largest number” through five interdependent and mutually synergistic strategies,
to be implemented in a phased manner over the next two decades
1. Extension of basic mental health care facilitiesto, the primary level.
2. Strengthening of psychiatric training in MedicalColleges at the undergraduate as well as
postgraduate level.
3. Modernization and rationalization of mental hospitals to develop them into tertiary care
centers of excellence.
4. Empowerment of Central and State Mental Health Authorities for effective monitoring,
regulation and planning of mental health caredelivery systems.
5. Promoting research in frontier areas to evolve better and more cost-effective therapeutic
interventions as well as to generate seminalinputs for future planning
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47. References
• J Kishore. National Health Programs of India. 10th ed. Century Publication. New Delhi.
2012
• mohfw.nic.in/WriteReadData/l892s/9903463892NMHP%20detail.pdf, 14/04.2014. 20.15
hours
• mohfw.nic.in/.../ComprehensiveReport%20Part%202-83145794.pdf 13/04/2014. 17.00
hours
• mhpolicy.files.wordpress.com/2012/07/final-dmhp-design-xii-plan2.pdf. 14/04/2014.
19.00 hours
• R. Srinivasa Murthy. Mental Healthcare by Primary Care Doctors. 4th ed.
Bangalore(India): Department of Psychiatry, NIMHANS; 2005.
• Park K. Textbook of Preventive and Social Medicine. 21st ed. Jabalpur(India): Banarsidas
Bhanot Publishers; 2011
•
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Editor's Notes
The National Mental Health Programme will focus special attention on psychiatric problems specific to certain vulnerable sections of the population who are often marginalized and neglected owing to lack of effective advocacy
the integration into
primary health care and the desirability of specialist facilities or satellite outpatient clinics
was interpreted by DMHP districts in different ways. In most places, the DMHP was
reduced to specialist enabled outreach clinics rather than primary care based delivery of
mental health services supported by the specialist.
rehabilitation is the responsibility of the
Ministry of Social Justice & Empowerment while mental health is the responsibility of the
MoHFW. Many persons with mental illness, especially those with chronic mental illness
require a combination of medical treatment and rehabilitation to facilitate recovery. The
lack of seamless provision of health and rehabilitation services to such individuals can be
partly attributed to this separation of responsibilities towards health and rehabilitation and
the lack of inter-sectoral co-ordination in the delivery of these services