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National Mental Health 
Program 
RAVI M R 
POST GRADUATE STUDENT 
JSS MEDICAL COLLEGE MYSORE
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. 
2
• 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. 
3
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. 
4
• 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. 
5
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) 
6
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) 
7
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. 
8
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. 
9
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. 
10
• 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. 
11
• 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. 
12
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. 
13
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 
14
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. 
15
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 
16
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. 
17
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 
18
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 
19
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 
20
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. 
21
• 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. 
22
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 
23
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. 
24
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). 
25
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. 
26
School Mental Health Services 
• Life Skills Education using standard training manuals 
• Counseling services through trained teachers/ HiredCounselors 
• Involvement of the NGOs 
27
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 
28
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 
29
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. 
30
• 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. 
31
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. 
32
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 
33
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. 
34
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. 
35
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 
36
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. 
37
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 
38
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. 
39
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. 
40
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. 
41
• 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. 
42
• 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. 
43
• 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. 
44
• 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. 
45
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 
46
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 
• 
47

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National mental health program

  • 1. National Mental Health Program RAVI M R POST GRADUATE STUDENT JSS MEDICAL COLLEGE MYSORE
  • 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. 2
  • 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. 3
  • 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. 4
  • 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. 5
  • 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) 6
  • 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) 7
  • 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. 8
  • 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. 9
  • 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. 10
  • 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. 11
  • 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. 12
  • 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. 13
  • 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 14
  • 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. 15
  • 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 16
  • 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. 17
  • 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 18
  • 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 19
  • 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 20
  • 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. 21
  • 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. 22
  • 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 23
  • 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. 24
  • 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). 25
  • 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. 26
  • 27. School Mental Health Services • Life Skills Education using standard training manuals • Counseling services through trained teachers/ HiredCounselors • Involvement of the NGOs 27
  • 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 28
  • 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 29
  • 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. 30
  • 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. 31
  • 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. 32
  • 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 33
  • 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. 34
  • 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. 35
  • 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 36
  • 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. 37
  • 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 38
  • 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. 39
  • 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. 40
  • 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. 41
  • 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. 42
  • 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. 43
  • 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. 44
  • 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. 45
  • 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 46
  • 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 • 47

Editor's Notes

  1. 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
  2. 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.
  3. 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