Community Mental Community Mental Health Services Health Services

Presenter: Ms. Sini MathewPresenter: Ms. Sini MathewDept. of PSWDept. of PSW

NIMHANSNIMHANSBangalore.Bangalore.

BHORE COMMITTEE REPORT 1947BHORE COMMITTEE REPORT 1947

“……………“…………….even if the proportion .even if the proportion of patients be taken as 2 per of patients be taken as 2 per thousand population in India, thousand population in India, hospital accommodation should be hospital accommodation should be available for 8,00,000 mental available for 8,00,000 mental patients as against the existing patients as against the existing provision for a little over 10,000 provision for a little over 10,000 beds for the country as whole”beds for the country as whole”

MUDLIAR COMMITTEE MUDLIAR COMMITTEE REPORT REPORT 19641964

“………“………. Reliable statistics . Reliable statistics regarding the incidence of regarding the incidence of mental morbidity in India are mental morbidity in India are not available…. as against the not available…. as against the total need of the number of beds total need of the number of beds available in mental hospitals in available in mental hospitals in india is only 15,000………”india is only 15,000………”

MENTAL HOSPITAL MENTAL HOSPITAL STUDYSTUDY

Three Mental Hospital Study Three Mental Hospital Study (Wing and Brown)(Wing and Brown)

Direct relationship between Direct relationship between quality of care and chronicity quality of care and chronicity

InstitutionalismInstitutionalism Institutional NeurosisInstitutional Neurosis

ATTITUDE TO FAMILYATTITUDE TO FAMILY

Prior to 1970 – Family as toxicPrior to 1970 – Family as toxic

1970 -Family as cause of 1970 -Family as cause of relapse (EE)relapse (EE)

1980 – Family as carer1980 – Family as carer

1990 - Family as partners1990 - Family as partners

INTEGRATION OF MENTAL INTEGRATION OF MENTAL HEALTH HEALTH

CARE WITH PHC - 1975 CARE WITH PHC - 1975 Raipur Rani Experiences, 1975, ChandigarhRaipur Rani Experiences, 1975, Chandigarh

RMHC services, Sakalawara, 1975, RMHC services, Sakalawara, 1975, BangaloreBangalore

Shiv Gautam, RajasthanShiv Gautam, Rajasthan

Karthikeyan Krishna Murthy, Karthikeyan Krishna Murthy, AndhrapradeshAndhrapradesh

National Mental Health National Mental Health Program Program

(1982)(1982) 1. Availability and accessibility 1. Availability and accessibility

of servicesof services

2. Application of knowledge to 2. Application of knowledge to general health caregeneral health care

3. Community participation3. Community participation

NMHP APPROACHES NMHP APPROACHES 19821982

1. Diffusion of mental health skills1. Diffusion of mental health skills

2. Task distribution2. Task distribution

3. Equity3. Equity

4. Integration of services4. Integration of services

5. Linkage with community 5. Linkage with community developmentdevelopment

1995-20021995-2002

Extension of DMHP to 25 districts in Extension of DMHP to 25 districts in 25 states25 states

Fully centrally fundedFully centrally funded

Mental Health care as part of Mental Health care as part of Primary Health care.Primary Health care.

COMMUNITY PSYCHIATRYCOMMUNITY PSYCHIATRY1995-20021995-2002

Extension of DMHP to 25 districtsExtension of DMHP to 25 districts 25 states25 states Fully centrally fundedFully centrally funded Mental Health care as part of Mental Health care as part of

Primary health care.Primary health care.

ERWADI TRAEDYERWADI TRAEDY August 2001August 2001

Belief in SupernaturalBelief in Supernatural

Concept of incurabilityConcept of incurability

Lack of servicesLack of services

Lack of recognition of human Lack of recognition of human rightsrights

SUPREME COURT SUPREME COURT INITIATIVES INITIATIVES AUGUST 2001AUGUST 2001

Enlarge the scope to whole countryEnlarge the scope to whole country

Emphasis on human rightsEmphasis on human rights

Responsibility of the state for mental Responsibility of the state for mental health carehealth care

INTERNATIONAL INTERNATIONAL DEVELOPMENTSDEVELOPMENTS

Deinstitutionalisation (Italy, 1978)Deinstitutionalisation (Italy, 1978)

Care in the communityCare in the community

Partnership with consumersPartnership with consumers

Partnership with familiesPartnership with families

Human rightsHuman rights

WORLD HEALTH REPORT WORLD HEALTH REPORT 20012001

MENTAL HEALTHMENTAL HEALTH

NEW UNDERSTANDING NEW UNDERSTANDING

NEW HOPENEW HOPE

RECOMMENDATIONS OF RECOMMENDATIONS OF WHR 2001WHR 2001

1.1. Provide treatment in primary careProvide treatment in primary care2.2. Make psychotropic medicines availableMake psychotropic medicines available3.3. Provide care in the communityProvide care in the community4.4. Educate the publicEducate the public5.5. Involve communities, families and consumerInvolve communities, families and consumer6.6. Establish National Policies, LegislationEstablish National Policies, Legislation7.7. Develop human resourcesDevelop human resources8.8. Link with other sectorsLink with other sectors9.9. Monitor community mental healthMonitor community mental health10.10. Support more researchSupport more research

PARTNERSHIP WITH PARTNERSHIP WITH FAMILIESFAMILIES

AMEND, BANGALOREAMEND, BANGALORE

ASHA, CHENNAIASHA, CHENNAI

RASHMI, DELHIRASHMI, DELHI

MILESTONES OF MENTAL MILESTONES OF MENTAL HEALTH CARE IN INDIAHEALTH CARE IN INDIA

1950 – Amritsar-family involvement1950 – Amritsar-family involvement 1960 – GHPU’S1960 – GHPU’S 1970 - Integration of MH care with 1970 - Integration of MH care with

PHC.PHC. 1980 - DMHP1980 - DMHP 1990 - NGO’s1990 - NGO’s 2000 – Human Rights2000 – Human Rights

IMPORTANT MILESTONES IMPORTANT MILESTONES – LEGAL– LEGAL

Narcotic and Psychotropic Narcotic and Psychotropic Substance Act (1985).Substance Act (1985).

Mental Health Act (1987)Mental Health Act (1987)

Persons With Disability Act Persons With Disability Act (1995)(1995)

LOOKING AHEAD - LOOKING AHEAD - CHALLENGSCHALLENGS

Very uneven distribution of Very uneven distribution of resources across states/UTs.resources across states/UTs.

Low human resources for mental Low human resources for mental health care health care

Poor training in psychiatryPoor training in psychiatry Lack of welfare programmes Lack of welfare programmes Public ignorancePublic ignorance Growth of private sectorGrowth of private sector

OPPORTUNITESOPPORTUNITES

Build on community resourcesBuild on community resources Community tolerance Community tolerance Family commitment Family commitment Limited barriers for professional workLimited barriers for professional work Partnerships with wide variety of Partnerships with wide variety of

community resourcescommunity resources Integration of servicesIntegration of services

HISTORY HISTORY

Community psychiatry unit started at Community psychiatry unit started at NIMHANS on October 1975NIMHANS on October 1975

Aim :to develop suitable training Aim :to develop suitable training programme for doctors and programme for doctors and multipurpose workers from PHCsmultipurpose workers from PHCs

Objectives:Objectives: Organizing servicesOrganizing services Human resource development-develop Human resource development-develop

training materials and conducting training materials and conducting training programstraining programs

Developing community based research Developing community based research Developing various models of care.Developing various models of care.Initial activitiesInitial activities Team studied the needs of the rural Team studied the needs of the rural

population one PHC(1975-80)population one PHC(1975-80) Identified the mentally ill persons at Identified the mentally ill persons at

their home through key informants and their home through key informants and those attending general hospital care.those attending general hospital care.

Initiated pilot experiment of integrating Initiated pilot experiment of integrating mental health with general health care mental health with general health care in one PHC with one lack population.in one PHC with one lack population.

Followed by the successfulFollowed by the successful

implementation of the similar implementation of the similar programme in another district with programme in another district with 2 million population 2 million population

The result of this project is The result of this project is completed in 1981 and now used as completed in 1981 and now used as the model district mental health the model district mental health programme.programme.

Initial activities at a Initial activities at a glanceglance

Primary health centre based rural Primary health centre based rural mental health programmemental health programme

General practitioner based urban General practitioner based urban mental health programmemental health programme

School mental health programmeSchool mental health programme Home based follow ups of psychiatric Home based follow ups of psychiatric

patientspatients Community based rehabilitation of Community based rehabilitation of

minor mentally ill persons.minor mentally ill persons.

Ongoing activitiesOngoing activities

ServiceService Teaching &TrainingTeaching &Training ResearchResearch

NEUROPSYCHIATRIC NEUROPSYCHIATRIC EXTENSION SERVICESEXTENSION SERVICES

Started in 1981Started in 1981 Five clinics-Five clinics-

Gunjur(25),Madhugiri(115),Maddur(75),KanakapGunjur(25),Madhugiri(115),Maddur(75),Kanakapura(50),Gowribidanur(75)ura(50),Gowribidanur(75)

ObjectivesObjectives Availability of serviceAvailability of service Accessibility of ServiceAccessibility of Service Affordability of ServiceAffordability of Service Community participationCommunity participation Integration of Mental health into PrimaryIntegration of Mental health into Primary Health CareHealth Care

NEUROPSYCHIATRIC EXTENSION NEUROPSYCHIATRIC EXTENSION SERVICESSERVICES

ServicesServices Brief intakeBrief intake Psychosocial assessmentPsychosocial assessment Psycho educationPsycho education Supportive therapySupportive therapy ReferralReferral Mobilization of resourcesMobilization of resources Marriage and Family CounselingMarriage and Family Counseling Health education Health education Making social welfare measures availableMaking social welfare measures available Brief Cognitive therapy for depressed Brief Cognitive therapy for depressed

clientsclients

RURAL M H SERVICESRURAL M H SERVICES

Rural Mental health Center at Rural Mental health Center at Sakalwara (1976)Sakalwara (1976)

Take care of Physical as well as Take care of Physical as well as Psychiatric casesPsychiatric cases

Trained GDMO, PSW, Cl. Trained GDMO, PSW, Cl. Psychologists and psychiatric nursesPsychologists and psychiatric nurses

one satellite clinic-Anekal one satellite clinic-Anekal 2828 Training center/ LaboratoryTraining center/ Laboratory

SATELLITE CLINICSATELLITE CLINIC

ObjectiveObjective

Availability of ServiceAvailability of Service Anekal 22 km from SakalwaraAnekal 22 km from Sakalwara

Every TuesdayEvery Tuesday Last Tuesday- for epilepsy(500-900)Last Tuesday- for epilepsy(500-900) 50-70 psy. Cases/clinic50-70 psy. Cases/clinic

CONSULTATION CONSULTATION SERVICESSERVICES

ObjectiveObjective Impart professional input when necessaryImpart professional input when necessary Sustaining the projectSustaining the project

NGOs working withNGOs working with mentally illmentally ill Mentally retardedMentally retarded HomelessHomeless Mental health/counselingMental health/counseling Disaster affected populationDisaster affected population

HOME CARE SERVICESHOME CARE SERVICES

Started in 1980s (Pai & Started in 1980s (Pai & Nagarajaiah,1981)Nagarajaiah,1981)

Multidisciplinary team make Home Multidisciplinary team make Home VisitsVisits

Provide drugs/counselingProvide drugs/counseling Crisis interventionCrisis intervention Relapse rate is almost nil after two Relapse rate is almost nil after two

years of F/Uyears of F/U

SCHOOL MENTAL HEALTH SCHOOL MENTAL HEALTH PROGRAMSPROGRAMS

Early detection Early detection and treatmentand treatment

Training of Training of TeachersTeachers

Impart Life skills Impart Life skills to childrento children

To enhance To enhance psychosocial psychosocial competencecompetence

Holistic approachHolistic approach

DISASTER MANAGEMENT DISASTER MANAGEMENT PROGRAMSPROGRAMS

Psychosocial Psychosocial assessmentsassessments

Capacity buildingCapacity building Support provisionsSupport provisions Working with Working with

NGOsNGOs Development of Development of

modelsmodels Evaluation Evaluation

exercisesexercises Policy implicationsPolicy implications

TEACHING & TRAININGTEACHING & TRAINING

Students ofStudents of M.Phil in Psychiatric Social Work M.Phil in Psychiatric Social Work M Phil in Clinical PsychologyM Phil in Clinical Psychology M.Sc and Diploma in Psychiatric NursingM.Sc and Diploma in Psychiatric Nursing MD in PsychiatryMD in Psychiatry Diploma in Psychological Medicine Diploma in Psychological Medicine Placement Students of Social Work, Placement Students of Social Work, Psychology, Psychiatry, Psychiatric NursingPsychology, Psychiatry, Psychiatric Nursing

Central/State Govt. Deputed Candidates Central/State Govt. Deputed Candidates WHO deputed CandidatesWHO deputed Candidates

TEACHING &TRAININGTEACHING &TRAINING School & School &

College College TeachersTeachers

Lay VolunteersLay Volunteers Volunteers in Volunteers in

Disaster Disaster ManagementManagement

Primary Care Primary Care Physicians/GPsPhysicians/GPs

Health WorkersHealth Workers

TRAINING METHODSTRAINING METHODS ManualsManuals Flip ChartsFlip Charts Video ReviewsVideo Reviews Group DiscussionsGroup Discussions WorkshopsWorkshops Didactic LecturesDidactic Lectures Field Field

Visits/Agency Visits/Agency VisitsVisits

Case Case DemonstrationsDemonstrations

RESEARCHRESEARCH EpidemiologiEpidemiologi

cal Researchcal Research Experimental Experimental

ResearchResearch Evaluative Evaluative

Research/serResearch/service delivery vice delivery researchresearch

Groups

Community samplesControl samplesStudy samples

Mean

SRQ_

TOTA

L

14

13

12

11

10

9

8

7

LEADING TO….LEADING TO….

Policy MakingPolicy Making Quality AssuranceQuality Assurance Decreasing StigmaDecreasing Stigma Continuity of CareContinuity of Care Ensure regular follow-upsEnsure regular follow-ups

ROLE OF PSW IN CMHROLE OF PSW IN CMH

MICRO LEVELMICRO LEVEL

MACRO LEVELMACRO LEVEL

MICRO LEVELMICRO LEVEL

IndividualIndividual Brief Psychosocial Brief Psychosocial

AssessmentAssessment Brief therapiesBrief therapies Placement servicesPlacement services

MICRO LEVELMICRO LEVEL

GroupGroup

Group PsychotherapyGroup Psychotherapy

Group Psycho educationGroup Psycho education

Group work with ChildrenGroup work with Children

FamilyFamily Family psychoeducationFamily psychoeducation Family counselling and Family Family counselling and Family

therapytherapy

MACRO LEVELMACRO LEVEL TrainerTrainer ConsultantConsultant Case ManagerCase Manager AdvocateAdvocate Resource MobilizerResource Mobilizer OrganizerOrganizer AdministratorAdministrator CollaboratorCollaborator ActivistActivist ResearcherResearcher

MENTAL HEALTH -AGENDA MENTAL HEALTH -AGENDA FOR ACTIONFOR ACTIONACTIVITIESACTIVITIES

ServicesServices Human resource developmentHuman resource development Support to familiesSupport to families Suicide preventionSuicide prevention Services for children and adolescentsServices for children and adolescents Support to voluntary organisationsSupport to voluntary organisations Integration with other sectorsIntegration with other sectors Research/Monitoring and evaluationResearch/Monitoring and evaluation Administrative structuresAdministrative structures

MENTAL HEALTH MENTAL HEALTH AGENDA FOR ACTIONAGENDA FOR ACTION

We have at our disposal the We have at our disposal the

knowledgeknowledge and and powerpower to significantly reduce the to significantly reduce the

burden of mental disorders.burden of mental disorders.