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COMMUNITY PSYCHIATRY

PRESENTER : DR. DAVIN


C/P : DR.SIDDARTH SHETTY
23/03/2012

INTRODUCTION
Mental

disorders :

Curse
Infliction
Result of bad deeds(present/past)
Wrong food
Un-understandable predicament to
be endured

Mental

patients fear,disgust,
pity/hostility among public

INTRODUCTION
No

effective treatment in past


Socio-cultural organisations(eg.
temples) offered help & support.
Self-sufficient village community
sheltered wandered off
patients.
This type of non-institutional
care of mentally ill a core
concept of community psychiatry
Practised in India all through the

DEFINITION
Defined

in many ways
Originates from historical background of
deinstitutionalisation in western
countries.
Generally denoted development of services
in many developing countries
Many, including India did not have adequate
number of institutions to care for mentally ill
Most care took place in the family
with/without involvement of mental health
services

DEFINITION
Thus

in India, it alludes to
establishment of new
services/programmes in the
community rather than
deinstitutionalisation.
Szmukler ,Thornicroft Definition :
Community Psychiatry
comprises the principles and
practices needed to provide
mental health services for a local

DEFINITION
1.
2.

3.

Establishing population-based needs for


treatment & care
Providing a service system linking a wide
range of resources of adequate capacity,
operating in accessible locations
Delivering evidence based treatments to
people with mental disorders

HISTORY
Ancient

India attempts to classify


mental disorders
6th century BC Charaka Samhita
unmaads
I. Endogenous group :
1. Due to body humor changes
a.
b.
c.
d.

Vatonmad(schizophrenia)
Pittonmad(mania)
Kaphonmad(depression)
Sannipatonmad(delirium/hysteria)

HISTORY
2.

Due to mental humors changes


a. Rajasonmad
b. Tamasonmad

Due to changes in both


II. Exogenous group(toxic
substances)
3.

a. Adhijonmad
b. Vishajonmad

HISTORY
Apasmara(convulsive

disorders)=
endogenous unmaada in etiology
prohibited, spoiled, unclean
food.
Exogenous unmaadaalcohol,other substances ,acts
offending Gods,sages, other
forces.

HISTORY
Ayurveda

emphasized
promotion of physical & mental
health
Prescribed right life style for
Control of passions
Fulfilment of basic needs
Achievement of life goals
Dharma(religion),artha(finance),kama(de
sire) ,moksha(salvation)

HISTORY
Maharishi

Patanjali- Ashtanga
yoga sutras
Charaka psychophysiological
parallelism mind corresponds to
body & vice versa.
Bhutavidya management of
mentally ill
Religious
rituals,exorcism,prayers,herbal
medicines(sarpagandha

HISTORY
Najabuddin

Unhammad(1222 AD)-

Unani
7 types of mental disorders:

Sauda-a-Tabee(schizophrenia)
Muree-Sauda(depression)
Ishk(delusion of love)
Nisyan(Organic mental disorder)
Haziyan(paranoid state)
Malikholia-a-maraki(delirium)

Psychotherapy

Ilaj-I-Nafsani

PRE INDEPENDENCE SCENARIO


18th

century period of political


instability
Psychological & social turmoil
Lunatic asylums established to
treat the Englishmen and Indian
sepoys employed under the
British
Growth was parallel to political
developments

PRE INDEPENDENCE SCENARIO


Establishment

of Lunatic Asylums(1784-

1857)
1784 Pitts India Bill Activities of EIC under
board of control
Earliest mental hospital established at
Bombay in 1745 accommodate 30 patients
Surgeon Kenderline started the 1st asylum in
Calcutta in 1787
Later, a private lunatic asylum was
constructed ,recognized by medical board
under charge of Surgeon William Dick &
rented to EIC.

PRE INDEPENDENCE SCENARIO


1st

government run lunatic asylum -17


April 1795 at Monghyr,Bihar for insane
soldiers
1st mental hospital in South India
Kilpauk,Madras in 1794 Surgeon
Vallentine Conolly.
Excited patients were treated with
opium,given hot baths,leeches applied
to suck their blood.
Music mode of therapy to calm down
patients

PRE INDEPENDENCE SCENARIO


But

mentally ill from general


population were taken care of by
local communities , traditional
Indian medicine doctors
Ayurveda ,Unani

PRE INDEPENDENCE SCENARIO


Growth

of mental asylums and humanistic


approach(1858-1919)
1858 enactment of 1 st Lunacy Act (Act No. 36)
Later modified by Bengal committee(1888)
New asylums in :East - Patna,Dacca,Calcutta, Berhampur(1874)
South- Waltair,Trichinapally(1871)
West -Colaba,Poona,Dharwar, Ahmedabad,
Ratnagiri(1865)
Others Hyderabad, Jabalpur,Banaras, Agra,
Bareilly, Tezpur,Lahore.

PRE INDEPENDENCE SCENARIO


Techniques

of moral
management systems
developed, implemented in the
West ,were adopted.
Drug treatments were introduced
(chloral hydrate) Aimed at
controlling patient behaviour,
allowing respite from their
condition through sleep.
Onset of World War in 1914

PRE INDEPENDENCE SCENARIO


3
1.

2.

Significant developments :
1905 Lord Morley transferred control from
Inspector General of Prisons to Directorate
of Health Services & Civil Surgeons.
1906 Central Supervision system
contemplated

3.

Specialists in psychiatry full time doctors

1912 Indian Lunacy Act Central


legislation
Growing concern among public about poor &
unhygienic conditions in hospitals

PRE INDEPENDENCE SCENARIO


1912

Capital shifted to Delhi


European Lunatic Asylum
established in Bhowanipore for
European patients ,later closed
down after establishment of
European Hospital at Ranchi
-1918.
Due to far-sightedness,hard work
& persistence of the then
superintendent Col. Owen

PRE INDEPENDENCE SCENARIO


Movement

away from mental


hospitals(1920-1947)
He persuaded Govt to change name
from asylum to hospital -1920
Origin of psychiatric rehabilitation
Habit Formation Chart(token economy)1920
Occupational therapy unit -1922
Hydrotherapy -1923

PRE INDEPENDENCE SCENARIO


G

S Bose Indian Psychoanalytical


Association(1922)
Berkeley Indian Association for Mental
Hygiene,Ranchi
Psychoanalysis for British patients of
WW1
Cardiasol-induced seizure treatment-1938
ECT 1943
Psychosurgery -1947
Rauwolfia extracts late 1940s

PRE INDEPENDENCE SCENARIO


Emphasis

shifted from custodial


care to curative approach
Efforts to train psychiatrists and
nursing personnel
Initial attempts to establish direct
links with patients family in the
form of family units

PRE INDEPENDENCE SCENARIO


Community

psychiatry movement 3 rd
Psychiatric revolution
(1st age of enlightenment in middle
ages ,where mental illness was viewed
as a consequence of sin & witchcraft)
(2nd development of psychoanalysis
hope for causative explanation)
Some refer to advent of
psychopharmacology before
community psychiatric movement.

PRE INDEPENDENCE SCENARIO


Inspiration

for community mental


health movement in India - 3
main sources :
1. Realization in Western countries
2. Institution based psychiatry is
expensive +no sufficient man
power & facilities in India.
3. Para & non professionals ,after
simple ,short training could
deliver adequate mental health

WESTERN INFLUENCES
Phillippe

Pinel in France,William Tuke in


England,Benjamin Rush in US ,led
movement against ill treatment of
mentally ill.
Started moral treatment human
care,avoiding physical restraints,open
door system,better staff-patient
interaction.
1909 Adolf Meyer Management of
patients outside institutions
community mental health approach

WESTERN INFLUENCES
Psychiatrists,family

physicians,police, teachers, social


workers together organize
primary, secondary & tertiary
preventive measures in
community.
Clifford Beers described awful
conditions in his book
formation of National Mental
Health Association in
USAMental Hygiene Movement

WESTERN INFLUENCES
1955-1980

era of
deinstitutionalization in the West.
1961 Action for mental health
1963 JF Kennedy establish
community mental health centres
Each catering 75k population
Range of servicesOP,IP,Emergency,education
Multidisciplinary team Psychiatrists,clin.
Psychologists,social workers,nurses,
occupational therapists

WESTERN INFLUENCES
Italy

- 1st country to start


deinstitutionalization of mental health care
& to develop a community-based
psychiatric system.
It originated samples of effective and
innovative service models and paved the
way for deinstitutionalization of mental
patients.
From 1971 to 1974, the efforts of Franco
Basaglia and were directed at changing the
rules and logic which governed the
institution

WESTERN INFLUENCES
In

1978, the passing ofBasaglia


Lawhad startedItalian psychiatric
reformthat terminated with the very
end of the Italian state mental hospital
system in 1998.
It was directed towards the gradual
dismantling of the psychiatric hospitals
and required a comprehensive,
integrated and responsible community
mental health service.

WESTERN INFLUENCES
The

object of community care


was to reverse the long-accepted
practice of isolating the mental ill
in large institutions, to promote
their integration in the
community offering them a milieu
which is socially stimulating,
while avoiding subjecting them to
too intense social pressures

WESTERN INFLUENCES
In

USA ,State Hospital beds


-5.6lakh61k in 1992
Over time ,approach went into
disrepute because :
1. Several ill patients not accepted
by families(transinstitutionalisation) nursing
homes/board & care institutionsneglected
2. People understood that severe
mental disorders were not

WESTERN INFLUENCES
3. Claim that community care was
cheaper & better not established
4. Confusion regarding responsibility
of care of mentally ill
Govt?,Family?,Hospitals?,social
institutions?

Basic

Model of Community
Mental Health
1967 Gerald Caplan
1. Responsibility to a population for
mental health care delivery
2. Treatment close to the patient in
community based centres
3. Provision of comprehensive
services
4. Multi disciplinary team approach

Providing continuity of care


6. Emphasis on prevention as well
as treatment
7. Avoidance of unnecessary
hospitalization.
5.

Community mental health in


India
Till

1946 ,government approach was


to establish custodial centres for a
small percentage of ill individuals
1920 Queen Victoria ordered
conversion of all existing asylums to
hospitals.
Col. M Taylor surveyed 17 hospitals
majority were out of date,designed
for detention & safe custody ,not for
curative treatment

Community mental health in


India
Bhore

Committee(1946) If
proportion of mental patients is
2/1000 ,beds were required for at
least 8 lakh ,but only 10k were
available in 17 hospitals
Bed ratio -1:40k
Report laid foundation by
combining both top down &
bottom up approaches
Substantive emphasis on mental

DR. VIDYASAGARS
CONTRIBUTION
Dr.

Vidya Sagar pioneer of community


psychiatry
Involved family members in treatment of
patients in Amritsar Mental Hospital ,for
practical reasons of shortage of staff.
Set up army surplus tents for relatives to
stay on & assist in nursing care
Every evening, he would assemble all for
an open case-conference- encouraged
to understand symptoms and treatment
methods

DR. VIDYASAGARS
CONTRIBUTION
Achievements
1.
2.
3.

4.

:
Reduced hostility in patients minds of
being abandoned in strange place
Removed old age myths of incurability
when family saw patients recover
By group sessions , relatives learnt
essential principles & were motivated
towards improvement.
Fast recovery,low relapse rates

PRIMARY CARE APPROACH


1950s

Establishment of All India


Institute fo Mental Health(later
NIMHANS),Bangalore ,AIIMS,Delhi
,All India Institute of Hygiene &
Public Health,Kolkata
Major guiding principle
reaching the unreached

PRIMARY CARE APPROACH


1970

primary care approach


Existing 42 mental hospitals -5060k pts/year
Catered to only 20% population
Epidemiological studies showed
equal prevalence of mental
disorders in both rural & urban
areas.

PRIMARY CARE APPROACH


Available

services not made use of

because:

Ignorance
Existing beliefs evil spirits cause illness
Black magic
Past bad deeds
Lack of knowledge
Long distance to be travelled
Stigma
Lack of resources-money,transport,others

Drop

out rates very high

PRIMARY CARE APPROACH


Number

of trained psychiatrists
increased
Govt failed to create specific
posts in hospitals.
Indian Psychiatric Society
conducted seminars & workshops
in major cities emphasizing need
to integrate mental health into
general health care ,and provide
care through primary care

GHPU
Next

phase was establishment of General


Hospital Psychiatric units(GHPUs)
1st was in 1933 R G Kar Med
College,Kolkata
1960s availability of antipsychotic drugs
dramatically controlled
agitation,aggression, withdrawal
tendencies of patients.
Thus possible to treat them in general
hospitals
Led to increase in graduates in Psychiatry

NIMHANS Crash
Programme
Dr

.R M Verma,Dr. Karan Singh


Oct 1975 Community Psychiatric
Unit
Launched experimental
programmes
1. PHC based rural mental health
programme : Manuals prepared
to train MPWs and PHC doctors
to diagnose & treat
2. GP based urban mental health

NIMHANS Crash
Programme
School mental health
programme :Teachers trained to
diagnose and counsel
4. Home based follow up of
psychiatric patients: Nurses
trained to follow up patients
through monthly visits
5. Psychiatric camps :involved
village leaders & reduced stigma
3.

FEASIBILITY STUDIES
Feasibility

studies done in 2 regions :1975-

80
Sakalawar,Bangalore & Raipur Rani,Haryana
Results :
1. Majority of mentally ill,epileptics,MR
children remained untreated inspite of
being nearer to a well established mental
hospital.
2. All families had approached traditional
healing centres,local healers for help but in
vain

FEASIBILITY STUDIES
3.
4.
5.

6.

7.

Majority were ill for > 2 years


Key informants , health workers could
easily identify , report about existing cases
Limited number of drugs were sufficient to
manage almost all cases , hospitalisation
rarely required.
Most improved with meds , rehabilitated
back into villages & joined mainstream of
life
Medical & non medical workers able to
learn in short term courses

Alternatives to
institutional care
Developed

by NIMHANS and other

institutions
1. Extensive use of outdoor
services :
Family members encouraged to
treat patients at home,get drugs and
suggestions from hospital by
periodic regular visits.
All types of treatment,including ECT
given in OP setups

Alternatives to
institutional care
Short

stay ward(upto 48hrs)


facility organised in OP building
acute problems managed & pt.
discharged
Free / subsidized drug supply to
improve drug compliance

Alternatives to
institutional care
Extension programs by
satellite clinics :
Mental health team conducts
weekly/monthly clinic at
Taluk/district HQs.
Local medical & NGOs motivated
to be local hosts & help in pt.
care.
Still functioning well even now.

2.

Alternatives to
institutional care
Domiciliary care program :
A MHP /visiting nurse delivers
required services to patients at
their doorsteps.
In a study with follow up of 6
mths,home group did better in
both clinical state & social
functioning.

3.

Alternatives to
institutional care
Organizing care through private
general practitioners :
Short term courses arranged to
improve knowledge & skills of pvt
GPs in managing psychiatric
problems
They are easily accepted by people
& deliver good care to the needy.
Supported by MHPs for managing
difficult cases.

4.

Alternatives to
institutional care
Training school teachers in
mental health care &
promotion of mental health
through schools
Training programs organized in 2
phases recognizing & managing
psychosocial problems of
students.
Sensitize them to recognize &
intervene

5.

Alternatives to
institutional care
Involvement of ICDS
personnel in child mental
heath care :
Anganwadi workers trained in
basic mental health care to
identify & refer children with
MR,behavioural problems
Improve child rearing practices
But have to be supervised &
effective referral linkages to be

6.

Alternatives to
institutional care
Training lay volunteers :
Interested, committed natural
helpers given 40 training
sessions in counselling help
individuals in distress
Supervised & monitored by
MHPs
Eg. marital discord, parents with
problem children, IP problems,
students with problems in

7.

Alternatives to
institutional care

Training village leaders:


Work like referral & change agents in
society
9. Student volunteers :
Part of NSS ,students educated &
motivated
Decreased authoritative & negative
attitudes in the trained group.
Allowed to interact with mentally ill in
hospital setup improvement in BPRS
scores
8.

Alternatives to
institutional care
10.Student

enrichment
program :
30 sessions
How to study,learn
better,communicate ,write in
exam ,role of emotional factors in
learning.
Better overall performance,self
esteem

Alternatives to
institutional care
11.Non-governmental

voluntary

organizations:
SCARF(Madras)
Medico-Pastoral
Association,Richmond Fellowship
of India ,Bangalore
Rehabilitate by organizing
vocational training ,half way
homes for chronic mentally ill and
disabled

Alternatives to
institutional care
Suicide

prevention centres
Helping Hand
,MPA(Bangalore),Sneha(Chennai),
Sahara(Mumbai),Sanjivini,Sumaitr
i(Delhi)
Helping hands to families
Pressure groups to mobilize
public opinion & concern for
improving services
Require good networking,periodic

ICMR-DST study on severe


mental morbidity
1st

& only prospective study where ability


of doctors & health workers to recognize
and manage at PHC level was examined
exhaustively
4 centres
Bangalore,Vadodara,Patiala,Kolkata
Motivation among MPWs were poor
Neither the doctor/HWs organised a
programme to impart eduction
Record keeping very poor
Lack of leadership

NATIONAL MENTAL HEALTH


PROGRAM
A

group of 68 experts formed in


1980
Final draft submitted to Central
council of health & family welfare
on 18-20 August 1982.
Appeared almost simultaneously
with the National Health Policy

OBJECTIVES
To

ensure availability &


accessibility of minimum mental
health care for all in the
foreseeable future ,particularly to
the most vulnerable &
underprivileged sections of
population.
To encourage application of
mental health knowledge in
general health care & in social
development.

OBJECTIVES
To

promote community
participation in the mental health
service development & to
stimulate efforts toward self-help
in the community.

AIMS
Prevention & treatment of
mental & neurological disorders
& their associated disabilities.
2. Use of mental health technology
to improve general health
services.
3. Application of mental health
principles in total national
development to improve quality
of life.
1.

STRATEGIES
Complementary
Centre

to periphery :
Establishment & strengthening of
psychiatric units in all district
hospitals ,with outpatient clinics
& mobile teams reaching the
population for mental health
services.

STRATEGIES
Periphery

to centre :
Training of an increasing number
of different categories of health
personnel in basic mental health
skills ,with primary emphasis
towards the poor & the
underprivileged ,directly
benefitting around 200 million
people.

SUBPROGRAMMES
TREATMENT
1.

: Multiple levels
Village ,subcentre level :Multi
purpose workers(MPW),Health
supervisors(HS),under supervision of
medical officer(MO) trained for:

Management of psychiatric emergencies


Administration & supervision of
maintenance treatment for chronic
psychiatric disorders
Diagnosis & management of grand mal
epilepsy , esp. in children

SUBPROGRAMMES
Liaison with local school teacher & parents
regarding MR & behaviour problems in
children.
Counselling in problems related to alcohol &
drug abuse.

PHC :MO,aided by HS,trained for:

2.

Supervision of MPWs performance


Elementary diagnosis
Treatment of functional psychosis
Treatment of uncomplicated cases of
psychiatric disorders assoc. with physical
diseases.

SUBPROGRAMMES
Management of uncomplicated psychosocial
problems.
Epidemiological surveillance of mental
morbidity
3.

District hospital :
At least 1 psychiatrist attached as integral
part
30-50 psychiatric beds
Psychiatrist devotes only part of his time in
clinical care , greater part in training &
supervision of non-specialist health workers.

SUBPROGRAMMES
4.

Mental hospitals & teaching


psychiatric units:
Help in care of difficult cases
Teaching
Specialised facilities such as
occupational therapy units,
psychotherapy, counselling,
behaviour therapy

SUBPROGRAMMES
REHABILITATION

:
Maintenance treatment of
epileptics & psychotics at
community levels
Development of rehabilitation
centres at both district level &
higher referral centres.

SUBPROGRAMMES
PREVENTION

:
Community based
Initial focus on prevention &
control of alcohol related
problems
Later, addictions,juvenile
delinquency & acute adjustment
problems(suicidal attempts) are
addressed.

Fundamental
1.
2.

3.

concepts :
Majority of mentally ill dont reach the
existing psychiatric services
Large proportion of mental disorders
as seen in the community are
ambulatory,self-limiting & manageable
Diseases are better managed if
recognized in initial stages,thus
preventing chronicity,disability, burden
on family & society

Reasons for poor progress


Looked

good on paper,extremely
unrealistic in its
targets,considering available
resources of manpower &
funds.Only a sum of Rs 10 million
was sanctioned
Top down approach did not take
into account ground realities
poor functioning of PHCs & poor
morale of health workers not
taken into account

Reasons for poor progress


Lack

of enthusiasm for the


programmme in the profession as
a whole no large scale training
programme/supervision possible
Lack of an administrative
structure to monitor progress in a
decentralised manner

District mental health program


In

1980s,NIMHANS ,District
Health & Family Welfare
Personnel, & District
administration of Bellary jointly
launched a pilot model
programme in Bellary district to
implement NMHP ,at a district
level
Considered a more rational
exercise

Bellary model
Decentralized

& phased training


courses conducted for all health
personnel of district
Covered 1.5million population-7 taluks
Program officer appointed organized
mental health clinic & toured entire
district to monitor program.
Simple recording & reporting system
developed.DHO monitored progress
every month

Bellary model
5

essential drugs made available for


distribution in all health centres.
1st 3 yrs -1200 psychotics,3525
epileptics,750 neurotics,380 MR
registered.42% psychotics & 53%
epileptics took regular treatment.70
% came from places within 5 km
range.
Good performers in this program were
good in all other health programs

Bellary model
As

services became
popular,people reached centres
within few days/weeks of illness
onset ,bypassing faith healers &
other agencies.
Gave insight to professionals on
how to organize services in cost
effective manner
Its being continued
still,financially supported by Zilla

Implications
Difficulties

in :

Correct diagnosis
Appropriate medication choice
Dosage & difficulty of handling side
effects
Administrative problems poorly
motivated personnel ,erratic supply
of drugs

Barwani experiment
3

tier model by Chatterjee et al.


1st OP programme
2nd MHW drawn from local
community
3rd family members & key
people in community
Compliance to treatment -63%
Village samitis added a positive
atmosphere

Progress since 1982


Some

ways very significant


Guiding principle for
development of mental health in
India.
Development of models for
integration of mental health with
primary healthcare
Eg.Raipur
Rani,Sakalawara,Bellary DMHP
Extension of DMHP to 25 districts

Progress since 1982


Community

care alternatives &


NGO initiatives
Included day care centres,half
way homes, long stay
homes,suicide prevention,school
mental health programmes.
Felt need + ,user-friendly

Progress since 1982


Human

resource development
Number of trained psychiatrists
have more than tripled to >3000
Unsatisfactory aspect fields of
clinical psychology,psychiatric
social work ,psychiatric nurses
not trained in adequate numbers.

Progress since 1982


Public

awareness
Due to community based mental
healthcare,voluntary
organisations initiatives,MHPs in
remote area
Use of media books,radio,TV
sharing mental health
information among general
public.

Progress since 1982


Others

related to mental health :


Legislations :
Narcotic Drugs & Psychotropic
Substances(NDPS) Act,1985
Mental Health Act 1987
Persons with Disability Act 1995 -1 st
time mental illness was included
Penal promotion,prevention,rights
approach

Progress since 1982


Recognition

of human rights of mentally


ill by NHRC systematic,intensive,critical
examination of mental hospitals
showed inadequacy of services &
upholding human rights
Revision of NHP in 2002 Recognises
mental health as part of general health.
Growth of mass media multiple
languages phone-in
programs,serials,features,panel
discussions etc.

Progress since 1982


Mental

health research ICMR


understanding cultural context of
mental disorders esp.
schizophrenia

Barriers to reach goals


Poor

Funding :
1st 3 5 yr plans made inadequate
funding allocation + not fully
utilised.
9th plan Rs 280 million,10th Rs
1900 million
DMHP showed that if funds are
available,states are ready to take
up programs,MHPs ready for
variety of initiatives

Barriers to reach goals


Limited

UG training in psychiatry
Inadequate mental health human
resources :
Many districts have no public sector
psychiatrists
Medical colleges inadequately staffed
Not enough training facilities for clinical
psychology,social work,nursing
Limited

number of models & their


evaluation :
Missing manuals to guide DMHP

Barriers to reach goals


Uneven

distribution of resources
across states:
National level implementation difficult

Non

implementation of MHA 1987 :

Insufficient norms for licensing &


maintaining care standards
Privatisation

of healthcare in the

1990s
India has least amount of public funding for
health care in 5% of GDP, 83% comes
from private

Major Developments in past 3


decades
Increased

range of treatments
Greater recognition of families role
Community mental healthcare
Wide variety of care models
Increased human resources
Judicial activism
Recognition of stigma & discrimination
Worldwide focus on mental health(2001
WHO report devoted to mental health)

Erwady Tragedy
Erwady

tragedy Tamil Nadu


Aug 6 2001
25 mentally ill persons were
burnt alive in a fire at the mental
home, in Erwadi, Tamil Nadu.
They could not escape as they
were chained.
The tragedy shook the nation and
the human rights activists all
over the world expressed their

Erwady Tragedy
All

15 mental homes at Erwadi


were closed on August 13 and
their 571 inmates taken under
the government's care
Forced the State government to
act & implement certain sections
of MHA 1987
Similar event in Ranchi Patients
escaped ,pitiable living conditions
were exposed in media

REVISED GOALS
Strengthening families &
communities for the care of
persons suffering from mental
disorders.
2. Organisation of a wide range of
mental health initiatives to
support individuals &
families,with special focus on
immediate delivery of the most
essential services to the ones
with the greatest needs
1.

REVISED GOALS
3.

Supporting through mental


health initiatives , rebuilding of
social cohesion,community
development,promotion of
mental health & the rights of
persons with mental health
disorders.

Plan of action
Organising services :
Recommended by WHO 2001 report
Provide mental health in primary
care :
1.

Easier ,faster access to servicesbetter


care,cuts wastage from unnnecessary
investigations & treatments
Mental health to be included in training
curricula + refresher courses to improve
effectiveness

Plan of action
Make

psychotropic drugs
available :
Provide an essential drugs list
Ameliorate symptoms,reduce
disability,shorten course ,prevent
relapse.
Levels of mental healthcare to be
developed depending on health
infrastructure in state.
Short-focused training

Plan of action
Community mental healthcare
facilities:
Better effect on outcome & QOL
Cost effective,respects human rights
Help in early intervention ,limit stigma
Large custdial hospitals replaced by
community care facilities,backed by
general hospital psychiatric beds,home
care support
Crisis support,protected housing,sheltered
employment
2.

Plan of action
Day

care centres,half way


homes,long stay homes,sheltered
workshops,de-addiction centres
,suicide prevention centres.
District leveltalukstowns

Plan of action
Support to families :
primary care providers
Require understanding of illness &
skills to care for the ill
Ensure medication
compliance,recognize signs of
relapse,handle crisis,reduce disability
State should :
Provide financial support
3.

Plan of action
Offer

public places for meetings


& organisations of day care
activities
Developing visiting nurses to
support families
Involving them in planning of
mental health programmes

Plan of action
Human Resource
development :
Trained
professionalsfoundation for
organisational services
UG training in psychiatry for
medical students
Plan to increase to 2 mths +
exam subject
Psychiatrists fuly staff

4.

Plan of action
Psychologists,social

workers,nurses minimum 3-6


months training at mental health
centres
Rehabilitation professionals
Short term training for medical
officers esp. experienced senior
officers -3 mths

Plan of action
Public mental health
education :
Reduce treatment
barriers,increase awareness
Reduce stigma,discrimination
thus bring branches of mental &
physical healthcare closer
AIR,DD,Print & folk media
utilized
Should be a continuous

5.

Plan of action
Private sector mental
healthcare:
Pvt psychiatrists can support by :

6.

Systematically recording their work to


provide understanding of magnitude of
mental health needs
Clarifying treatment utilization
Working as honorary consultants
Training PHC personnel,supporting NGOs
Encouraging public mental health
education

Plan of action
Support to voluntary
organisations
Valuable community resource
More sensitive to local
realities,strongly committed to
innovation & change
Fill gap b/w community needs &
available services
Govt should develop funding
mechanisms to cover all states

7.

Plan of action
Promotion & preventive
activities :
Life skills education programmes
for school children
Initial efforts undertaken by
NIMHANS already
Psycho-social care of disaster
survivors part of
relief,rehab,reconstruction &
reconciliation programmes

8.

Plan of action
Administrative support :
Full time Joint Director(Mental
health) to be appointed at
Directorate of Health services.
District level :2 mental health
teams Result in bth clinical care
& integration of mental health at
periphery
Increase mental health budget
to atleast 10% of total health

9.

Future Priorities
Family

as the focus of care


Public mental health education
Intersectoral collaboration
Role of voluntary organisations
Integration with general health services
HRD
Enhancing funding for mental
healthcare
Emphasis on prevention & promotion
Administrative structures

Suggestions
Continued

efforts to improve
psychiatry education in MBBS
courses little need of manuals
then!
PHCs should employ local people
in service delivery,to ensure high
motivation levels
State must not give up
responsibility of looking after
chronically ill patients ,innovative

Suggestions
Networking

of non-professional
counselling services,training
courses for lay counsellors, better
monitoring of services.
New programmes to be
continuously evaluated by
researchers(external).
Professionals should make
contact with religious ,spiritual
centres providing help to

Suggestions
Special

focus on high risk groups


women,children,elderly people
MHPs remain sensitive to
changing values & attitudes
accompanying socio-economic
uplifting programmes
Exercise their democratic right to
influence public opinion

World mental health report,2001


Focused

on mental health
(Mental Health:New
understanding,New Hope)
Slogan : -Stop Exclusion:Dare to Care
1 in every 4 affected by mental
disorder at some stage of life.
Psychiatric disorders -12% of global
burden of disease
Mental health budgets <1% of total
expenditures

World mental health report,2001


10
1.
2.
3.
4.
5.
6.

recommendations of action :
Provide treatment in primary
care
Make psychotropic drugs
available
Give care in the community
Educate the public
Involve
communities,families,consumers
Establish national

World mental health report,2001


Develop human resources
8. Link with other sectors
9. Monitor community mental
health
10.Support more research
7.

Conclusion
Current

poltical,economic,social
conditions are changing at a rate faster
than what a human mind can
comprehend.
Community programs should be flexible
enough to adjust to such changes
Nothing can carry on out of sync with
environment except for eternal values
Weak & powerless should be
supported ,helped by others to live in a
manner which raises their self respect

Conclusion
Such

eternal value will lead to


stability,prosperity & dignity of
the nation.

THANK YOU

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