Community mental health in India- way ahead

Dr K.V.Kishore Kumar Psychiatrist

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Magnitude of mental disorders

• 10-15% of adult population affected

• 20% of patients seeking primary health care have one or more mental disorders, though not recognised

• One in four families have at least one member with a behavioural or mental disorder at any point in time.

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World Health Survey 2003 – Karnataka

• A national sample of 10,000 individuals were surveyed as part of WHS 2003

• States selected were Assam, West Bengal, Rajasthan, Karnataka and Maharasthra.

• Sample size of Karnataka was 1300• 9% of the sample were diagnosed as

depression• Psychosis was < 1%

Burden of mental disorders

6%

6%

4%

3%3%

6%7%

5%

13%

3%

10%

4%3%

12% Cardiovascular diseases

Diabetes

Malignant neoplasms

Digestive diseases

Neuropsychiatric disorders

Other NCDs

Injuries

Other CD causes

Maternal conditions

Malaria

Childhood diseases

Tuberculosis

Diarrhoeal diseases

Perinatal conditions

HIV/AIDS

Respiratory infections

Respiratory diseases

Nutritional deficiencies

Sense organ disorders

Diseases of the genitourinary systemMusculoskeletal diseases

Congenital abnormalities

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Burden of disease% attributed to mental and behavioural disorders

of total DALYs lost world-wide

• 1990 10 %

• 2000 12.3 %

• 2020 (projected) 15 %

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Global estimates

340 million Depression 45 million Schizophrenia 91 million Alcohol use disorders 15 million Drug use disorders50 million Epilepsy 29 million Dementia 8.77 lakh people complete suicide every year One out every four seeking help have mental

/behavioral / neurological- most of them untreated or undiagnosed

Global recommendations • Integrate mental health in primary care • Educate communities – mental disorders • Ensure availability of psychotropics • Involve families communities and groups • Establish policy, program and legislation at

national level.• Provide and develop human resource for mental

health • Intersectoral linkages for mental health care • Promote research and evidence

1950- Amritsar – Family involvement1960- GHPU’s

1969 - Mudaliar committee recommendation on mental health 1970 - Integration of mental health care with primary health care 1974 - Srivatsava committee recommendation on community level volunteer 1975 - Launch of community mental health services

1985- Bellary DMHP 1985 – NDPS act 1987 – Mental health act 1990 - NGO’s 1992 - Rehabilitation council of India act 1995- Disability act 1997 -Quality assurance in mental health care

1999- mental health identified as priority for the WHO 1999 – National trust act

2001- World health report 2003- world health survey 2003 – evaluation of DMHP 2007 – UNCRPD 2007-08 – Up-scaling DMHP to 123 Districts‘ 2011-12 – mental health policy initiatives 2013 – Union Cabinet clears mental health care bill

Important Milestones of Mental Health Care in India

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Community-based carebenefits

• Services close to home• Focus on disabilities as well as symptoms• Focus on the individual • Wide range of services• Ambulatory rather than static services• Partnership with carers• Better quality of life for ill persons• Prevents inappropriate admissions

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Depression

Up to 60% of patients recover

Substance Abuse

Up to 60% reduction in drug use

Epilepsy

Up to 73% of patients live free from seizures

Schizophrenia

Up to 77% of patients live without relapses

Effectiveness of Treatment

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Poor utilisation of servicesexample from Australia 1997

Table 3.1 Utilization of professional services for mental problems, Australia, 1997

Consultations for mentalproblems

No disorder Any disorder > 3 disorders

% % %

General practitioner onlya 2.2 13.2 18.1

Mental health professional onlyb 0.5 2.4 3.9

Other health professional onlyc 1.0 4.0 5.7

Combination of healthprofessionals

1.0 15.0 36.4

Any health professionald 4.6 34.6 64.0

a Refers to persons who had at least one consultation with a general practitioner in the previous12 months but did not consult any other type of health professional.

b Refers to persons who had at least one consultation with a mental health professional(psychiatrist/psychologist/mental health team) in the previous 12 months but did not consult any othertype of health professional.

c Refers to persons who had at least one consultation with another health professional(nurse/non-psychiatric medical specialist/pharmacist/ambulance officer/welfare worker or counsellor)in the previous 12 months but did not consult any other type of health professional.

d Refers to persons who had at least one consultation with any health professional in theprevious 12 months.

Source: Andrews G et al. (2001). Prevalence, comorbidity, disability and service utilisation: overviewof the Australian National Mental Health Survey. British Journal of Psychiatry, 178: 145153.

Tab

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Cost of care

753.27

997.41

352.34

476.37395.03

451.07

1554.66

1357.951278.58 1294.32

962.091001.95

1075.691016.72

884.81

295.28280.54299.75279.07

76.91.6317.416.72

83.9312.41

1556.69 1505.5

1182.76

0

200

400

600

800

1000

1200

1400

1600

1800

Baseline 3 months 6 months 9 months 12 months 15 months 18 months

Co

st in

Ru

pee

s

Service Travel & time Family Total

Leading cause of years lived with disability • Unipolar depression = 11.9%• Hearing loss adult onset = 4.6• Iron def anaemia = 4.5• Chronic obstructive airway disease = 3.3• Alcohol use disorders = 3.1• Osteoarthritis =3.0• Schizophrenia =2.8 • Injury =2.8• BPAD =2.5• Asthma =2.1

Needs of persons with mental disorders

NMHP- 1982

1. Availability and accessibility of minimal MH services for all

2. Application of knowledge to general health care and social development

3. Stimulate Community participation

Approaches:1. Diffusion of mental health skills2. Task distribution

3. Equity4. Integration of services5. Linkage with community development

National Mental Health Programme (1982

Long-Stay Facilities

&Specialist Services

Community MentalHealth Services

PsychiatricServices in General Hospitals

Mental Health ServicesThrough PHC

Informal Community Care

Self Care

highhigh

lowlow highhigh

lowlow

COSTSCOSTSFREQUENCY FREQUENCY OF NEEDOF NEED

Optimal mix of different mental health services Optimal mix of different mental health services (WHO 2003(WHO 2003))

QUANTITIY OF SERVICES NEEDEDQUANTITIY OF SERVICES NEEDED

Some important insights

• Community care is possible • Economical and effective • Non mental health professional can partner with

mental health professionals to deliver such a care.

• Community accepts the approach to care • Ineffective implementation is due to systemic,

professionals and inadequate use of resources.

IEC-Manual for Health workers

IEC-Manual for medical officers

Ten features of mental disorder- Flip charts and posters

Interactive computer-based video training modules (6 CDs)

Institutional response to mental health problems.

• Mental Health Problems are large in magnitude • Challenge of mental health care is essentially

collective responsibility of the Government, Civil society and Non-governmental voluntary agencies

• Community based approach to mental health care is critical to reach the masses

• Integrating mental health care into general health care is the key strategy

Community care in India-DMHP

• 123 DMHP as part of 10th 5 year plan.• DMHP will extended to all the district in the

country in the 11th plan period period.• A sum of 1089 crores will allocated for the

mental health program • Current approaches to provide community

care through DMHP uses restrategized methods

Mental Disorders and poverty

Mental health gap action program • WHO launched 2008• Program to reduce treatment

gap • Up Scaling of services • Asserts that with proper

care, psychosocial assistance and medication, tens of millions could be treated for depression, schizophrenia, and epilepsy, prevented from suicide and begin to lead normal lives– even where resources are scarce.

Changing paradigm in mental health • Technical – political response • Exclusion – inclusion • Individual to public health approach • Hospitalization – Ambulatory to primary

care • Individual action to team work • Hospital – community

Gaps in mental health

• Promotion and prevention • Access to quality care • Policy and financing • Human rights • Values and Knowledge

Institutional response- continued • Man power resource development –

increase in the number of psychiatrist by substantial increase in PG training centres

• Innovative approaches to fill the void- training public health personnel to provide mental health care at PHC level and to manage mental health care programs at district level.

• Deinstitutionalization (Italy, 1978)• Care in the community• Partnership with consumers• Partnership with families• Human rights

International Developments

Psychiatric beds and professional

Psych beds World S-E- Asia India

Total 1.69 0.33 0.25

MH 1.16 0.27 0.2

GH 0.33 0.03 0.05

Others 0.20 0.03 0.01

Psychiatrists 1.20 0.20 0.08

NS 0.20 0.03 0.06

P Nurses 2.0 0.10 0.05

Psychologist 0.60 0.03 0.03

SW 0.40 0.04 0.03

Beds/10T Professional One lakh

Barriers to care • Though cost effective treatments exist • Serious mental illness is not recognized• Benefits of treatment not well understood • Policy makers, insurance companies, health and

labour policies, General public all discriminate between physical and mental disorders

• LAMIC allocate less 1% health expenditure to mental health

• Consequently, community care, policy, legislation and treatment does not get the priority they deserve

Evaluation Barriers in DMHP

Administrative Barriers Lack of clarity in guidelines Lack of manpower resources Motivational barriers General Issues

Extension of DMHP • 1996-1997 = 4 Districts

• 1997-1998= 7 Districts

• 1998-1999= 5 Districts

• 1999-2000= 4 Districts

• 2000-2001= 7 Districts

• 2003-2004= 22 Districts

• 2005-2006=94 Districts

• 2007-2012=123 Districts

MENTAL HEALTH - NEW UNDERSTANDING

- NEW HOPE

WORLD HEALTH REPORT 2001

1. Provide treatment in primary care

2. Make psychotropic medicines available

3. Provide care in the community

4. Educate the public5. Involve communities, families and

consumers

RECOMMENDATIONS OF WHR 2001

6. Establish National Policies, Legislation7. Develop human resources8. Link with other sectors9. Monitor community mental health10. Support more research

WHR 2001 – RECOMMENDATIONS

LOOKING AHEADCHALLENGES

1. Very uneven distribution of resources across states / UTs.2. Low human resources for mental

health care3. Poor UG training in Psychiatry4. Lack of welfare programmes5. Public ignorance6. Growth of private sector

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

community resources• Integration of services• Using technology to improve access to care

OPPORTUNITIES

Conclusions • Mental Health Problems are common and

universal • There is no health care without mental

health care• Mental Disorders are disabling and

burdensome • Effective and safe interventions are

available in the country • Integrating mental health care with general

health services is an important strategy

Conclusions- continued • Strengthening medical colleges and

development of regional institutes of mental health is crucial for increase in mental health manpower resource

• Considering and implementing innovative approaches to fill the void in manpower is an important short term measure.

• Development of telemedicine facilities to disseminate knowledge , skills is of parmount importance

Conclusions- continued

• Empowering families to strengthen partnership with service providers.

• Investing on data base of people with mental health problems to facilitate accurate estimation of treatment gap.

• Intensification of IEC activities • Research to understand outcomes of

interventions. • Upgrading resource material so as to incorporate

recent developments • Professional commitment to incorporate research

evidence into service delivery.