Professional Documents
Culture Documents
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
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.
HISTORY
Ancient
Vatonmad(schizophrenia)
Pittonmad(mania)
Kaphonmad(depression)
Sannipatonmad(delirium/hysteria)
HISTORY
2.
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
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.
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
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.
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.
WESTERN INFLUENCES
Phillippe
WESTERN INFLUENCES
Psychiatrists,family
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
WESTERN INFLUENCES
In
WESTERN INFLUENCES
The
WESTERN INFLUENCES
In
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
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.
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
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
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
NIMHANS Crash
Programme
Dr
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
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.
Alternatives to
institutional care
Developed
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
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
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
OBJECTIVES
To
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:
SUBPROGRAMMES
Liaison with local school teacher & parents
regarding MR & behaviour problems in
children.
Counselling in problems related to alcohol &
drug abuse.
2.
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.
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
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
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
Bellary model
5
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
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.
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.
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
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
distribution of resources
across states:
National level implementation difficult
Non
of healthcare in the
1990s
India has least amount of public funding for
health care in 5% of GDP, 83% comes
from private
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
Erwady Tragedy
All
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.
Plan of action
Organising services :
Recommended by WHO 2001 report
Provide mental health in primary
care :
1.
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
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
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
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.
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
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
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
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
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
THANK YOU