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Trends and issues in community mental health programs in India: The Ranchi Institute of Neuropsychiatry and Allied Sciences experience
Deepak Kumar Giri1, Suprakash Chaudhury2, Prashanta Kumar Chakraborty1
1 Department of Psychiatry, Ranchi Institute of Neuropsychiatry and Allied Sciences, Ranchi, Jharkhand, India
2 Department of Psychiatry, Dr. D. Y. Patil Medical College, Dr. D. Y. Patil Vidyapeeth, Pune, Maharashtra, India
|Date of Submission||03-Mar-2021|
|Date of Acceptance||22-Mar-2021|
|Date of Web Publication||10-Jun-2021|
Department of Psychiatry, Dr. D. Y. Patil Medical College, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune - 411 018, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Psychiatric disorders are among the leading causes of disability the world over. With the World Health Organization, spearheading the crusade to incorporate the mental health component into primary health care, developing countries also have accepted the need for community care of patients with psychiatric disorders. Since independence various initiatives by the government has led to a significant change in the place of mental health care as part of the general health care. At the time of independence apart from mental hospitals, there was practically no organized mental health care. Since then General Hospital Psychiatry units and also Psychiatric Nursing homes have started. Currently, mental health issues are actively seen as part of the public agenda in the various forms. The overall effect has been the movement to recognize mental health as an important issue in the community and services to move beyond mental hospital care to care to the community. Majority of population in Jharkhand is residing in rural areas. Due to the lack of proper communications and infrastructure, Ranchi Institute of Neuropsychiatry and Allied Sciences (RINPAS) had started community outreach program way back in 1999. At present, these centers are running in four different areas of the state with great success. RINPAS experience shows that how even with resource constraints, quality services can be provided to unreached population.
Keywords: Community outreach, community psychiatry, epilepsy, psychiatric disorders
|How to cite this URL:|
Giri DK, Chaudhury S, Chakraborty PK. Trends and issues in community mental health programs in India: The Ranchi Institute of Neuropsychiatry and Allied Sciences experience. Ind Psychiatry J [Epub ahead of print] [cited 2021 Jun 15]. Available from: https://www.industrialpsychiatry.org/preprintarticle.asp?id=318120
The National Mental Health Survey reported the prevalence of psychiatric morbidity in India as 10.6%. The survey also observed that about 150 million people are in need of active psychiatric treatment and nearly 12 million people are living with serious mental disorders in India. This clearly brings out the enormity of the problem. Even the World Health Organization (WHO) estimated that globally psychiatric disorders affect one in four persons. India has been progressively developing basic health services infrastructure since independence. The overall goal has been to go as near the homes as possible instead of large numbers gravitating toward centralized hospitals.
Community mental health services aim to treat people with mental disorders in their homes or domiciliary settings, instead of a psychiatric hospital. The provision of community-based treatment services to persons with psychiatric disorders is not a new concept. The Geel Colony in North Belgium has been providing shelter to persons with serious mental illnesses under community sponsorship since as early as 13th century.
Three factors served as inspirations for the community mental health movement in India. The first was the identification in Western countries that following long-term hospitalization psychiatric patients develop institutionalization or social breakdown syndrome and had difficulty in reintegrating into the community. Therefore, prolonged treatment of psychiatry patients in Mental hospital may in fact was counterproductive. Second is the recognition that the cost of delivering psychiatric care by well-trained doctors located in hospitals is prohibitive. As a result, developing countries like India are not likely to have enough trained professionals and infrastructure to deliver services through conventional methods in the foreseeable future. The third was the discovery in other developing countries that para- and nonprofessionals could be trained with innovative, short, and simple courses to deliver reasonably adequate mental health care. This greatly reduces the cost of delivery of mental health care, albeit with some compromises.,
Since independence various initiatives by the government has led to a significant change in the place of mental health care as part of the general health care. At the time of independence apart from mental hospitals, there was practically no organized mental health care. Since then General Hospital Psychiatry units and also Psychiatric Nursing homes have started. Currently, mental health issues are actively seen as a part of the public agenda in the various forms. Some of the examples are:
Formulation of National Mental Health Programme (NMHP); incorporation of mental health care in primary health care (PHC) at the district levels; Supreme Court judgments about mental hospitals and attempted suicide; Adoption of Persons with Disabilities Act 1995 and the Mental Health Care Act 2017; Initiatives of voluntary agencies in the areas of alcohol and drug dependence, rehabilitation, and suicide prevention and wide media coverage of mental health issues. The overall effect has been the movement to recognize mental health as an important issue in the community and services to move beyond mental hospital care to care to the community.
Before independence, the health services had not formulated any plans for the care of the persons with psychiatric disorders. Although the “asylums” had been renamed as hospitals, the approach was still custodial rather than therapeutic. Moreover, due to overcrowding combined with paucity of medical personnel and infrastructure, the condition of many of the mental hospitals was abysmal. Around the time of independence, the situation with regard to mental health services is best presented in the recommendation of Bhore Committee (1946): even if the prevalence of psychiatric disorders in India is assumed to be 2 per thousand of the population 8,700,000 psychiatric hospital beds would be needed. However, the actual number of beds for psychiatric patients was about 10,000. As compared to a ratio of one psychiatric hospital bed to 300 population in the UK, in India, the in the ratio is one bed to approximately 40,000 populations. The next review of the health situation in the country was done by the Mudaliar Committee (1962). This committee reviewed the progress made subsequent to the Bhore Committee, i.e., in the period of two decades and observed that reliable statistics regarding the incidence of mental morbidity in India are not available. The total beds available in Mental Hospitals were only 15,000. General hospitals lacked facilities for the treatment of psychosomatic disease. As a result of the recommendations in the Ministry of Health, a mental health advisory group was created. Further, treatment facilities for psychiatric disorders were made available at a number of district hospitals. Subsequently, the progress of health care in the country was reviewed by the Srivastava Committee (1974). One of the recommendations of the committee was the introduction of Community Health Volunteer (CHV) scheme. The plan was to train one CHV for about 1000 population. Mental health was included in the training of CHVs. The WHO conference at Alma Ata, 1978, was a major event in the international health planning, and a turning point in the organization of health services in developing countries. As a result of the recommendations, parliament adopted The National Health Policy (1983) to provide a new direction for health planning in India. One of the main recommendations was the increased emphasis on community participation and empowerment of the community for health.
| Community Psychiatry in India|| |
Community psychiatry in India originated from the work of Dr. Vidya Sagar who in the late 1950s began to involve family members in the treatment of mentally ill patients who were admitted to the Amritsar Mental Hospital. Due to this patients did not feel that they had been abandoned at a strange place, resulting in less hostility. The relatives observed that patients with mental illness improved with treatment. They also were taught the basic principles of mental health care.
The first general hospital psychiatric units (GHPU) began functioning in 1933 at the R.G. Kar Medical College Calcutta, followed by one at JJ Hospital Bombay (1938), Patna Medical College hospital (1939), and KEM hospital Bombay (1940). Army Medical Corps also played a part with the establishment of GHPUs in Military Hospitals during World War II. However, most of them were established in the 1960s because with the introduction of antipsychotic drugs the aggressive and violent behavior of psychiatric patients could be rapidly controlled so that it was possible to treat psychiatric patients in the general hospitals. As a result of the GHPUs, psychiatric treatment became easily accessible and acceptable to the general population and reduced the social stigma. These units have brought a change in the mental health training of professionals. In the last five decades, a large number of GHPUs have started functioning all over the country. Most of them are 30–50 bed units. As of now, there are over 3000 beds under this facility in different parts of the country. Subsequently, this was extended to districts with the setting up of district hospital psychiatric units. Initially, taken up systematically in Kerala and Tamil Nadu, this is also being gradually extended to other states. Thereafter, advances in mental health services in India have shifted the emphasis to the community care paradigm. The thrust for this approach came from the following sources.
- Obligation of the country to provide health services to all
- Availability of a large infrastructure of general health services (PHC system)
- The Alma Ata declaration of PHC
- The approach to utilize rural Doctors and Multipurpose Workers to provide health care to rural people
- Recognition of the amount of severe mental disorders in the community (at least 1%) and availability of simple interventions for these conditions
- Experiences of community mental health care at Bangalore and Chandigarh centers.
| Rural Psychiatric Services|| |
The incorporation of psychiatric services as an essential part of PHC has been a key improvement in the health services in India. This was based on projects undertaken by NMHANS, Bangalore and PGI, Chandigarh.
| The Bellary project|| |
NIMHANS launched a Community Psychiatry program in 1976. The aim of the rural project was to create appropriate training programs for the doctors and the multipurpose workers so that the trained personnel of the PHC could provide basic psychiatric care. The team initially studied the needs of the rural population in one PHC (1975–1980). This was carried out by identifying the mentally ill persons in their homes through key informants and those attending the general health facilities. Thereafter, a pilot project was undertaken at one PHC with a population of 100,000 to study to possibility of incorporating psychiatric care with PHC (1980–1986). Following this, a model program covering a district with a population of 2 million was developed.,,
However, the success of the Bellary model has been questioned. The program officer in charge of the Bellary model spoke of the difficulties in diagnosing psychiatric disorders, selecting suitable medication, and its dose as well as managing adverse effects of medicines. There were also administrative problems such as the transfer of personnel who had been trained, low motivation of staff, and the irregular supply of drugs. He also described steps to improve the functioning of the model program, but before he could carry out these measures, he also was transferred. Enquiry from people working in the Bellary district revealed that the model unfortunately fizzled away in the very district where it was first tried out.
| Raipur Rani Project|| |
The Chardigarh efforts to prepare a model for rural psychiatric services were initiated in 1975, based on the observation that hospital-based psychiatric services were inadequately utilized, especially by the rural population. The essential advance in this model was the incorporation of psychiatric care with general medical care, thus providing basic mental health care at the doorstep. In addition, this project gave an opportunity to comprehend the needs of the rural patients with psychiatric disorders and evaluate mechanisms of providing psychiatric care using the available resources., Based on the experience of providing mental health care through different methods as well as the overall goals of health care in general, the government launched the NMHP in 1982.
One of the most important initiatives undertaken under the NMHP was the integration of mental health with PHC at the district level. To implement the NMHP at district level NIMHANS launched a pilot project in the Bellary district in 1985. Later, in 1996–1997, the DMHP was implemented in one district each in Andhra Pradesh, Assam, Rajasthan, and Tamil Nadu. During the ninth 5-year plan, it was extended to 27 districts across 22 states/union territories. The NMHP was modified during the tenth 5-year plan with the expansion of DMHP to 110 districts. In addition, upgrading of 23 government mental hospitals, modernization of psychiatry departments of 71 government medical colleges/general hospitals along with research, and training in mental health service delivery was funded. There was emphasis on execution of information, education, and communication activities. Is the DMHP, the panacea for rural mental health? The jury is still out, but experts have pointed out few drawbacks. The most serious being low rates (20%–40%) of identification of psychiatric disorders, poor training of staff, poor training, motivation and retention of staff, and overburdened PHC doctors being allotted extra work.
| The Barwani Experiment|| |
For the delivery of mental health care services in this experiment, a three tied model was proposed. The outpatient services of hospitals were the first tier. Mental health workers from the local community were the second tier. Local health groups consisting of family members and key people in the community formed the third tier. The major result was that treatment compliance was much higher in the experimental group (64%) compared to a group that only attended the psychiatry outpatient service (46%). The improved compliance was due to improved communication with patients and their families by the mental health workers, who belonged to the local community, thereby promoting treatment adherence. Prior to this two landmark projects of Raipur Rani and Sakalwara carried out in north and south India emphasized the necessity as well as practicability of effectual community psychiatry outreach services in the country.
| The Camp Approach to Community Psychiatry|| |
For many decades in India, the health camp approach has been used to provide psychiatric services to rural population. These camps provide mental health-care services to a remote population who are unable to access hospital services. Usually, the camps are for 1 day, although a few have included follow-up. The camp approach has often been used for treatment of addictions.
| Jharkhand Scenario|| |
State of Jharkhand has a population of about 27 million. Rich in natural sources and home to some major industries; but it remains relatively backward with regard to infrastructures and communications. Unemployment is high and health facilities are inadequate. Most of the 22 districts in the state have no mental health care facilities at all. Furthermore, major population of Jharkhand is residing in rural areas. To manage rural population is problematic because of lack of proper communications to reach interiors and shortage of trained professionals in the state. Most of the trained professional and those in the practice have settled down in cities. The advances made in the management of psychiatric and neurological diseases have not been made available to rural population. The challenges to mental health care in India identified by Srinivasamurthy are particularly applicable to Jharkhand. There is a large “unmet need” for psychiatric care in the community. There is a lack of understanding that psychiatric disorders require medical intervention and limited acceptance of psychiatric treatment in the general population. There is a shortage of psychiatrists, psychiatric nurses and clinical psychologists and district mental health facilities. The available services are poorly utilized by the needy. There is a lack of rehabilitation facilities and half way homes that may help in reintegration of psychiatric patients in the community. Institutionalized mechanisms for organization of mental health care are lacking.
| Ranchi Institute of Neuropsychiatry and Allied Sciences Experience|| |
Ranchi Institute of Neuropsychiatry and Allied Sciences (RINPAS) is a tertiary care teaching hospital and research institute situated in the outskirts of Ranchi. Knowing its limitation to reach unreached population of the state and considering lack of trained professionals, RINPAS started community outreach program in 1999. Initially, the program was started at Jonha and other nearby villages of Ranchi district. Team from RINPAS used to visit these centers every week. Members used to make door to door visit of every village, meet village leaders, and tried to convince family members to come to the center. Initially attendance in these centers was very less but gradually people started coming seeing the response of medication and patients becoming asymptomatic and active member of the family.
Encouraged by this fact RINPAS in year 2003 started three more centers at Khunti, Sariakella – Kharsawan, and Hazaribagh. The main criterion of selection of place was lack of services. The objectives of starting these community outreach program are to provide services in the rural areas, to study the efficacy of these services, to involve the community in organization of services and provide free medicines to the needy and poor patients. After selecting the place, Nongovernmental Organizations (NGOs) having special interest in the field of mental health care were selected. These NGOs help in spreading the news about the clinics, organization of camps, and in identifying mental patients and helping in follow-up treatment. To develop better understanding and integration of professionals and community members of the NGOs from the same area are selected. People were informed that the mental illness require prolonged uninterrupted treatment. If the patient discontinues the drugs, he will not improve and/or after improvement will have relapses quickly.
A team consisting of three psychiatrists, physician, psychiatric Social Worker (PSW), nurses, and postgraduate trainees from RINPAS attend the monthly camps regularly. The same team continues to attend the camp except for the trainees who change periodically. The date, time, and place of camps are fixed. Sociodemographic and clinical details are recorded in a structured pro forma by postgraduate trainees. After completion of pro forma, patients are sent to psychiatrist for diagnosis and treatment. After examining the patient, the psychiatrist prescribe medicines or refer cases to RINPAS for further management and necessary investigations [Figure 1]. Medicines for 1 month are distributed free of cost to these patients. In addition, patients are also counseled by clinical psychologist and social workers. Workers from the NGOs are from local population who can interact with patient and their family members. They identify these patients; teach them about the illness and monitor follow-up. RINPAS conducts training sessions for these workers from time to time.
|Figure 1: Ranchi Institute of Neuropsychiatry and Allied Sciences model of community outreach program|
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Initially, the Community Outreach Programme was started in Jonha in 1999 and gradually became popular. Subsequently, camps were started at three other centers, namely, Khunti, Saraikella-Kharsawan, and Hazaribag. During the period September 2003–May 2006, a total of 39,829 patients attended 131 community outreach camps conducted by RINPAS. The distribution of camps was as follows: 33 at Jonha, 33 at Khunti, 32 at Saraikella, and 33 at Hazaribagh. The year-wise patient attendance at these camps is given in [Figure 2]. The average attendance at each camp during the period was 298. However, during the past 6 months, the average attendance has been significantly higher at 457 highlighting the increasing popularity of these camps as shown in [Figure 3]. Community-based services that tap into local environments not only reduce the duration of untreated psychosis but also provide improved long-term outcomes for patients with first-episode psychosis, as observed in two new studies.,
|Figure 2: Attendance at Ranchi Institute of Neuropsychiatry and Allied Sciences community outreach camps|
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|Figure 3: Average attendance in Ranchi Institute of Neuropsychiatry and Allied Sciences community outreach camps|
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Breakup of male and female patient [Figure 4] showed that male patients outnumber female patients in all the centers. This may be due to the fact that males being the main bread-earner are attended more promptly. Out of 38,998 patients seen in the entire period highest number were from Hazaribag (38.06%), followed by Khunti (22.74%), Saraikella (21.78%), and Jonha (17.39%). The broad diagnostic group of patients' attending these clinics is shown in [Figure 5]. The most common disorder was epilepsy (56.53%). Highest numbers of epilepsy patients are in Hazaribag (7836), while in Saraikella psychiatric disorder outnumbers epilepsy patients. Others which include medical illnesses constitute major group of patients in Jonha (34.44%). Reason behind this is probably because of its distance from Ranchi, the nearest place where psychiatric consultation is available. Another reason may be due to people of adjoining districts are also availing the outreach facilities. On the other hand, patients from Jonha and Khunti are also coming directly to RINPAS for psychiatric consultation, while people from Saraikella are also availing psychiatric facilities at Jamshedpur.
|Figure 4: Break up of male and female patients attending Ranchi Institute of Neuropsychiatry and Allied Sciences community outreach camps|
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|Figure 5: Disease patterns in patients attending Ranchi Institute of Neuropsychiatry and Allied Sciences community outreach camps|
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Epilepsy constitutes the major portion of patients in almost all the centers, except Saraikella. These results are similar to the report from NIMHANS extension services. It is estimated that, in India, about 10 million patients with epilepsy living in India. Many of them are not receiving appropriate treatment. In Jonha patient suffering with physical illnesses constitute about 34% of patients. Community outreach programmes where first stated in Jonha. Initially, these patients also attended the centers. Gradually, by proper counseling, these patients were advised to attend local primary health centers. In Saraikella, major group is suffering from psychiatric illness. May be because of industrial belt in that area more and more patients are suffering from psychiatric illness.
| Conclusion|| |
The experience gained through these extension services has confirmed that majority of these serious psychoses and epilepsy can be managed without sophisticated investigations. The involvement of the NGOs has helped in eradicating the misconceptions, stigma, and provides better awareness regarding mental illness. This has also proved that crucial aspects of management of these patients are continuous, uninterrupted, prolonged medication and the involvement of family members in the management process. Under the existing circumstances and poor resources, the professionals can provide services to the neglected population in the rural areas by starting extension services as one of the approach. Psychiatrists even in academic institutions can spare 1 day in a week to provide extension services at four rural areas in a month and thereby ensure regular and continuous services. If all major hospitals and academic institutions were to take this up, a sea change will occur in rural psychiatric services. Our experience showed that monthly follow-up is adequate and for the vast majority of patients more frequent treatment follow-ups were not needed. By this approach, services of highly trained psychiatric doctors are available at low cost and easily accessible by the majority of the population. The experience gained through these extension services clearly showed that, with minimal resources, psychiatric services can be provided to most needed population. More and more involvement of local people is needed and wide coverage in media along with time to time training courses for health workers is needed for success of such type of program.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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