Community Psychiatry - Dr Jateen - 3-7-15 (1).pptx

8/16/2019 Community Psychiatry - Dr Jateen - 3-7-15 (1).pptx

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Community Psychiatry

ByDr Jateen Ukrani

DNB Resident, VIMHANS Hospital

Chairperson – Dr Santosh God D!M,DNB


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World scenario(1900 – 1950)

Mental Hy$iene Mo%e&ent

Philippe Pinel WilliamTuke

BenjaminRush

AdolfMeyer

0


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Three Revolutions in Psychiatry

1st re%oltion

•The age of enlightenment following the&iddle a$es, )hen &ental illness )as%ie)ed as a "onse2en"e o# sin and)it"h"ra#t

/nd re%oltion

• the development of psychoanalysis)hi"h o3ered hope #or a "asati%ee4planation o# psy"hiatri" disorders(

0rd re%oltion

• Born in 1560, the community psychiatry&o%e&ent has 'een hailed as the third

psychiatric revolution.


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But

-he "o&&nity psy"hiatry &o%e&ent )as&ade possi'le 'y another re%oltion, thead%ent o# psy"hophar&a"olo$y(

So it &ay 'e &ore appropriate to re#er to

"o&&nity psy"hiatry as the fourth psychiatricrevolution.


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Deinstitutionalization

-he period #ollo)in$ 1577 )as an era o#deinstittionalisation in USA and other

8estern "ontries, "onsistin$ o# dis"har$in$&entally ill patients #ro& &ental hospitals, to'e "ared #or in the "o&&nity spported 'y"o&&nity &ental health "entres(

-his pro%ided an i&pets to the de%elop&ento# "o&&nity psy"hiatry(


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Deinstitutionalization


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1962 - Ken Kesey publishedOne FlewOver the Cuckoo's Nest

A +"tional storya'ot a'ses in a&ental hospital(

It dra&ati:ed"onditions andhelped trn p'li"opinion a$ainstele"tro;sho"k

therapy, "o&&onlysed at the ti&e


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The Community Mental Health Act of 1963

I a& proposin$ a ne) approa"h to &ental illness and Mental retardation( -his approa"h is desi$ned, in lar$e &easre, to se #ederal resor"es tosti&late state, lo"al, and pri%ate a"tion( 8hen "arried ot, relian"e on the

"old &er"y o# "stodial isolation )ill 'e spplanted 'y the open )ar&th o#"o&&nity "on"ern and "apa'ility(.


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The rise & fall of Community Mental HealthMovement As a part o# this approa"h 'eds in state psy"hiatri" hospitals

red"ed #ro& 7,6>,>>> in 1577 to 61,>>> in 155/(

Bt, o%er a period o# ti&e this approa"h #ell into disrepte deto the #ollo)in$ reasons?

1(Se%erely ill patients )ho )ere released #ro& the hospitalsdidn*t $o to CMHCs( -hey )ere not a""epted 'y their #a&ilies(( -his reslted in trans;instittionali:ation @ )ere ne$le"ted(

/( -he sta3 "oldn*t "on%in"e the athorities that the pre%enti%e&easres led to de"rease in the &or'idity(

0(Cost;e3e"ti%eness )as not pro%ed(

(

Con#sion e4isted re$ardin$ the responsi'ility(

As a result the community psychiatry movement in USAhad its rise & fall between 1950s & 0s!


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Attitude towards Family

15> ; ;


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Development of Community

Psychiatry in India


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BHORE COMMITTEE REPORT 1947

(e%en i# theproportion o# patients 'etaken as / per thosandpoplation in India, hospitala""o&&odation shold 'e

a%aila'le #or F,>>,>>>&ental patients as a$ainstthe e4istin$ pro%ision #or alittle o%er 1>,>>> 'eds #or

the "ontry as )hole.

"uantitative #ap


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Formation of AIIMH to reduce QuantitativeGap

$n 195% the All $ndia $nstitute of 'ental (ealth was

established which in 19)% became an autonomous$nstitute called *$'(A*S!


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Condition of Mental Hospitals

•

A)ay #ro& the "o&&nity• D&pin$ $rond #or the &entally ill

• Cstodial rather than therapeti"

• Rn 'y )ardens* rather than do"tors*

• ater o'ser%ations; !oor h&an ri$hts re"ord

• "ualitative #aps

16


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Dr Vidya Sagar and Amritsar FamilyInvolvement Histori"ally, in India,

#a&ilies )ere part o# thetreat&ent pro"ess at ati&e )hen #a&ilyin%ol%e&ent )as

"onsidered as to4i"* in&any other parts o# the)orld(

Dr Vidya Sa$ar initiatedthe trend at A&ritsarMental Hospital, )ho isa""lai&ed to 'e the #athero# #a&ily therapy in India(


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MUDALIAR COMMITTEE REPORT1964

( Relia'lestatisti"s re$ardin$ thein"iden"e o# &ental&or'idity in India are

not a%aila'le( asa$ainst the total needo# the n&'er o# 'edsa%aila'le in &ental

hospitals in india isonly 17,>>>.


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MENTAL HEALTH DISORDERS IN INDIA

All kinds o# &ental and 'eha%ioral disorders )ere

)idely pre%alent in Indian poplation( Re%ie) o# the sitation o# psy"hiatri" disorders in

India hi$hli$hted the gross neglect of mentaldisorders Neki and

Carstairs, 1975E de to? !er%asi%e sti$&a, )idespread &is"on"eptions

Grossly inade2ate 'd$ets #or &ental health"are

A"te shorta$e o# trained &ental health personnel

-hey Con"lded that

n developing countries !asic mental health careshould !e decentralized and integrated with thee"isting system of general health services#.


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FACTORS CONTRIBUTING TO THE

DRAFTING OF THE NATIONALMENTAL HEALTH PROGRAMME FORINDIA


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Recommendation From WHO

Re"o&&endations 'y an e4pert "o&&ittee onor$ani:ation o# &ental health ser%i"es in de%elopin$

"ontries. 8orld Health r$ani:ation( 157E?Basic mental health care should be integrated withgeneral health serices and be proided by non!specialized health workers at all leels"


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Starting of First“Community MentalHealth Unit” by NIMHANS , Bangalore

#A$A%WARA PR&'()T +


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Raipur Rani Project

Chandi$arh !ro$ra&? 8as "arried ot in Raipr rani 'lo"k, A&'ala

distri"t o# Haryana state drin$ 157;15F/

It )as a part o# 8H proKe"t titled Strate$ies

#or e4tendin$ &ental health "are. Syste& o# priority sele"tion to train the

e4istin$ pri&ary health "are personnel

-his e4perien"e reslted in the pra"ti"al

&anal o# Mental disorders and Mental healthed"ation &aterials(

,ocus on testin- and evaluatin-

models!/0


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Aimed to achiee *+ealth for All by

,---. by uniersal proision of primary health care


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Collaboration with ICMR

-o e%alate the #easi'ility o# trainin$ o# !HC sta3 to pro%ide&ental health "are as part o# their rotine )ork

*A.$/*A '*.A (A.(


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*A.$/*A '*.A (A.(P2/#2A'' 3*'(P4 /, $*$A

15F>

•Go%ern&ent o# India #elt the ne"essity o# e%ol%in$ aplan o# a"tion ai&ed at the &ental health "o&ponent o#the National Health !ro$ra&&e(


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National Mental Health Program, 1982

/


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Objectives of NMHP

1E -o ensre the aailability and accessibility ofminimum mental healthcare #or all in the#oreseea'le #tre, parti"larly to the &ost %lnera'leand nderpri%ile$ed se"tions o# the poplation(

/E -o en"ora$e the application of mental health

knowledge in $eneral health"are and in so"ialde%elop&ent(

0E -o pro&ote community participation in the &entalhealth ser%i"e de%elop&ent and to sti&late e3ortsto)ards sel#;help in the "o&&nity(


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Aims of NMHP

-o ensre treat&ent and pre%ention o# &entaland nerolo$i"al disorder(

Use o# &ental health te"hnolo$y

Appli"ation o# &ental health prin"iples in total

national de%elop&ent to i&pro%e 2ality o#li#e(


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Strategies for Implementation of NMHP

Centre to periphery strate-y?

sta'lish&ent and stren$thenin$ o#psy"hiatri" nits in all distri"t hospitals, )ithotpatient "lini"s and &o'ile tea&s rea"hin$

the poplation #or &ental health ser%i"es( Periphery to centre strate-y?

-rainin$ o# an in"reasin$ n&'er o# pri&ary

health "are health personnel in 'asi" &entalhealth skills to pro%ide &ini&& &ental health"are to the people( 8ith a%aila'ility o# re#erralser%i"e(


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Approaches1( Di3sion o# &ental health skills to the periphery o# the health

ser%i"es syste&

/( Inte$ration o# 'asi" &ental health "are into $eneral health

ser%i"es(

0( Appropriate allot&ent o# tasks in &ental health "are #or di3erent

le%els o# health personnel(

( 2ita'le and 'alan"ed territorial distri'tion o# resor"es(

7( inka$e to "o&&nity de%elop&ent(

6( I&pro%e &ental health trainin$ in all instittions, )here &edi"al

and para&edi"al )orkers are trained(


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Achievements in Initial Years:

Workshops for mental health professionals,health directorate officials were held,

sensitization to mental health issues

Preparation of support materials in form of

manuals, health records and health educationmaterials with inputs from NIMHANS, CIP and

PIM!"

#rainin$ for teachers in ps%chiatr%


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Weaknesses

!mphasis on curati&e rather than promotion or

pre&enti&e aspects of mental health

Communit% resources like famil% was not $i&en

due importance No clear cut model for macro implementation


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What happened after 1982?? Adoption o# the national &ental health pro$ra&&e )as a $reat

a"hie%e&ent

Isses le#t n"lear No 'd$etary esti&ates or pro%isions

a"k o# "larity re$ardin$ )ho shold #nd the pro$ra&&e –

Central $o%ern&ent or the state $o%ern&ents )ho perpetallyhad inade2ate #nds #or health "are(

A %ery lke)ar& response L al&ost reKe"tion o# the pro$ra&&e'y psy"hiatrists(

Do'ts )ere e4pressed a'ot the #easi'ility o# i&ple&entin$the pro$ra&&e in lar$er poplations and in real )orld settin$s

2eali8in- that the *'(P was not liely to be

implemented on a lar-er scale without demonstration ofits feasibility in lar-er populations the need forplannin- for the implementation of the pro-ramme at adistrict level was hi-hli-hted(


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Barriers to the Implementation of NMHP

Limited undergraduate training in psychiatry Inadequate mental health human resourcesLack of policy driven epidemiological data and

research driven mental healthcare policies

Limited number of models and their evaluationUneven distribution of resources across states Non-implementation of the MHA !"#$

%rivati&ation of healthcare in the !""'s(


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DISTRICTMENTALHEALTH


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Co&ponents o# the DMH! at Bellary )ere?

trainin$ #or all pri&ary "are sta3in a de"entrali:ed &annerE

pro%ision o# 6 essential psy"hotropi" and anti epilepti" dr$s"hlorpro&a:ine, a&itryptiline, trihe4yphenidyl, inKe"tion

phena:ine dea"onate, pheno'ar'itone and diphenylhydantoinE at all !HCs and s' "entres

a syste& o# si&ple &ental heath "ase re"ords, a syste& o#&onthly reportin$

re$lar &onitorin$ and #eed 'a"k #ro& the distri"t le%el&ental health tea&

)as reiewed e%ery &onth at the distri"t le%el 'y thedistri"t health o"er drin$ the &onthly &eetin$ o# pri&aryhealth "entre &edi"al o"ers(

DISTRICT MENTAL HEALTHPROGRAMME (DMHP)

DISTRICTMENTALHEALTH


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DISTRICT MENTAL HEALTHPROGRAMME (DMHP) in 9th five yearplan (1997-2002)

n 199$ the %&'(),*ovt. &f ndia formulated districtmental health programme +under national mentalhealth programme as a fully centrally funded

programme"i&ple&ented in t)o phases,

!hase I taken p drin$ 1556;5,

!hase II 'e a "ontination o# the pro$ra&&e drin$

the IO >/E(

'd$et line #or i&ple&entation o# the DMH! as a&aKor "o&ponent o# the NMH! )as "reated in 1556Q 1

years a#ter CCH


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an"hed in 1556–5 in #or distri"ts, one ea"h inAndhra !radesh, Assa&, RaKasthan, and -a&ilNad

4panded to / distri"ts 'y end o# 5 th +%e yearplan

At present the pro$ra& is in pla"e in 1/distri"ts/>1/E

DMH! is also 'ein$ started in 0/7 ne) distri"ts

-he "entral $rant #or i&ple&entation o# DMH! perdistri"t )ith a%$ poplation o# /> lakh #or +%eyears )ill 'e Rs( /(7 "rore

>

DISTRICT MENTAL HEALTHPROGRAMME (DMHP)


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DMHP Objectives:

'(

#o Pro&ide sustaina)le )asic mental healthser&ices in communit% and inte$ration of these

with other ser&ices

*( !arl% detection and treatment in communit%

itself +( #o ensure ease of care $i&ers

( #o take pressure off mental hospitals

-( #o reduce sti$ma.( #o reha)ilitate patients within the communit%

/( #o detect ,mana$e 0 refer cases of epileps%


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Components of DMHP

1. Training of medical, paramedical personneland community leaders

2.Community Mental Health care throughexisting infrastructure of the health services

3.Information, Education and Communication(IEC) activities


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Services Offered under DMHP

Distri"t Mental Health -ea& )ill pro%ide ser%i"esto the &entally ill and their #a&ilies as #ollo)s?;

Daily t;patient !DE ser%i"es

-en 'edded in ser%i"es #a"ility I!DE Re#erral ser%i"e

iaison )ith !ri&ary Health Center !HCE

!ro%ide #ollo) p ser%i"e

Co&&nity Sr%ey i# #easi'le Re&o%e sti$&a o# &ental illness 'y "reatin$

a)areness in the "o&&nity

ProgressofCommunityPsychiatry


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Progress of Community Psychiatry1995-2002

4tension o# DMH! to /7 states


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SUPREMECOURTINITIATIVES N


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SUPREME COURT INITIATIVES – NRamdass Committee Report

nlar$e the s"ope to )hole "ontry

&phasis on h&an ri$hts

Responsi'ility o# the state #or &ental health"are

RECOMMENDATIONSOFWHR2001


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RECOMMENDATIONS OF WHR 2001

1( !ro%ide treat&ent in pri&ary "are

/( Make psy"hotropi" &edi"inesa%aila'le

0( !ro%ide "are in the "o&&nity

( d"ate the p'li"

7( In%ol%e "o&&nities, #a&ilies

and "ons&er6( sta'lish National !oli"ies,

e$islation

( De%elop h&an resor"es

F( ink )ith other se"tors

5( Monitor "o&&nity &ental health1>( Spport &ore resear"h

2eport identi:ed that ;one personin every four will be a


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Revised Goals

• Stren$thenin$ Co&&nity and


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Modernization of State RunMental Hospitals

-he assistan"e nder this s"he&e is pro%ided #or&oderni:ation o# state rn &ental hospitals #ro& "stodial"are to "o&prehensi%e &ana$e&ent(

• A one;ti&e $rant )ith a "eilin$ o# Rs(0(>> "rores per hospitalis pro%ided(

• -he $rant "o%ers a"ti%ities s"h as "onstr"tionLrepair o# e4istin$ 'ildin$sE,

pr"hase o# "ots and e2ip&ents,

pro%ision o# in#rastr"tre s"h as )ater; tanks and toilet#a"ilities et"(

• Does not "o%er re"rrin$ e4penses to)ards rnnin$ the&ental hospitals and "ost to)ards dr$s and "ons&a'les(

• Grant is #or &oderni:ation o# the &ental hospitals only andany in"rease in the n&'er o# 'eds in the hospital is notper&itted(


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Up gradation of Psychiatric Wings of MedicalColleges/General Hospitals

%ery &edi"al "olle$e shold ideally ha%e a Depart&ent o#!sy"hiatry )ith

&ini&& o# three #a"lty &e&'ers

inpatient #a"ilities o# a'ot 0> 'eds as per the nor&s laid

do)n 'y the MCI s"he&e #or stren$thenin$ o# the psy"hiatri" )in$s o#

$o%ern&ent &edi"al "olle$esLhospitals )hi"h pro%ides #or aone;ti&e $rant o# Rs(7> lakhs #or p $radation o#in#rastr"tre and e2ip&ent as per the e4istin$ nor&s(

ai& o# the s"he&e is to stren$then the trainin$ #a"ilities #orUG@ !G at !sy"hiatry )in$s o# $o%ern&ent &edi"al"olle$esLhospitals(

$rant "o%ers "onstr"tion o# ne) )ard, repair o# e4istin$)ard, pro"re&ent o# ite&s like "ots, ta'les and e2ip&ents

#or psy"hiatri" se s"h as &odi+ed C-s(


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2007 -2012 – 11th Five Year Plan

• In the OI


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Centres of Excellence (Scheme A)

• Under S"he&e;A?

at least 11 Centres o# 4"ellen"e in &ental health )ereto 'e esta'lished in the IOth plan period 'y p$radin$e4istin$ &ental health instittionsLhospitals(

A $rant o# p to Rs(0> "rores is a%aila'le #or ea"h "entre -he "o&&it&ent to take o%er the entire #ndin$ o# the

s"he&e a#ter the 11th +%e year plan period #ro& thestate $o%ern&ent is re2ired(

-he proposal o# the State Go%ern&ents #or these

"entres &st in"lde de+nite plan )ith ti&elines #orinitiatin$L in"reasin$ !G "orses in !sy"hiatry, Clini"al

!sy"holo$y, !S8 and !sy"hiatri" Nrsin$(


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Setting Up/ Strengthening PG Training Departmentsof Mental Health Specialities (Scheme B)

-o pro%ide #rther i&pets to &anpo)er de%elop&ent inMental Health, Go%ern&ent Medi"al Colle$esL Hospitals arespported to start !G "orses in Mental Health or

to in"rease the intake "apa"ity #or !G trainin$ in MentalHealth(

-he spport in%ol%es "apital )ork #or esta'lishin$Li&pro%in$ &ental health depart&ents

!sy"hiatry, Clini"al !sy"holo$y, !sy"hiatri" So"ial 8ork, and!sy"hiatri" Nrsin$E,

e2ip&ents, tools and 'asi" in#rastr"tre,

spport #or en$a$in$ re2iredLde+"ient #a"lty #orstartin$Lenhan"in$ the !G "orses(

-he spport o# p to Rs( 71 la"s to Rs( 1 "rore per !Gdepart&ent is a%aila'le(


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Strategies 11th Five Year Plan

DMH!; All Distri"ts o# all States

Dire"t #ndin$ o# Distri"ts

!ri%ate Medi"al Colle$es as Nodal Instittions

-rainin$ Distri"t Medi"al "er in Mental Health @

Ad&inistration

n"ora$e !ri%ate !sy"hiatristsL !ra"titioners in

!sy"hiatri" Care(

!'li" !ri%ate !arti"ipation

In"rease Bd$et – 1> o# total Health Bd$et(

7F


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School mental health program

In />1>, this pro$ra& has 'een san"tioned to'e i&ple&ented in all DMH! distri"ts in the"ontry

!ro%ide Class -ea"hers )ith =no)led$e and Skills toIdenti#y &otional, Cond"t !ro'le&s in their stdents

!ro%ide Class -ea"hers )ith a syste& o# re#erral #or

stdents )ith psy"holo$i"al pro'le&s to the Distri"tMental Health -ea& #or inpts and treat&ent(

!ro%ide Class -ea"hers )ith


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Missing links from NMHP till 11 five year plan

1! $nadeFuate provision of care for full ran-e of mentalillness+ no pro%ision #or "hild , adoles"ent and s'stan"ea'se "ases

!Crisis mana-ement and in patient service? -here )as

also a near total a'sen"e o# any "risis inter%ention ser%i"es inthe DMH! ther ser%i"es s"h as a&'latory ser%i"es, day"are, &ental health +rst aid are non;e4istent in the DMH!pro$ra&&e(

! Continuin- care in the community+ -he DMH! does not

pro%ide any #or& o# "ontinin$ "are in the "o&&nity(Conse2ently, the DMH! has #ailed to address the on$oin$health and so"ial "are needs o# persons )ith "hroni" andse%ere &ental illness(


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Principles of NMHP – 12th five year plan


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p y p(2012-2017) -he key prin"iples nderlyin$ the pro$ra&&e "o&ponents are as

#ollo)s ? iE A li#e "orse perspe"ti%e )ith attention to the ni2e needs o#

"hildren, adoles"ents and adlts(

iiE A re"o%ery perspe"ti%e, thro$h pro%ision o# ser%i"es a"ross the"ontin& o# "are and e&po)er&ent o# persons )ith &ental illnessand their "are;$i%ers(

iiiE An e2ity perspe"ti%e thro$h spe"i+" attention to %lnera'le$rops and to ensre $eo$raphi"al a""ess to &ental health ser%i"es 1

i%E An e%iden"e 'ased perspe"ti%e 'y #ollo)in$ esta'lished$idelines and e4perien"es on treat&ents and deli%ery &odels(

%E A health syste&s perspe"ti%e )ith "learly de+ned roles and

responsi'ilities #or ea"h se"tor #ro& "o&&nity to distri"t hospitaland in"ldin$ a "as"adin$ &odel o# "apa"ity 'ildin$ and sper%ision(

%iE A ri$hts 'ased perspe"ti%e to ensre ri$hts o# persons )ith &entalillness are prote"ted and respe"ted 'y &ental health ser%i"es(

Goals&ObjectiveofDMHP–12thfive


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-he -oal of the '(P is to improvehealth and social outcomes related tomental illness

-he primary obHective of the istrict'ental (ealth Pro-ramme is to reducedistress disa'ility and pre&atre &ortalityrelated to &ental illness and enhan"ere"o%ery #ro& &ental illness 'y ensrin$ the

a%aila'ility o# and a""essi'ility to &entalhealth "are #or all in the OIIth !lan period,

parti"larly the &ost %lnera'le andnderpri%ile$ed se"tions o# the poplation(

Goals & Objective of DMHP 12 five year plan (2012-2017)

OtherobjectivesoftheDMHPare:


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Other objectives of the DMHP are:

aE -o red"e the sti$&a atta"hed to)ards &ental illnessQ

'E -o pro&ote "o&&nity parti"ipation in the &ental health ser%i"e de%elop&entand to sti&late e3orts to)ards sel#;help in the "o&&nityQ

"E -o in"rease a""ess to pre%enti%e ser%i"es to the poplation at risk, inparti"lar, addressin$ the risk o# si"ide and atte&pted si"ideQ

dE -o in#or& the person )ith &ental illness,their "are $i%ers, pro#essionals andother stakeholders o# the ri$hts o# persons )ith &ental illness and ensre that

ri$hts are respe"ted drin$ the pro%ision o# "are and ser%i"esQ eE to 'road 'ase &ental health into other related pro$ra&s s"h as RCH, SSA,

)ork pla"e inter%ention and si&ilarQ

#E to ensre a &oti%atin$ and e&po)erin$ )ork pla"e #or sta3 'y allo)in$ anopportnity to i&pro%e their skills and re"o$nition o# their )orkQ

$E to $enerate kno)led$e and e%iden"e related to the deli%ery o# &ental health"are and ser%i"esQ

hE to i&pro%e the in#rastr"tre #or &ental health ser%i"e deli%eryQ

iE -o esta'lish $o%ernan"e, ad&inistrati%e and a""onta'ility &e"hanis&s torealise the a'o%e o'Ke"ti%esQ

f


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Future of Community Psychiatry

%resent situation in the country - "million psychotics ) severely mentally

retarded

! bed for *'''' people

+ime for non-institutional community based mental health care

Limited mental health man po,er not going to increase in required

proportion is an indication to involve non specialists and paraprofessionals

in care of mental ill and handicapped

.ortunately dependable family support system

/ood future for 0%

%olitical ,ill to give funds

%rofessional ,ill to implement NMH%

1ocial ,ill to accept the ill and provide them opportunities to lead an useful

life

6F


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.han @ou for your

Community Psychiatry - Dr Jateen - 3-7-15 (1).pptx

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