Community Psychiatry

COMMUNITY PSYCHIATRY

COMMUNITY PSYCHIATRYPRESENTER : DR. DAVINC/P : DR.SIDDARTH SHETTY23/03/2012

INTRODUCTIONMental disorders :CurseInflictionResult of bad deeds(present/past)Wrong foodUn-understandable predicament to be enduredMental patients fear,disgust, pity/hostility among public

INTRODUCTIONNo effective treatment in pastSocio-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 ages

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

DEFINITIONThus 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 population by :-

DEFINITIONEstablishing population-based needs for treatment & careProviding a service system linking a wide range of resources of adequate capacity, operating in accessible locationsDelivering evidence based treatments to people with mental disorders

HISTORYAncient India attempts to classify mental disorders6th century BC Charaka Samhita unmaadsEndogenous group :Due to body humor changesVatonmad(schizophrenia)Pittonmad(mania)Kaphonmad(depression)Sannipatonmad(delirium/hysteria)

HISTORYDue to mental humors changesRajasonmadTamasonmadDue to changes in bothExogenous group(toxic substances)AdhijonmadVishajonmad

HISTORYApasmara(convulsive disorders)= endogenous unmaada in etiology prohibited, spoiled, unclean food.Exogenous unmaada- alcohol,other substances ,acts offending Gods,sages, other forces.

HISTORYAyurveda emphasized promotion of physical & mental healthPrescribed right life style for Control of passionsFulfilment of basic needsAchievement of life goals Dharma(religion),artha(finance),kama(desire) ,moksha(salvation)

HISTORYMaharishi Patanjali- Ashtanga yoga sutrasCharaka psychophysiological parallelism mind corresponds to body & vice versa.Bhutavidya management of mentally illReligious rituals,exorcism,prayers,herbal medicines(sarpagandha Rauwolfia serpentina, cannabis,alcohol)Food restrictions routinely prescribed.

HISTORYNajabuddin Unhammad(1222 AD)-Unani7 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 SCENARIO18th century period of political instabilityPsychological & social turmoilLunatic asylums established to treat the Englishmen and Indian sepoys employed under the BritishGrowth was parallel to political developments

PRE INDEPENDENCE SCENARIOEstablishment of Lunatic Asylums(1784-1857)1784 Pitts India Bill Activities of EIC under board of controlEarliest mental hospital established at Bombay in 1745 accommodate 30 patientsSurgeon Kenderline started the 1st asylum in Calcutta in 1787Later, a private lunatic asylum was constructed ,recognized by medical board under charge of Surgeon William Dick & rented to EIC.

PRE INDEPENDENCE SCENARIO1st government run lunatic asylum -17 April 1795 at Monghyr,Bihar for insane soldiers1st 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 SCENARIOBut mentally ill from general population were taken care of by local communities , traditional Indian medicine doctors Ayurveda ,Unani

PRE INDEPENDENCE SCENARIOGrowth of mental asylums and humanistic approach(1858-1919)1858 enactment of 1st 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 SCENARIOTechniques 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 new changes

PRE INDEPENDENCE SCENARIO3 Significant developments :1905 Lord Morley transferred control from Inspector General of Prisons to Directorate of Health Services & Civil Surgeons.1906 Central Supervision system contemplatedSpecialists in psychiatry full time doctors1912 Indian Lunacy Act Central legislationGrowing concern among public about poor & unhygienic conditions in hospitals

PRE INDEPENDENCE SCENARIO1912 Capital shifted to DelhiEuropean 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 Berkeley Hill

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

PRE INDEPENDENCE SCENARIOG S Bose Indian Psychoanalytical Association(1922)Berkeley Indian Association for Mental Hygiene,RanchiPsychoanalysis for British patients of WW1Cardiasol-induced seizure treatment-1938ECT 1943Psychosurgery -1947Rauwolfia extracts late 1940s

PRE INDEPENDENCE SCENARIOEmphasis shifted from custodial care to curative approachEfforts to train psychiatrists and nursing personnelInitial attempts to establish direct links with patients family in the form of family units

PRE INDEPENDENCE SCENARIOCommunity psychiatry movement 3rd 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 SCENARIOInspiration for community mental health movement in India - 3 main sources :Realization in Western countries Institution based psychiatry is expensive +no sufficient man power & facilities in India.Para & non professionals ,after simple ,short training could deliver adequate mental health care.

WESTERN INFLUENCESPhillippe 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 INFLUENCESPsychiatrists,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 INFLUENCES1955-1980 era of deinstitutionalization in the West.1961 Action for mental health1963 JF Kennedy establish community mental health centresEach catering 75k populationRange of services-OP,IP,Emergency,educationMultidisciplinary team Psychiatrists,clin. Psychologists,social workers,nurses, occupational therapists

WESTERN INFLUENCESItaly - 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 INFLUENCESIn 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 INFLUENCESThe 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 INFLUENCESIn USA ,State Hospital beds -5.6lakh61k in 1992Over time ,approach went into disrepute because :Several ill patients not accepted by families(trans-institutionalisation) nursing homes/board & care institutions-neglectedPeople understood that severe mental disorders were not preventable

WESTERN INFLUENCESClaim that community care was cheaper & better not establishedConfusion regarding responsibility of care of mentally ill Govt?,Family?,Hospitals?,social institutions?

Basic Model of Community Mental Health1967 Gerald CaplanResponsibility to a population for mental health care deliveryTreatment close to the patient in community based centresProvision of comprehensive servicesMulti disciplinary team approach

Providing continuity of careEmphasis on prevention as well as treatmentAvoidance of unnecessary hospitalization.

Community mental health in IndiaTill 1946 ,government approach was to establish custodial centres for a small percentage of ill individuals1920 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 IndiaBhore 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 hospitalsBed ratio -1:40kReport laid foundation by combining both top down & bottom up approachesSubstantive emphasis on mental health issues.

DR. VIDYASAGARS CONTRIBUTIONDr. Vidya Sagar pioneer of community psychiatryInvolved 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 careEvery evening, he would assemble all for an open case-conference- encouraged to understand symptoms and treatment methods

DR. VIDYASAGARS CONTRIBUTIONAchievements :Reduced hostility in patients minds of being abandoned in strange placeRemoved old age myths of incurability when family saw patients recoverBy group sessions , relatives learnt essential principles & were motivated towards improvement.Fast recovery,low relapse rates

PRIMARY CARE APPROACH1950s Establishment of All India Institute fo Mental Health(later NIMHANS),Bangalore ,AIIMS,Delhi ,All India Institute of Hygiene & Public Health,KolkataMajor guiding principle reaching the unreached

PRIMARY CARE APPROACH1970 primary care approachExisting 42 mental hospitals -50-60k pts/yearCatered to only 20% populationEpidemiological studies showed equal prevalence of mental disorders in both rural & urban areas.

PRIMARY CARE APPROACHAvailable services not made use of because:IgnoranceExisting beliefs evil spirits cause illnessBlack magicPast bad deedsLack of knowledgeLong distance to be travelledStigmaLack of resources-money,transport,othersDrop out rates very high

PRIMARY CARE APPROACHNumber of trained psychiatrists increasedGovt 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 approach.

GHPUNext phase was establishment of General Hospital Psychiatric units(GHPUs)1st was in 1933 R G Kar Med College,Kolkata1960s availability of antipsychotic drugs dramatically controlled agitation,aggression, withdrawal tendencies of patients.Thus possible to treat them in general hospitalsLed to increase in graduates in Psychiatry

NIMHANS Crash ProgrammeDr .R M Verma,Dr. Karan SinghOct 1975 Community Psychiatric UnitLaunched experimental programmesPHC based rural mental health programme : Manuals prepared to train MPWs and PHC doctors to diagnose & treatGP based urban mental health programme : Manual to teach GPs

NIMHANS Crash ProgrammeSchool mental health programme :Teachers trained to diagnose and counselHome based follow up of psychiatric patients: Nurses trained to follow up patients through monthly visitsPsychiatric camps :involved village leaders & reduced stigma

FEASIBILITY STUDIESFeasibility studies done in 2 regions :1975-80Sakalawar,Bangalore & Raipur Rani,HaryanaResults :Majority of mentally ill,epileptics,MR children remained untreated inspite of being nearer to a well established mental hospital.All families had approached traditional healing centres,local healers for help but in vain

FEASIBILITY STUDIESMajority were ill for > 2 yearsKey informants , health workers could easily identify , report about existing casesLimited number of drugs were sufficient to manage almost all cases , hospitalisation rarely required.Most improved with meds , rehabilitated back into villages & joined mainstream of lifeMedical & non medical workers able to learn in short term courses

Alternatives to institutional careDeveloped by NIMHANS and other institutionsExtensive 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 careShort stay ward(upto 48hrs) facility organised in OP building acute problems managed & pt. dischargedFree / subsidized drug supply to improve drug compliance

Alternatives to institutional careExtension 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.

Alternatives to institutional careDomiciliary 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.

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

Alternatives to institutional careTraining school teachers in mental health care & promotion of mental health through schoolsTraining programs organized in 2 phases recognizing & managing psychosocial problems of students.Sensitize them to recognize & interveneApproach to problem children changed for the better

Alternatives to institutional careInvolvement of ICDS personnel in child mental heath care :Anganwadi workers trained in basic mental health care to identify & refer children with MR,behavioural problemsImprove child rearing practicesBut have to be supervised & effective referral linkages to be established

Alternatives to institutional careTraining lay volunteers :Interested, committed natural helpers given 40 training sessions in counselling help individuals in distressSupervised & monitored by MHPsEg. marital discord, parents with problem children, IP problems, students with problems in studies.

Alternatives to institutional careTraining village leaders:Work like referral & change agents in societyStudent 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

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

Alternatives to institutional careNon-governmental voluntary organizations:SCARF(Madras)Medico-Pastoral Association,Richmond Fellowship of India ,BangaloreRehabilitate by organizing vocational training ,half way homes for chronic mentally ill and disabledSelf help groups also very helpful

Alternatives to institutional careSuicide prevention centres Helping Hand ,MPA(Bangalore),Sneha(Chennai),Sahara(Mumbai),Sanjivini,Sumaitri(Delhi)Helping hands to familiesPressure groups to mobilize public opinion & concern for improving servicesRequire good networking,periodic evaluation

ICMR-DST study on severe mental morbidity1st & only prospective study where ability of doctors & health workers to recognize and manage at PHC level was examined exhaustively4 centres Bangalore,Vadodara,Patiala,KolkataMotivation among MPWs were poorNeither the doctor/HWs organised a programme to impart eductionRecord keeping very poorLack of leadership

NATIONAL MENTAL HEALTH PROGRAMA group of 68 experts formed in 1980Final draft submitted to Central council of health & family welfare on 18-20 August 1982.Appeared almost simultaneously with the National Health Policy

OBJECTIVESTo 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.

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

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

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

STRATEGIESPeriphery 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.

SUBPROGRAMMESTREATMENT : Multiple levelsVillage ,subcentre level :Multi purpose workers(MPW),Health supervisors(HS),under supervision of medical officer(MO) trained for:Management of psychiatric emergenciesAdministration & supervision of maintenance treatment for chronic psychiatric disordersDiagnosis & management of grand mal epilepsy , esp. in children

SUBPROGRAMMESLiaison 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:Supervision of MPWs performanceElementary diagnosisTreatment of functional psychosisTreatment of uncomplicated cases of psychiatric disorders assoc. with physical diseases.

SUBPROGRAMMESManagement of uncomplicated psychosocial problems.Epidemiological surveillance of mental morbidityDistrict hospital :At least 1 psychiatrist attached as integral part30-50 psychiatric bedsPsychiatrist devotes only part of his time in clinical care , greater part in training & supervision of non-specialist health workers.

SUBPROGRAMMESMental hospitals & teaching psychiatric units:Help in care of difficult casesTeachingSpecialised facilities such as occupational therapy units, psychotherapy, counselling, behaviour therapy

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

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

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

Reasons for poor progressLooked good on paper,extremely unrealistic in its targets,considering available resources of manpower & funds.Only a sum of Rs 10 million was sanctionedTop 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 progressLack of enthusiasm for the programmme in the profession as a whole no large scale training programme/supervision possibleLack of an administrative structure to monitor progress in a decentralised manner

District mental health programIn 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 levelConsidered a more rational exercise

Bellary modelDecentralized & phased training courses conducted for all health personnel of districtCovered 1.5million population-7 taluksProgram officer appointed organized mental health clinic & toured entire district to monitor program.Simple recording & reporting system developed.DHO monitored progress every month

Bellary model5 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 modelAs 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 mannerIts being continued still,financially supported by Zilla Parishad,Bellary

ImplicationsDifficulties in :Correct diagnosisAppropriate medication choiceDosage & difficulty of handling side effectsAdministrative problems poorly motivated personnel ,erratic supply of drugs

Barwani experiment3 tier model by Chatterjee et al.1st OP programme2nd MHW drawn from local community3rd family members & key people in communityCompliance to treatment -63%Village samitis added a positive atmosphere

Progress since 1982Some ways very significantGuiding principle for development of mental health in India.Development of models for integration of mental health with primary healthcareEg.Raipur Rani,Sakalawara,Bellary DMHPExtension of DMHP to 25 districts in 20 states b/w 1995-2000 (10th 5yr plan 100)

Progress since 1982Community care alternatives & NGO initiativesIncluded day care centres,half way homes, long stay homes,suicide prevention,school mental health programmes.Felt need + ,user-friendly

Progress since 1982Human resource developmentNumber 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 1982Public awarenessDue to community based mental healthcare,voluntary organisations initiatives,MHPs in remote areaUse of media books,radio,TV sharing mental health information among general public.

Progress since 1982Others related to mental health :Legislations :Narcotic Drugs & Psychotropic Substances(NDPS) Act,1985Mental Health Act 1987Persons with Disability Act 1995 -1st time mental illness was includedPenal promotion,prevention,rights approach

Progress since 1982Recognition of human rights of mentally ill by NHRC systematic,intensive,critical examination of mental hospitals showed inadequacy of services & upholding human rightsRevision 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 1982Mental health research ICMR understanding cultural context of mental disorders esp. schizophrenia

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

Barriers to reach goalsLimited UG training in psychiatry Inadequate mental health human resources :Many districts have no public sector psychiatristsMedical colleges inadequately staffedNot enough training facilities for clinical psychology,social work,nursing Limited number of models & their evaluation :Missing manuals to guide DMHP

Barriers to reach goalsUneven distribution of resources across states:National level implementation difficultNon implementation of MHA 1987 :Insufficient norms for licensing & maintaining care standardsPrivatisation 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 decadesIncreased range of treatmentsGreater recognition of families roleCommunity mental healthcareWide variety of care modelsIncreased human resourcesJudicial activismRecognition of stigma & discriminationWorldwide focus on mental health(2001 WHO report devoted to mental health)

Erwady TragedyErwady tragedy Tamil Nadu Aug 6 200125 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 concern.

Erwady TragedyAll 15 mental homes at Erwadi were closed on August 13 and their 571 inmates taken under the government's careForced the State government to act & implement certain sections of MHA 1987Similar event in Ranchi Patients escaped ,pitiable living conditions were exposed in media

REVISED GOALSStrengthening families & communities for the care of persons suffering from mental disorders.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

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

Plan of actionOrganising services :Recommended by WHO 2001 reportProvide mental health in primary care :Easier ,faster access to servicesbetter care,cuts wastage from unnnecessary investigations & treatmentsMental health to be included in training curricula + refresher courses to improve effectiveness

Plan of actionMake psychotropic drugs available :Provide an essential drugs listAmeliorate symptoms,reduce disability,shorten course ,prevent relapse.Levels of mental healthcare to be developed depending on health infrastructure in state.Short-focused training programmes using IT based tele-training facilities

Plan of actionCommunity mental healthcare facilities:Better effect on outcome & QOLCost effective,respects human rightsHelp in early intervention ,limit stigmaLarge custdial hospitals replaced by community care facilities,backed by general hospital psychiatric beds,home care supportCrisis support,protected housing,sheltered employment

Plan of actionDay care centres,half way homes,long stay homes,sheltered workshops,de-addiction centres ,suicide prevention centres.District leveltalukstowns

Plan of actionSupport to families :primary care providersRequire understanding of illness & skills to care for the illEnsure medication compliance,recognize signs of relapse,handle crisis,reduce disabilityState should :Provide financial support

Plan of actionOffer public places for meetings & organisations of day care activitiesDeveloping visiting nurses to support familiesInvolving them in planning of mental health programmes

Plan of actionHuman Resource development :Trained professionalsfoundation for organisational servicesUG training in psychiatry for medical studentsPlan to increase to 2 mths + exam subjectPsychiatrists fuly staff departments in colleges,district hospitals & support voluntary organisations

Plan of actionPsychologists,social workers,nurses minimum 3-6 months training at mental health centresRehabilitation professionalsShort term training for medical officers esp. experienced senior officers -3 mths

Plan of actionPublic mental health education :Reduce treatment barriers,increase awarenessReduce stigma,discrimination thus bring branches of mental & physical healthcare closerAIR,DD,Print & folk media utilizedShould be a continuous activity

Plan of actionPrivate sector mental healthcare:Pvt psychiatrists can support by :Systematically recording their work to provide understanding of magnitude of mental health needsClarifying treatment utilizationWorking as honorary consultantsTraining PHC personnel,supporting NGOsEncouraging public mental health education

Plan of actionSupport to voluntary organisations Valuable community resourceMore sensitive to local realities,strongly committed to innovation & changeFill gap b/w community needs & available servicesGovt should develop funding mechanisms to cover all states

Plan of actionPromotion & preventive activities :Life skills education programmes for school childrenInitial efforts undertaken by NIMHANS alreadyPsycho-social care of disaster survivors part of relief,rehab,reconstruction & reconciliation programmes

Plan of actionAdministrative 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 peripheryIncrease mental health budget to atleast 10% of total health budget.

Future PrioritiesFamily as the focus of carePublic mental health educationIntersectoral collaborationRole of voluntary organisationsIntegration with general health servicesHRDEnhancing funding for mental healthcareEmphasis on prevention & promotionAdministrative structures

SuggestionsContinued 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 levelsState must not give up responsibility of looking after chronically ill patients ,innovative programmes required

SuggestionsNetworking 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 mentally distressed.

SuggestionsSpecial focus on high risk groups women,children,elderly peopleMHPs remain sensitive to changing values & attitudes accompanying socio-economic uplifting programmesExercise their democratic right to influence public opinion

World mental health report,2001Focused on mental health(Mental Health:New understanding,New Hope)Slogan : -Stop Exclusion:Dare to Care1 in every 4 affected by mental disorder at some stage of life.Psychiatric disorders -12% of global burden of diseaseMental health budgets