LOK SABHA SECRETARIAT PARLIAMENT LIBRARY AND REFERENCE, RESEARCH, DOCUMENTATION AND INFORMATION SERVICE (LARRDIS) MEMBERS’ REFERENCE SERVICE REFERENCE NOTE . No. 33/RN/Ref./December/2013 For the use of Members of Parliament Not for Publication MENTAL HEALTH CARE The reference material is for personal use of the Members in the discharge of their Parliamentary duties, and is not for publication. This Service is not to be quoted as the source of the information as it is based on the sources indicated at the end/in the text. This Service does not accept any responsibility for the accuracy or veracity of the information or views contained in the note/collection.
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LOK SABHA SECRETARIAT
PARLIAMENT LIBRARY AND REFERENCE, RESEARCH, DOCUMENTATION AND INFORMATION SERVICE (LARRDIS)
MEMBERS’ REFERENCE SERVICE
REFERENCE NOTE .
No. 33/RN/Ref./December/2013
For the use of Members of Parliament Not for Publication
MENTAL HEALTH CARE
The reference material is for personal use of the Members in the discharge of their Parliamentary duties, and is not for publication. This Service is not to be quoted as the source of the information as it is based on the sources indicated at the end/in the text. This Service does not accept any responsibility for the accuracy or veracity of the information or views contained in the note/collection.
MENTAL HEALTH CARE
INTRODUCTION
Mental health is an integral and essential component of health. The World Health
Organization (WHO) defines mental health as a state of well-being in which an
individual realizes his or her own abilities, can cope with the normal stresses of life, can
work productively and is able to make a contribution to his or her community. In this
positive sense, mental health is the foundation for individual well-being and the effective
functioning of a community1.
Mental and behavior problems are increasing part of the health problems the
world over. The burden of illness resulting from psychiatric and behavioural disorders is
enormous. Psychiatric symptoms are common in general population in both sides of
the globe. These symptoms viz. worry, tiredness, and sleepless nights affect more than
half of the adults at some time, while as many as one person in seven experiences
some form of diagnosable neurotic disorder.
INTERNATIONAL SCENARIO
Prevalence of mental disorders as per World Health Report (2001) is around
10% and it is predicted that burden of disorders is likely to increase by 15% by 2020. At
the international level, mental health is receiving increasing importance as reflected by
the WHO focus on mental health as the theme for the World Health Day (4th October
2001), World Health Assembly (15th May 2001) and the World Health Report 2001 with
Mental Health as the focus22.
In 2008, the WHO Mental Health Gap Action Programme (mhGAP) was
launched which aims at scaling up services for mental, neurological and substance use
disorders for countries especially with low and middle income.
1 WHO, Mental Health: Strengthening our Response, February 2013. 2 Indian Council of Medical Research, Mental Health Research in India 2005.
-2-
Taken together, mental, neurological and substance use disorders accounting for
13% of the total global burden of disease in the year 2004. Depression alone accounts
for 4.3% of the global burden of disease and is among the largest single causes of
disability worldwide (11% of all years lived with disability globally), particularly for
women. The gap between the need for treatment and its provision is large all over the
world. WHO’s Mental Health Atlas 2011 provides data that demonstrate the scarcity of
resources within countries to meet mental health needs3.
The Director General, World Health Organization launched the Mental Health
Action Plan 2013-2020 on 7 October 2013. The action plan recognizes the essential
role of mental health in achieving health for all people. It aims to achieve equity through
universal health coverage and stresses the importance of prevention. The four major
objectives of the Action Plan are to:
Strengthen effective leadership and governance for mental health.
Provide comprehensive, integrated and responsive mental health and social care services in community-based settings.
Implement strategies for promotion and prevention in mental health.
Strengthen information systems, evidence and research for mental health.
Every year on 10 October, the World Health Organization joins in celebrating the
World Mental Health Day. The day is celebrated at the initiative of the World
Federation of Mental Health and WHO supports this initiative through raising awareness
on mental health issues. The theme of the day in 2013 was “Mental Health and Older
Adults”.
On 10 December 2013 the Human Rights Day, WHO launched the MiNDbank. It
is a new online platform which brings together key international resources and national
policies, strategies, laws and service standards for mental health, substance abuse,
general health, disability, human rights and development. MiNDbank will facilitate
3 Sixty-sixth World Health Assembly, Comprehensive Mental Health Action Plan 2013-2020.
-3-
debate, dialogue, advocacy and research in order to promote national reform in line with
international human rights and best practice standards.
INDIAN SCENARIO
According to various community based surveys, prevalence of mental disorders
in India is 6-7% for common mental disorders and 1-2% for severe mental disorders. In
India the rate of psychiatric disorders in children aged between 4 to 16 years is about
12% and nearly one-third of the population is less than 14 years of age. With such a
magnitude of mental disorders it becomes necessary to promote mental health services
for the well being of general population, in addition to provide treatment for mental
illnesses. Treatment gap for severe mental disorders is approximately 50% and in case
of Common Mental Disorders it is over 90%4.
As per the National Survey of Mental Health Resources carried out by the
Directorate General of Health Services, Ministry of Health and Family Welfare during
May and July, 2002, the details of number of patients with mental disorders and
proportionate availability of psychiatrist, psychiatric nurses and social workers,
clinical psychologist and mental hospitals and beds in the Country, State/UT wise
is given in Annexure-I.
As per the same survey, the ideal required number of mental health
professionals has been calculated and the details of present requirement and
availability of mental health professionals in the country are given in Annexure-II5.
In India the Government has been implementing several programmes to address
mental disorder as explained below:
NATIONAL MENTAL HEALTH PROGRAMME The National Mental Health Programme (NMHP) was started in 1982 with the
objectives to ensure availability and accessibility of minimum mental health care for all,
4 Ministry of Health and Family Welfare, Annual Report 2012-13, p. 161
to encourage mental health knowledge and skills and to promote community
participation in mental health service development and to stimulate self-help in the
community.
The strategies of National Mental Health Programme were - integration of mental
health with primary health care through the NMHP; provision of tertiary care institutions
for treatment of mental disorders; to eradicating stigmatization of mentally ill patients
and protecting their rights through regulatory institutions like the Central Mental Health
Authority, and State Mental Health Authority.
Gradually the approach of mental health care services has shifted from hospital
based care (institutional) to community based mental healthcare, as majority of mental
disorders do not require hospitalization and can be managed at community level. The
National Mental Health Programme Division conducts nationwide mass media
campaign through audio-video and print media6.
DISTRICT MENTAL HEALTH PROGRAMME The District Mental Health Programme (DMHP) was initiated in 1996 during the
Ninth Five Year Plan based on Bellary Model developed by the National Institute of
Mental Health and Neuro Sciences (NIMHANS), Bangaluru. During the plan period, 27
districts were covered under DMHP. At present DMHP is covering 123 districts in 30
States and Union Territories. In addition to early identification and treatment of mentally
ill, District Mental Health Programme has now incorporated promotive and preventive
activities for positive mental health which include School Mental Health Services,
College Counselling Services, Work place Stress Management and Suicide Prevention
Services. The issues of awareness regarding mental illness and availability of
treatment are addressed through Information, Education and Communication (IEC)
activities at District level by the DMHP7.
6 Op.cit,. Annual Report 2012-13, pp. 161-162
7 Ibid
-5-
The components of District Mental Health Programme include- training
programmes of all workers in the mental health team at the identified Nodal Institute in
the State; public education in the mental health to increase awareness and reduce
stigma; for early detection and treatment, the OPD and indoor services are provided ;
providing valuable data and experience at the level of community to the state and
Centre for future planning, improvement in service and research.
Agencies like World Bank and WHO have been contacted to support various
components of the programme. Funds are provided by the Government of India to the
State Governments and the nodal institutes to meet the expenditure on staff,
equipments, vehicles, medicine, stationary, contingencies, training, etc. for initial 5
years and thereafter they should manage themselves.
As per the Mental Health Act, 1987, there is provision for constitution of Central
Mental Health Authority (CMHA) at central level and State Mental Health Authority
(SMHA) at State Level. These statutory bodies are entrusted with the task of
development, regulation and coordination of mental health services in a State/Union
Territory, etc.
The National Human Rights Commission also monitors the conditions in the
mental hospitals along with the Government of India and the states are acting to ensure
quality in delivery of mental care.
MANPOWER DEVELOPMENT SCHEMES Establishment of Centre of Excellence in Mental Health Centres of Excellence in the field of mental health are being established by
upgrading and strengthening identified existing mental health hospitals/institutes for
addressing acute manpower gap and provision of state of the art mental health care
facilities in the long run. Eleven such Centres of Excellence were envisaged. Total
budgetary support of up to Rs 338 crore (Rs 30 crore per center) was provided for
undertaking capital work, equipment, library, faculty induction and retention for the plan
-6-
period. 11 Mental Health Institutes have been funded for developing as Centres of
Excellence in Mental Health.
Establishment/up-gradation of Post Graduate Training Departments To provide an impetus to development of Manpower in Mental Health Training
Centers, Government Medical Colleges/Government General Hospitals/ State run
Mental Health Institutes were also to be supported for starting Post Graduate (PG)
courses or increasing the intake capacity for PG training in Mental Health. Support was
to be provided for setting up/strengthening 30 units of Psychiatry, 30 Departments of
Clinical Psychology, 30 Departments of Psychiatric Social Work (PSW) and 30
Departments of Psychiatric Nursing. Total budget allocated for this scheme was Rs 70
crores during Eleventh Plan period with a limit of Rs 51 lacs to Rs 1 crore per PG
Department. As of now, 23 PG Departments in 11 Institutes have been taken up during
the Eleventh Plan period.
MAINSTREAMING NMHP INTO NATIONAL RURAL HEALTH MISSION Efforts are being made to mainstream the components of NMHP under the
overall umbrella of National Rural Health Mission so that the States are able to plan
requirements concerning mental health services as part of their respective Programme
Implementation Plans (PIPs)8.
FIVE YEAR PLANS AND MENTAL HEALTH CARE Tenth Five Year Plan
The thrust areas of Mental Health Programme in the Tenth Five Year Plan were:
District Mental Health Programme in an enlarged and more effective form covering the entire country.
Streamlining/ modernisation of mental hospitals in order to modify their custodial role.
8 Ibid
-7-
Upgrading department of psychiatry in Government medical colleges and enhancing the psychiatry content of the medical curriculum at the undergraduate as well as postgraduate level.
Strengthening the Central and State Mental Health Authorities with a permanent secretariat. Appointment of medical officers at state headquarters in order to make their monitoring role more effective;
Research and training in the field of community mental health, substance abuse and child/ adolescent psychiatric clinics9.
Eleventh Five Year Plan
Under the Eleventh Five Year Plan, the National Mental Health Programme has
been restructured to include the following components:
Manpower Development Scheme: i) Establishment of Centres of Excellence (Scheme - A); ii) Scheme for manpower development in Mental Health (Scheme - B); and
District Mental Health Programme with added components of Life Skills Education and Counseling in Schools and Colleges, Suicide Prevention Services etc.
Up-gradation of Psychiatric Wings of Government Medical Colleges.
Modernization of Government Mental Hospitals10. (The List of Government Mental Hospitals and Grants-in-aid provided for their modernisation are given at Annexure-III and IV)
Rs 623.445 crore was approved as Eleventh Plan outlay for the National Mental
Health Programme. Year wise financial allocation for the NMHP and expenditure
incurred is as given in the table below –
Financial Year Allocation ( Rs. crore) Expenditure(Rs. Crore)
9 http://www.nihfw.org/NDC/Documentation Services/National Health Programme
10 Lok Sabha Unstarred Question No. 1976 dated 8 March 2013.
-8-
Twelfth Five Year Plan
The Government has accorded high priority particularly to child and adolescent
mental health care during the Twelfth Five Year Plan. The Government is integrating
different components of National Mental Health Programme with the components of
National Rural Health Mission namely School Health, Reproductive Child Health and
Adolescent Friendly Clinics during the Twelfth Five Year Plan to reach out to the
community in a more effective manner11.
OTHER INITIATIVES
The Ministry of Social Justice and Empowerment, under its Central Sector
Deendayal Disabled Rehabilitation Scheme (DDRS) has provided financial assistance
to Non-Governmental Organizations (NGOs), for providing various services to persons
with disabilities including special schools, half way homes etc. for mentally retarded
persons. The National Trust for the Welfare of Persons with Autism, Cerebral Palsy,
Mental Retardation and Multiple Disabilities implements various other schemes for the
rehabilitation of such persons. The State-wise details of funds released under DDRS
by the Ministry of Social Justice and Empowerment for the rehabilitation of the
mentally retarded persons during the last three years is given at Annexure-V.
THE MENTAL HEALTH CARE BILL, 2013
The Mental Health Care Bill, 2013 which seeks to provide for mental health
care and services for persons with mental illness and to protect, promote and fulfil the
rights of such persons during delivery of mental health care and services and for
matters connected therewith or incidental thereto, was introduced in the Rajya
Sabha on 19 August 2013. The Bill was referred to the Departmentally Related
Standing Committee on Health and Family Welfare. The Bill repeals the Mental Health
Act, 1987.
The key features of the Bill are:
The Central and State Mental Health Authorities will continue as regulatory agencies.
11
Ibid
-9-
All persons have the right to access mental health care and treatment from mental health services run or funded by the Government. Such services should be affordable, of good quality and available without discrimination.
Any person with or without mental illness can make an Advance Directive stating how he/she wishes to be treated for a future mental illness and also how he does not wish to be treated.
A person with mental illness had the right to live in, be part of and not segregated from society .The Government has an obligation to provide for half way homes, community caring centres etc.
Provision for Mental Health Review Commission (MHRC). The MHRC is a quasi-judicial body to provide an independent oversight to the functioning of mental health facilities and protect the rights of persons with mental illness in these facilities. It thus meets the need for an independent review mechanism as required under the Convention on the Rights of Persons with Disabilities (CRPD)12.
CONCLUSION
Problems relating to mental health would be managed with sensitivity at the
community level, through better training of community workers and primary care teams,
and through education of care givers. However, to address the huge burden of mental
disorders and shortage of qualified professionals in the field of mental health, the
Government is implementing the National Mental Health Programme since 1982 .
Further there are 3 centrally run mental health institutes, 43 Government run mental
hospitals and institutions and 381 medical colleges both Government and Private
across the country equipped to treat the patients suffering from mental illness. The
Mental Health Care Bill 2013 would bring about a paradigm shift in the area of mental
health. The National Institute of Mental Health and Neuro Sciences (NIMHANS),
Bangalore which has become an institution of national importance would mentor and
support child and adolescent mental health services13.
12
Departmentally Related Parliamentary Standing Committee on Health & Family Welfare, ‘Seventy-
Fourth Report on ‘The Mental Health Care Bill, 2013’, pp. 10-12. 13
Press Information Bureau, Ministry of Health and Family Welfare, 25 September, 2013.
-10-
ANNEXURE - 1
Number of Patients with mental disorder and proportionate availability of
Psychiatrist, Psychiatric Nurses and Social Workers etc.
S.No State
(1) Population
(2)
De
nsi
ty/
Sq K
m (
3)
Estimated case load (4) Existing facilities Hospital beds
(5)
Manpower resources (6)
Psychiatrists Clinical psychologists Psy. social workers Psychiatric nurses
Major mental disorders
Minor mental disorders
Govt. sector
Pvt. sector
Ava
ilab
le
Ide
al r
eq
.
De
fici
t
Ava
ilab
le
Ide
al r
eq
.
De
fici
t
Ava
ilab
le
Ide
al r
eq
.
De
fici
t
Ava
ilab
le
Ide
al r
eq
.
De
fici
t
i ii iii iv v vi vii viii ix x xi xii xiii xiv xv xvi xvii xviii xix xx
Grand Total 10270165 51251625 20893 5096 2219 9696 7477 343 13259 12926 290 19064 17118 ** (6527)
4036 **
Note
*figures unreliable: Nurses with some psychiatric training but without a Diploma in Psychiatric Nursing (DPN) appear to have been included. ** Figures unreliable
Column 2.The population figures have been taken from the Census of India-2001 as published in Provisional Population Totals (Registrar General Census Commissioner, India).
Column 3.Population density per square kilometre together with geographical terrain is a useful input in planning deployment of mental health resources.
Column 4.Case-load in respect to major mental disorders has been calculated at the rate of 1% of the population and that of minor mental
disorders at the rate of 5% of population.
SOURCE: National Survey of Mental Health Resources carried out by the Directorate General of Health Services, Ministry of Health &