DMHP & NMHP by DR.UJJWAL KHAJANCHI

District mental health programme

1. DMHP Dr. UJJWAL KHAJANCHI

2. Table of Contents Introduction and background information Aims and objectives of this programme Development Organizing Body XIIth Plan: DMHP Clinical Team DMHP – Clinical Services Operational Guideline for the FY 2018-19 of NMHP & DMHP Evaluation Of District Mental Health Programme Timelines Future Directions and Possible Solutions References

3. background “Mental health has been defined as a state of balance between the individual and the surrounding world, a state of harmony between oneself and others, a coexistence between the realities of the self and that of other people and that of the environment-” World Health Organization  (WHO). All kinds of mental and behavioral disorders are widely prevalent in Indian population. Review of the situation of psychiatric disorders in India highlighted the gross neglect of mental disorders ( Neki and Carstairs, 1975) due to:  Pervasive stigma, widespread misconceptions  Grossly inadequate budgets for mental healthcare  Acute shortage of trained mental health personnel

4. Cont.. Recommendations by an expert committee on “organization of mental health services in developing countries” ( World Health Organization. 1975):  Basic mental health care should be integrated with general health services and be provided by non-specialized health workers at all levels. Starting of “Community Mental Health Unit” by NIMHANS , Bangalore – 1975  SAKALWARA PROJECT :Focus on developing services and model. WHO Multi-country project: “Strategies for extending mental health services into the community” (1976-1981)  RAIPUR RANI PROJECT- Focus on testing and evaluating models. Indian Council of Medical Research – Department of Science and Technology (ICMR-DST) Collaborative project (1980):  To evaluate the feasibility of training of PHC staff to provide mental health care as part of their routine work.

5. Cont.. In 1980 the Government of India felt the necessity of evolving a plan of action aimed at the mental health component of the National Health Programme . In February 1981, a drafting committee met in Lucknow and prepared the first draft of the NMHP. This was presented at a workshop at New Delhi on 20–21 July 1981. In August 1982, the highest policy making body in the field of health in the country, the Central Council of Health and Family Welfare (CCHFW) adopted and recommended for implementation of National Mental Health Programme (NMHP). The Government of India launched the National Mental Health Programme (NMHP) in 1982, keeping in view the heavy burden of mental illness in the community, and the absolute inadequacy of mental health care infrastructure in the country to deal with it. The district Mental Health Program was added to the Program in 1996.

6. Development of the pilot district mental health Programme at Bellary district in Karnataka:  population of about 20 lakhs  located about 350 kms away from Bangalore  chosen for the pilot development of a (DMHP). Components of the DMHP at Bellary were:  training for all primary care staff,  provision of 6 essential psychotropic and anti epileptic drugs (chlorpromazine, amitryptaline , trihexyphenidyl, injection fluphenazine deaconate, phenobarbitone and diphenyl hydantoin) at all PHCs and sub centres ,  a system of simple mental heath case records,  a system of monthly reporting,  regular monitoring and feed back from the district level mental health team

7. The psychiatrist - mental health clinic at the district hospital to review patients referred from the PHCs.  admit up to 10 patients at the district hospital for brief in patient The mental health programme was reviewed every month at the district level by the district health officer during the monthly meeting of primary health centre medical officers. The Ministry of Health and Family Welfare, Govt. of India formulated District Mental Health Programme (under National Mental Health Programme) . The District Mental Health Programme (DMHP) is the flagship mental health intervention programme of the Government of India as part of the National Mental Health Programme.  The programme was to be implemented in two phases,  Phase I taken up during 1996-97,  Phase II be a continuation of the programme during the IX Five Year Plan period (1997-2002).  Budget line for implementation of the DMHP as a major component of the NMHP was created in 1996; 14 years after CCHFW approved the NMHP.  DMHP was to be implemented as a fully “centrally supported” project.

8. Launched in 1996–97 in four districts, one each in Andhra Pradesh, Assam, Rajasthan, and Tamil Nadu. 1X th 5-year Plan (1997-2002) - 27 districts. X th 5-year Plan (2002-2007)- 110 districts. X1 th 5-year Plan (2007-2012)- 123 districts XII th 5-year Plan (2012-2017)- DMHP is also being started in 325 new districts The central grant for implementation of DMHP per district with avg population of 20 lakh for five years will be Rs. 2.5 crore National Health Policy: specified the inclusion of mental health in general health services, in 2002.

9. NMHP Objectives - To ensure the availability and accessibility of minimum mental healthcare for all in the foreseeable future; To encourage the application of mental health knowledge in general healthcare and in social development To promote community participation in the mental health service development To enhance human resource in mental health sub-specialties. DMHP Objective: - To provide sustainable basic mental health services to the community and to integrate these services with other health services Early detection and treatment of patients within the community itself To reduce the stigma of mental illness through public awareness. To treat and rehabilitate mental patients within the community.

10. key principles underlying the Programme components i ) A life course perspective with attention to the unique needs of children, adolescents and adults. ii) A recovery perspective, through provision of services across the continuum of care and empowerment of persons with mental illness and their care-givers. iii) An equity perspective through specific attention to vulnerable groups and to ensure geographical access to mental health services iv) An evidence based perspective by following established guidelines and experiences on treatments and delivery models. v) A health systems perspective with clearly defined roles and responsibilities for each sector from community to district hospital and including a cascading model of capacity building and supervision. vi) A rights based perspective to ensure rights of persons with mental illness are protected and respected by mental health services.

11. Implementation of DMHP The DISTRICT MENTAL HEALTH PROGRAMME was started as " a community based approach ’’ , which includes:  Provide services for early detection and treatment of mental illness in the community itself with both OPD and indoor treatment and follow-up of discharged cases.  Increase awareness in the care necessity about mental health problems.  Training of the mental health team at the identified nodal institutes within the State.  Provide valuable data and experience at the level of community in the state and Centre for future planning, improvement in service and research.

12. Based on the evaluation conducted by Indian Council of Marketing Research (ICMR) in 2008 and feedback received from a series of consultations DMHP has now incorporated promotive and preventive activities for positive mental health which includes:  School mental health services: life skill education in schools, counselling.  College counselling services: Through trained teachers/ counsellors.  Work place stress management: Formal and informal sector, including farmers, women etc.  Suicide prevention services: Counselling center at district level, sensitization workshops, IEC, helpline

13. Organizing body 1. At the Central Level: Central Implementation Team 2. At the State Level: State Implementation Team 3. At the District Level: A full-time District Programme Manager with a background in public health management will have overall administrative responsibility for implementation of the DMHP in that district.

14. ( XIIth 5-year Plan (District Mental Health Programme) DMHP Clinical Team District Hospital Level a ) Psychiatrists : All DMHP districts shall appoint two full-time psychiatrists to the DMHP Programme. b) Nurses –7 Nurses shall be appointed for in-patient and outpatient care. c) Clinical Psychologist : Two clinical psychologists will be appointed. d) Psychiatric Social Worker : Four psychiatric social workers will be appointed. e) Programme Assistant (1 Nos) g) M&E Officer (1 Nos) h) Ward Assistants/Orderlies (4 Nos)

15. DMHP – Clinical Services District Hospital Outpatient services & Inpatient services, Child mental health services, Collaboration with RCH services to address post partum mental disorders, Specialist Counselling and Therapy services, Availability and Provision of psychotropic medications Clinical support to continuing care services Disability Certification Laboratory Services Interventions for persons attempting suicide Support and supervision to PHC staff Outreach outpatients at CHC/Taluk Hospitals Capacity building and Training Activities Emergencies Administrative and Managerial support to all clinical services

16. CHC/Taluk Hospitals: Outpatients services Inpatient services Specialist counselling services Social support PHCs Management of common mental disorders, Management of mental health emergencies, Referrals to District Hospitals, Follow up of patients with SMD with a treatment plan drawn up by District DMHP Team Identification of persons with SMD in community and mobilizing them for assessment to PHC Community based rehabilitation for persons with severe mental disorders Assist in accessing services in the community ( eg day care centres ). Assist in accessing social benefits Availability and Provision of psychotropic medications DMHP – Continuing Care Services Ambulance Services

17. 12 th 5 year plan for nmhp & DMHP April 2012-2017 Strategy: Manpower development scheme centre for excellence Strengthening PG departments in mental health specialities Upgrading central mental health institutes to provide basic neurological and neurosurgical facilities on the pattern of NIMHANS, Bangalore. Support for central and state health authorities Central mental health team for NMHP Training and research activities IEC activities Monitoring and evaluation of mental health information management system

18. Key Lessons on the functioning of the DMHP in the XI & XII th 5-YEAR Plan Large gaps exist in the coverage of the DMHP within the country. Although the DMHP is supposed to be active in 123 (X1 th ) districts, it was barely functional in most districts. Performance of the Programme was not entirely satisfactory in most districts, there was an emerging pattern of the Programme functioning better in some states while in others there were no districts where the DMHP was implemented. The method of selection of the 123 districts itself resulted in a skewed distribution of DMHP districts with certain parts of the country (south and west) enjoying many DMHP districts while the north, central having comparatively fewer districts.

19. District mental health program - Need to look into strategies in the era of Mental Health Care Act, 2017 and moving beyond Bellary Model Medical officers trained under the program have better awareness of mental illness but still lack of confidence in treating mental disorders. There is also lack of confidence on the part of beneficiaries from taking treatment from nonmental health professionals even after so many years. The Mental Healthcare Act (MHCA), 2017 allows only emergency treatment for 72 h by a physician before referral to higher center, and there is no provision for treatment by a nonmental health professional during follow-up. Even there will be serious limitation in treating drug abuse cases in primary care. MHCA requires diagnosis by internationally recognized classificatory systems like International Classification of Diseases 10th Revision. It will be an uphill task for primary care physicians to become familiar with such systems.

20. DMHP IN THE STATE ASSAM

21. Operational Guideline for the FY 2018-19 of NMHP & DMHP Activity No. 1 Targeted interventions at community level Activities & interventions targeted at schools, colleges, workplaces, out of schools, colleges, workplaces, out of school adolescents, urban slums and suicide prevention Aim: To sensitize the whole community by the trained community health workers about mental health, features of mental disorders, screening of mental health disorders among whole population, availability of their management in the PHCs/CHCs/District Hospitals and benefits of treatment.

22. Activity No. 2 District Counseling Centre (DCC) and crisis helpline outsourced to psychology department/NGO per year. Guideline: This activity will be started under the supervision of State Programme Officer for Counseling Centre and Crisis Helpline in collaboration with “The SARATHI 104”- Health information helpline service for answering all health queries.

23. Activity No. 3 District DMHP centre , Counseling centre under psychology department in a selected college including crisis helpline Activity No. 4 Equipment Aim: For providing all equipments along with the assessment tools in District Hospitals.

24. Activity No. 5 Name of the Activity: Drugs and supplies under NMHP Aim: For providing all needed psychotic drugs to the District Hospitals. Activity No. 6: Name of the Activity: Ambulatory Services About the activity: Ambulatory services for the mobility of the patients

25. Activity No. 7 Name of the Activity: Training of PHC Medical Officers, Nurses, Paramedical Workers & Other Health Staff working under NMHP. About the activity: Training of MOs, Staff Nurses, Paramedical workers, drivers, police personals, Jail Doctor, Personal from Social Welfare deptt ., Govt. officials, Magistrates and NGO workers for mentally ill patient.

26. Activity No. 8 Name of the Activity: Others (Training) Aim: For providing training to the Non- Psychiatric Medical Officers along with Clinical Psychologist and Psychiatric Social Worker at Lokpriya Gopinath Bordoloi Regional Institute of Mental Health (LGBRIMH), Tezpur under National Mental Health Programme (NMHP). Activity No. 9 Name of the Activity: Translation of IEC materials and distribution Aim: For providing the IEC materials and training modules to the districts

27. Activity No. 10 Name of the Activity: Awareness generation activities in the community, schools, workplaces with community involvement. Activity No. 11 Name of the Activity: NGO based activities Aim: To develop 3 (Three) Day Care Centre in the existing registered NGOs in 3 (Three) different districts in the state.

28. Activity No. 12 Name of the Activity: Operational expenses of the district center: rent, telephone expenses, website etc. About the activity: Operational expenses of the district center: rent, telephone expenses, website will be formulated accordingly. Activity No. 13: Name of the Activity: Contingency under NMHP About the activity: Contingency costs including Miscellaneous costs, Travel costs and Contingency costs

29. Regional Workshops on NMHP & DMHP In order to disseminate the guidelines of revised National Mental Health Program, Mental Health Program Division of Ministry of Health and Family Welfare organized five regional workshops of 2 days each, across the country. (2011-12). The agenda items for discussion in the regional workshops were following: 1. To discuss and disseminate revised DMHP guidelines and other added components of NMHP. 2. Role and responsibilities of the various stakeholders of NMHP in the states. 3. Issues of concerns and bottlenecks for the implementation of NMHP in the respective states. 4. To discuss the action plan for implementing the revised DMHP. 5. NMHP strategy for the 12th FYP.

30. EVALUATION OF DISTRICT MENTAL HEALTH PROGRAMME MENTAL HEALTH SERVICE UTILIZATION: Site of contact of beneficiaries under DMHP  61%-district hospital  12.7%-CHCs  11.5%-PHCs  18% of the total respondents were referred to district level for treatment. “So mental health services have been decentralized at least to the district level if not to the level of PHCs, from mental hospitals and medical college hospitals with partial integration of these services with the general health services”.

31. DRUG SUPPLY UNDER DMHP  25% of the districts under DMHP have regular inflow of drugs .  80% beneficiaries received at least some medicines from the health centers. “ This is because of lack of dedicated drug procuring mechanism for DMHP” 90% of the patients were of the opinion that diagnosis was explained to them.  61% of the beneficiaries confirmed that the possible side effects of the medicines were explained to them.  25% of the beneficiaries received counseling services under DMHP. More than 50% of the respondents from the DMHP districts agreed that proper medications and counselling can help in the treatment of mentally ill people against only 30% in Non DMHP districts. Awareness about the types of mental illness were found to be significantly higher in DMHP districts as compared to non-DMHP districts. This indicates that DMHP has been able to spread awareness in the districts where it was being implemented

32. FUND UTILIZATION:  One third of the districts utilized over 99%, one third has utilized 63-91%, and rests have utilized 37-47% of the total amount they have received.  Only 10% of the districts, utilized funds allocated for IEC activities . 20% of the districts did not utilize funds under IEC and rest 70% district had partially utilized. “This is mainly due to administrative delay, difficulty in recruiting and retaining qualified mental health professional, low utilization in training and IEC components” 55% of the health personnel confirmed that they had received training.  More than half of the health personnel (54.7%) trained were satisfied with the training programme . “Training and IEC components which require a lot of ground work, coordination and networking in the community is below par in most of the districts” The ICMR review reported that over half of the patients had to travel more than 5 kms to access treatment services; 40% had to travel over 10 kms. patients spend Rs 43.5 (min Rs 10 – max Rs 250) on travel to the hospital to access services provided under the DMHP.

33. National Mental Health Survey of India 2015–2016 by R. Srinivasa Murthy Professor of Psychiatry ( Retd ), Formery of NIMHANS, Bangalore, Karnataka, India Treatment gap for mental disorders ranged between 70% and 92% for different disorders: common mental disorder - 85.0% severe mental disorder - 73.6%; psychosis - 75.5%; BPAD - 70.4%; alcohol use disorder - 86.3%; and tobacco use - 91.8%. The median duration for seeking care from the time of the onset of symptoms varied from 2.5 months for depressive disorder.

34. National Mental Health Survey (NMHS) – Assam (2015-16) As of 2015 -16, the treatment gap for mental disorders in Assam was 82.58% . Homeless Mentally Ill: Despite advances in treatment modalities and available facilities, almost every day, 1-2 homeless mentally ill persons are found on the streets. The state did not have any written dedicated mental health policy, defining the, values, vision, mission, principles, objectives and mechanisms for improving mental health care. Mental health activities are carried out in the state, but were fragmented and dis-organized. The DMHP program was implemented in 5 districts (Nagaon, Tinsukia, Nalbari , Goalpara & Morigaon ) of the state, prior to 12th five-year plan period.

35. Later, 7 more districts were identified for DMHP supported by state government. However, apart from appointing a few psychiatrists in district hospitals during the early part of 2012, under implementation of the scheme “State Support for Mental Health Programme”, DMHP has not been implemented during the 12th five-year plan from 2012 -2016. DMHP covered only 14.29% of the districts of Assam and less than a quarter (22.08%) of the total population. There was no reliable information on the functioning of DMHP in these districts. Some of the barriers in successful implementation of DMHP in the state are non-regularization of post for DMHP staff, irregular salary of contractual staff, medicines and lack of co-ordination between state officials and district hospital. Failure to utilize the granted amount and submit utilization certificates as per requirement lead to discontinuation of DMHP in the districts of Tinsukia, Morigaon and Nalbari .

36. timeline 1969- Mudaliar Committee recommendations on Mental Health 1974- Srivastava Committee recommendation of Communiy Health Volunteer (CHV) includes Mental health in scope of work 1975- Training of General practitioners in psychiatry started at NIMHANS 1976- Program of Community Psychiatry launched at NIMHANS 1975-80- Needs of rural population studied by NIMHANS in one primary health centre 1976-81- Raipur Rani project as part of WHO multi centric project on strategies for extending mental health care 1980-86 Pilot experiment to integrate Mental health into primary health care at one Primary health centre of population of 1 lac at select talukas of Bellary district. 1982-84- Indian Council of Medical Research (ICMR) project at three sites tests out the NIMHANS material for training of GP in psychiatry 1984- Bellary model upscaled to entire Bellary district 1985-90- DMHP Pilot test in Bellary district

37. 1985-87 ICMR Project – Mental Health in PHC – Solur , Karnataka 1987 ICMR-DST project at four locations in the country (Collaborative study on severe mental morbidity) 1995 Meeting of Central Council of Health 1996 Recommendation on starting mental health program at a workshop of all health administrators in Bangalore 1996-97 DMHP launched in 4 districts of the country 1997 Quality Assurance in Mental health care services report by National Human Rights Commission 1997-2000 Phased expansion of DMHP districts 1999 Mental Health agenda of World Health Organisation set; MH identified as priority for WHO’s work 2001 World Health Day theme based on Mental Health 2001 World Health Report with focus on Mental Health 2003 World Health Survey involving 5 states 2007-08 DMHP in 123 districts 2008-09 Evaluation of DMHP by Indian Council of Marketing Research (ICMR) in 20 of 127 districts 2011 A review of 23 districts of four southern state DMHP conducted by NIMHANS 2012 WHO Executive Board adopts a Resolution (proposed by India, US and Switzerland) on co-ordinated health and social sector response to mental health problems 2012-2017 ( XII th 5-year plan)

38. Future Directions and Possible Solutions Human resource development: Undergraduate training to be strengthened Departments of psychiatry to be strengthened Filling of lacunae like scarcity in numbers of PSW, psychologists and psychiatric nurses Involvement of private health care services Support to voluntary organizations active in mental health Better administrative support and responsibility.

39. references National health portal; MoHFW , Govt. of India. XIIth Plan District Mental Health Programme (DMHP) prepared by Policy Group 29th June 2012. OPERATIONAL GUIDELINES 2018-19 NATIONAL MENTAL HEALTH PROGRAMME ( National Health Mission, Assam, Saikia Commercial Complex, Christian Basti, Guwahati-05). DIRECTORATE GENERAL OF HEALTH SERVICES Ministry of Health & Family Welfare ,Government of India. Mental health care act, 2017 National health programs of India: J Kishore 11th ed Regional Workshops on National Mental Health Programme (2011-12). National Mental Health Survey India, 2015-16 ASSAM State Report (Conducted by Lokopriya Gopinath Bordoloi Regional Institute of Mental Health ). National mental health program of India: a review of the history and the current scenario Sarbjeet Khurana1*, Shweta Sharma ( Institute of Human Behaviour and Allied Sciences , 2016 )

40. Thank you