National Mental Health Programme

The National Mental Health Programme is a programme run by the Ministry of Health and Family Welfare (MoHFW) under the National Health Mission (NHM). This presentation deals with the rationale behind setting up this programme, and also has a critical appraisal of this programme.

1. National Mental Health Programme Presenter- Dr. Sandeep Das Center for Community Medicine AIIMS, New Delhi

2. Outline 1. Introduction 2. Burden of Mental Disorders- Global and India 3. History of NMHP 4. NMHP Objectives Strategies Components Implementation 5. DMHP 6. Mental Health Policy 7. Mental Health Act 2017 ‹#›

3. Introduction Mental disorders were the leading cause of disease burden in terms of years lived with disability (YLDs) and the sixth leading cause of disability-adjusted life-years (DALYs) in the world in 2017, posing a serious challenge to health systems Mental health is being recognized as one of the priority areas in health policies around the world and has also been included in the Sustainable Development Goals. 1. Sagar R, Dandona R, Gururaj G, Dhaliwal RS, Singh A, Ferrari A, et al. The burden of mental disorders across the states of India: the Global Burden of Disease Study 1990–2017. The Lancet Psychiatry. 2020 Feb 1;7(2):148–61. ‹#›

4. Magnitude of mental health problems [1] In 2017, 197.3 million Indians ( 14.3% ) suffering from various mental disorders. (100 districts) Of these, 45.7 million had depression and 44.9 million had anxiety disorders. (23 districts each) Treatment gap- 50% for severe mental disorders and over 90% for common mental disorders Contribution to total DALYs increased from 2.5% in 1990 to 4.7% in 2017. Mental disorders were the leading contributor in India to years lived with disability (YLDs) , contributing 14.5% of all YLDs in 2017. Depression contributed 33.8% of all mental disorder DALYs in India in 2017, followed by anxiety disorders (19.0%), idiopathic developmental intellectual disability (10.8%), and schizophrenia (9.8%). Interpretation: One in seven Indians were affected by mental disorders of varying severity in 2017. The proportional contribution of mental disorders to the total disease burden in India has almost doubled since 1990. According to WHO country data of 2014, India has 43 mental hospitals with 2.1/100000 mental hospital beds and 0.6/100000 mental health workers.(4) 1. Sagar R, Dandona R, Gururaj G, Dhaliwal RS, Singh A, Ferrari A, et al. The burden of mental disorders across the states of India: the Global Burden of Disease Study 1990–2017. The Lancet Psychiatry. 2020 Feb 1;7(2):148–61. ‹#›

5. The life time prevalence in the surveyed population was 13.7%. Nearly 150 million Indians are in need of active interventions ‹#›

6. As per the National Survey of Mental Health Resources carried out by the DGHS, MoHFW, GOI during May and July, 2002, the ideal required number of mental health professionals has been calculated [1] Psychiatrist: 1.0 per 1,00,000 population Clinical Psychologists: 1.5 per 1,00,000 population Psychiatric Social Workers: 2.0 per 1,00,000 population Psychiatric Nurses: 1.0 per 10 psychiatric beds. Based on the above, the details of present requirement and availability of mental health professionals in the country is: Burden Manpower Requirement Availability Psychiatrist 11,500 3,800 Clinical Psychologist 17,250 898 Psychiatric Social Workers 23,000 850 Psychiatric Nurses 3,000 1,500 Total 54,750 7,038 Shortage of 47702 HCWs Availability of only 12.87% 1. National Mental Health Programme [Internet]. Pib.gov.in. 2003 [cited 4 February 2021]. Available from: https://pib.gov.in/newsite/PrintRelease.aspx?relid=101742 ‹#›

7. History British rule - Mental asylums. 1920s- proposal to change the name of mental asylums to mental hospitals. 1940s- emphasis to improve the conditions of existing mental health care and treatment programmes . The Bhore committee report 1946 Prevalence of mental illness during that period: 2/1000 general population India had only 10,000 psychiatric beds and 30 institutions for a population of over 400 million. Need - 1,000,000 for country as whole . MS salary was equal to that of a first class mechanic in Tatas Works. 6 of them had little to no PG training in psychiatry. Madras Lunatic Asylum (1794) Full-filling only 1% of the total need. ‹#›

8. Bhore Committee (1946) The committee recommended to create mental health organizations as part of Directorate General of Health Services at the center and as a part of Directorate of Health Services in the states i mprove existing mental hospitals in British India and establish two new institutions during first five years and five more during the next five years, provide training facilities for mental health to medical and paramedical personnel in India and abroad, and establish a Department of Mental Health in the proposed All India Medical Institute. ‹#›

9. Mudaliar Committee (1959) The committee observed; Reliable statistics were not available regarding the burden of mental health problems/morbidity in India. There must be a huge number of patients requiring assistance and treatment. The provision for treatment of psychosomatic diseases was limited. There were no avenues for education of mentally sick. The committee recommended; The setting up of in-patient and outpatient departments at hospitals. Setting up of Independent Psychiatric and Mental health clinics and Institutions for mentally sick. To develop the Psychiatric clinics with 5-10 beds in each district.(6) Later, implementation of community care approaching provision of mental health services. Several centers starting with Central Institute of Psychiatry, Ranchi, in 1964 adopted Community Mental Health work. Later on taken up by other centres like NIMHANS, PGIMER followed by the centres at Baroda, Kolkata, Hyderabad, Lucknow, Jaipur, Patiala, Delhi and Vellore. ‹#›

10. Milestones leading to NMHP In the post independence time, the initial two decades were focused on increasing the number of beds for mental hospitals. Some new mental hospitals were started and All India Institute Mental Health was setup in 1954 which later became NIMHANS in 1974. The concept of community psychiatry was initiated by CIP Ranchi by starting a rural mental health clinic in 1967 at Mandar. Major community mental health initiatives were taken at NIMHANS Bangalore and PGIMER Chandigarh during 1970’s. Community Psychiatry unit was established by NIMHANS. India is one of the first few countries in the developing world to formulate the NMHP. ‹#›

11. Development of NMHP A set of recommendation by an Expert Committee of WHO- endorsed the strategy of integrating the mental health services into the primary care services. Starting of “Community Mental Health Unit” at National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore: In 1975. Sakalwara Project. Community Mental Health Unit at NIMHANS carried out the mental health need assessment and situation analysis in nearly 200 villages around the Sakalwara rural mental health centre, covering a population of 100,000. Simple ways of identifying and managing persons with mental illness, epilepsy mental retardation were developed. The Mental Health education material was developed which could be used by the MPW in rural areas. Manuals for PHC personnel were developed and it was also decided that how the training‟s provided to the PHC personnel can be evaluated. The overall experience of Sakalwara Project led to development of strategy for provision of Mental Health care to the rural areas through the existing primary health care network. Multi Country Project WHO: “Strategies for extending Mental Health Services into the Community (1976-1981). This model of care proposed the integration of mental health with general health services and provision of basic mental health care by trained health workers and doctors. This was executed as a multicounty project in 7 developing countries. The department of Psychiatry at PGIMER Chandigarh was the centre in India and the model was developed in Raipur Rani Block of Haryana. The “Declaration of Alma Ata” to achieve “Health for all by 2000” (1978). The increasing awareness regarding the mental health problems and the Alma-Ata Declaration in 1970, which emphasizes on the health for all by 2000 led to the launching of NMHP by Govt. of India in 1982. ICMR-DST Collaborative Project on “Severe Mental Morbidity” ‹#›

12. National Mental Health Program (NMHP) In 1982- the Central Council of Health and Family Welfare (CCHFW) adopted as well as recommended the implementation of NMHP in India. NMHP was launched in 1982 with very comprehensive objectives which stand true even today. ‹#›

13. Objectives mental healthcare for all in the foreseeable future particularly to the most vulnerable and most underprivileged sections of the population. To ensure the availability and accessibility of mental health knowledge in general health care and social development. Encourage application of mental health services development and stimulate efforts towards self-help in community. Promote community participation in ‹#›

14. Strategies Integration of mental health with primary health care through the NMHP . Provision of tertiary care institutions for treatment of mental disorders. Eradicating stigmatization of mentally ill patients and protecting their rights through regulatory institutions like the Central Mental Health Authority (CMHA) and State Mental Health Authority (SMHA). ‹#›

15. · Diffusion of mental health skills to the periphery of health services · Appropriate appointment of tasks · Equitable and balanced distribution of resources. · Integration of basic mental health care with general health services · Linkage with community development Specific approaches [1] 1. Chandrashekhar CR. Community psychiatry (Chapter 25 from Handbook of psychiatry A South Asian Perspective Edited by Dinesh Bhugra, GopinathRanjith, Vikram Patel.) Byword Viva Publishers Pvt Ltd, New Delhi. ‹#›

16. Mental Health services in the recent times Mental hospitals or mental asylums are no longer considered institutions of choice - results in isolation of the patients from the community, loss of social skills, stigmatization, abandonment by the families, maltreatment and human rights abuse. - availability of new generation antipsychotic drugs. -treat most patients on outpatient basis and high effectiveness of community-based care, Hence, community-based care is preferred over the obsolete strategy of mental asylums. Source: National Mental Health Programme-Annual progress Report (1982-1990), DGHS, New Delhi ‹#›

17. Components of NMHP NMHP District Mental Health Programme Up-gradation of Psychiatric Wings of Govt. Medical Colleges Modernization of Govt. Mental Hospitals During the 11th Five Year Plan, the NMHP was restructured to include Manpower Development Schemes. NMHP ‹#›

18. Service components ‹#› Teaching psychiatric units and mental hospitals District Hospital Primary Health Centre Village and sub centre level Management of psychiatric emergencies. Administration and supervision of maintenance treatment for chronic psychiatric disorders. Diagnosis and management of Grand –mal epilepsy. Liaison with local school teacher and parents regarding mental retardation and behavior problems in children. Counselling in problems related to alcohol and drug abuse. Supervision of MPW’s performance. Elementary diagnosis. Treatment of functional psychosis. Treatment of uncomplicated cases of psychiatric disorders associated with physical diseases. Management of uncomplicated psychosocial problems. Epidemiological surveillance of mental morbidity. The district hospital to have 30-50 psychiatric beds Atleast 1 psychiatrist attached to every district hospital. The psychiatrist was entrusted with the responsibility of clinical care of patients and training and supervision of non-specialist health workers. Providing help for difficult cases. Teaching. Specialized facilities such as occupational therapy units, psychotherapy, counselling and behavior therapy.

19. Service components [1] Rehabilitation Maintenance treatment of epileptics and psychotics at the community levels. Development of rehabilitation centers at both the district level and the higher referral centers. Prevention Community based , with the initial focus on the prevention and control of alcohol related problems. Later on other issues like addictions, juvenile delinquency and suicides. 1. Ahuja N. Community Psychiatry (from A short Textbook of Psychiatry, Pg 236,7th Ed) Jaypee Brothers Medical Publishers (P) Ltd, New Delhi. ‹#›

20. Implementation [1] National Mental Health Programme after being initiated in 1982 did not make much headway during Seventh or Eighth Plan . During 1996-97, District Mental Health Programme was launched with a community-based approach (developed by NIMHANS, known as Bellary Model) under NMHP, As a pilot in four districts, one each in the states of Andhra Pradesh, Tamil Nadu, Assam and Rajasthan. The programme now covers 339 districts, across all 36 states/UTs in the country. 1. Sixty sixth World Health Assembly, Comprehensive Mental Health Action Plan 2013-2020. Available at: apps.who.int/gb/ebwha/pdf_files/WHA66/A66_R8-en.pdf ‹#›

21. Implementation The main strength of NMHP document drafted in 1982 was that it envisaged the integration of mental healthcare with the general primary healthcare. On the other hand there was some inherent weakness of this model of care: Emphasized more on curative components rather than the preventive and promotive. Role of support of families in the treatment of the patient was not given importance; Short term goals were given priority over the long term planning The administrative structure of the program was not clearly outlined No estimates of budgetary support were made. 1. Sixty sixth World Health Assembly, Comprehensive Mental Health Action Plan 2013-2020. Available at: apps.who.int/gb/ebwha/pdf_files/WHA66/A66_R8-en.pdf ‹#›

22. Implementation [1] Despite progress made during 1982-88, the financial constraints restricted it. In the 9th five year plan ₹28 crores were allocated to NMHP. In depth analysis and consultation with the stakeholders led to a major change in NMHP and was launched with certain changes in 2003.14 NMHP 10th five year plan was launched , with a plan to extend the DMHP to 100 districts. In the 10th plan allocated ₹139 crores to NMHP and emphasized: The need to broaden the scope of existing curriculum for undergraduate training in psychiatry and to give more exposure to psychiatry in undergraduate years and internship. Need for DMHP to be spread to the entire country in a more effective manner. Streamlining /modernization of mental hospitals to overcome their custodial role. Strengthening the Central and State mental health authorities with a permanent secretariat. Appointment of MO at state headquarters. Research and training in the field of community mental health, substance abuse and child/adolescent psychiatric clinics. [2] Khurana S, Sharma S. National mental health program of India: a review of the history and the current scenario. Int J Community Med Public Health 2016;3:2696-704 Agrawal SP, Goel DS, Ichpujani RL. Mental Health: Indian Perspectives, 1946-2003. Directorate General of Health Services, Ministry of Health and Family Welfare: New Delhi. 2004 ‹#›

23. Implementation During the 11th Five year plan in NMHP the focus was on establishing centers of excellence in mental health, increasing intake capacity and starting postgraduate courses in psychiatry, modernization of mental hospitals and up-gradation of medical college psychiatry departments, focus on non-government organizations (NGOs) and public sector partnerships, media campaign to address stigma , a focus on research and several other measures.[1] 1. Ahuja N. Community Psychiatry (from A short Textbook of Psychiatry, Pg 236,7th Ed) Jaypee Brothers Medical Publishers (P) Ltd, New Delhi. ‹#›

24. Implementation NMHP in 12 th FYP- on psychiatric problems specific to certain vulnerable sections of the population who are often marginalized and neglected owing to lack of effective advocacy. Special issues Senior citizens suffering from severely disabling diseases such as depressions of late onset and other psycho geriatric disorders. Victims of child sexual abuse, marital/ domestic violence and dowry related ill-treatment, rape and incest. Children and adolescents affected by problems of maladjustment of other scholastic problems, depressions, psychosis of early onset, attention deficit hyperactivity disorders and suicidal behavior resulting from failure in examination or other environmental stressors. Victims of poverty, destitution and abandonment such women thrown out of the marital home or old and infirm parents left to fend for themselves. Khurana S, Sharma S. National mental health program of India: a review of the history and the current scenario. Int J Community Med Public Health 2016;3:2696-704 . ‹#›

25. Optimal mix of different mental health services (Source: Mental health policy and service guideline package. Geneva: WHO; 2003 pp 34 & World Health Report, 2006) ‹#›

26. District Mental health program (DMHP) NIMHANS developed a program to operationalize and implement the NMHP in a district. DMHP was launched in 1996 with an aim to achieve the objectives of NMHP. Pilot of DMHP- Bellary district in Karnataka . Total population- 20 lakhs at that time. The main approaches of DMHP were training of medical, paramedical personnel and community leaders, Community Mental Health care through existing infrastructure of the health services and the most important component being the Information, Education and Communication (IEC) activities . ‹#›

27. District Mental health program (DMHP) Initially the community based mental health care at district level was initiated in four districts in 1996. It was extended to 27 districts across 22 states/UTs in the 9th 5- year plan. NMHP was re-strategized during the 10th 5 year plan: DMHP was expanded and more components were added to make it more comprehensive. There was expansion of DMHP to 100 districts all over the country , modernization of state-run mental hospitals, up-gradation of Psychiatry wings in the Government medical colleges/general hospitals, IEC activities, research and training in mental health for improving service delivery. At the end of the 10th 5 year plan, DMHP was extended to 110 districts , up-gradation of psychiatric wings of 71 medical colleges. Modernization of 23 mental hospitals and general hospitals was funded. In the 11th five year plans DMHP was spread to 123 districts in 30 states /UTs. [1] 1. Salhan RN, Sinha SK, Kaur J. Asia Australia Community Mental Health Development Project, Asia Australia Mental Health. Melbourne. Country Report-India. 2008 ‹#›

28. District Mental health program (DMHP) Team (district) :- DMHP has now incorporated promotive and preventive activities for positive mental health which includes:17 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 centre at district level, sensitization workshops, IEC, helpline Psychiatrist Clinical Psychologist Psychiatric Social worker Psychiatry/Community Nurse Program Manager Program/Case Registry Assistant Record Keeper ‹#›

29. Other objectives of the DMHP are: To reduce the stigma attached towards mental illness; To promote community participation in the mental health service development and to stimulate efforts towards self-help in the community To increase access to preventive services to the population at risk, in particular, addressing the risk of suicide and attempted suicide; To inform the person with mental illness, their caregivers, professionals and other stake-holders of the rights of persons with mental illness and ensure that rights are respected during the provision of care and services; To broad base mental health into other related programmes , such as RCH, SSA, workplace intervention and similar programmes; To ensure a motivating and empowering workplace for staff by allowing an opportunity to improve their skills and recognition of their work To generate knowledge and evidence related to the delivery of mental health care and services To improve the infrastructure for mental health service delivery: To establish governance , administrative and accountability mechanism to realize the above objectives. DMHP in the 12 th FYP plan [1] Goal of the DMHP : To improve health and social outcomes related to mental illness. Primary Objective To reduce distress , disability and premature mortality related to mental illness and enhance recovery from mental illness by ensuring the availability of and accessibility to mental health care for all in the 12 th Plan period, particularly the most vulnerable and underprivileged sections of the population. Promotive and preventive activities funded under DMHP: Life skills education: In schools, counselling services College counselling trained services: Through teachers/counsellors Workplace stress management: Formal and informal sectors, including farmers, women, etc. Suicide prevention services: Counselling Centre at District level, Sensitization Workshops, IEC, Helplines, etc. ‹#›

30. Manpower Development Scheme 11 th FYP - effort to address the main barrier : the shortage of manpower . A component of manpower development scheme was developed; To improve the training infrastructure in mental health, Government of India had approved the Manpower Development Components of NMHP for 11 th five year plan. It has two schemes: a. Centers of excellence (Scheme - A) b. Setting up/ Strengthening PG Training Department of Mental Health Specialties (Scheme - B). Centers of excellence (Scheme – A) At least 11 Centers of Excellence in Mental health were to be established by upgrading existing mental health institutions/ hospitals. A grant of ₹30 crores for each centre (total 338 crores) was made available for undertaking the capital work, equipment, library, faculty induction and retention. At present the academic sessions have already started in 8 out of 11 centers and the process in the rest have been initiated. ‹#›

31. Manpower Development Scheme Setting up/strengthening PG training department of mental health specialties (Scheme - B) Government Medical College/Hospitals -supported to start PG Courses in Mental Health or to increase the intake capacity for PG training in Mental Health. Establishing/improving mental health departments 30 departments of Psychiatry, 30 departments of Clinical Psychology, 30 departments of Psychiatric Social work 30 departments of Psychiatric Nursing); Equipment, tools and basic infrastructure Support for engaging required/ deficient faculty for starting/enhancing the PG Courses . The support of up of ₹ 51 lakhs to ₹ 1 crore per PG Department was made available. As of now the 27 PG departments in 11 institutes have been taken up. The manpower development and the expansion of DMHP services will gradually lead to increase in number of mental health professionals in the districts and in the Institutions which have been given grant for manpower development schemes. ‹#›

32. Monitoring and evaluation In order to strengthen the monitoring and improve implementation of existing NMHP schemes in states, support has been approved under the programme during Eleventh Plan period. Financial support available for the same. A survey to ascertain the number of mentally ill patients and availability of mental health resources in the country has been commissioned through NIMHANS, Bengaluru in 2012. ‹#›

33. Information, Education and Communication To overcome low awareness regarding mental illness and availability of treatment, Reduce stigma attached to mental illness and provisions under Mental Health Act, District Mental Health Programme addresses these issues through IEC activities at the district level. In addition to the district level activities, NMHP division conducts nationwide mass media campaign through audio, video and print media . Awareness activities are also conducted during World Suicide Prevention Day on 10th September and World Mental Health Day on 10th October. ‹#›

34. Research and Training Funds are provided to institutes/organisations for carrying out basic, applied and operational research in mental health field. In order to address shortage of skilled mental health manpower a short-term skill-based training is provided to the DMHP teams at identified institutes. Standard treatment guidelines, training modules , CME, distance learning courses in mental health, surveys, etc. are also supported ‹#›

35. Support for Central and State Mental Health Authorities As per 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/UT Also responsible for the implementation of Mental Health Act, 1987, in their respective states and union territories. States are required to have functional SMHAs to operationalize the mental health programme activities. Till date funds have been a provided to State Mental Health Authorities in 32 states/UTs . ‹#›

36. NGO Support and Public-Private Partnership Contribute in IEC Activities; Support for health promotion using life skill approach; Support for follow up of severely mentally ill persons in community; Support for mentally retarded children and their families.; Organization of mental health camps ; Networking with primary health care team; Facilitation of disability welfare benefits for the mentally ill and mentally challenged and also for home care of severely mentally ill person. Khurana S, Sharma S. National mental health program of India: a review of the history and the current scenario. Int J Community Med Public Health 2016;3:2696-704 . ‹#›

37. Mainstreaming NMHP into NHM There has been an intensified effort to mainstream the components of NMHP under the National health mission so as to enable the states to plan requirements concerning mental health services for their specific areas. The existing district where the DMHP is presently under implementation continues to be supported under the NRHM on the existing norms. The advantages of mainstreaming the NMHP through NHRM are: Optimal use of existing infrastructure at various levels of the health care delivery system. Use of the NHRM platform for transfer /flow of funds to the states/UTs for better accountability and flexibility in implementation of program Integrated IEC activity under NHRM Involvement of NHRM infrastructure for training related to the mental health in the district Use of NHRM machinery for procurement of drugs for NMHP Using improved linkages /communication under the NHRM for MIS (Management Information System) in NMHP Sustaining DMHP after the expiry of the period of central assistance in the district by its integration in the district health system. NUHM would ensure: Resources for addressing the health problems in the urban areas Partnership with the community for a proactive involvement in planning, implementation and monitoring of health activities Khurana S, Sharma S. National mental health program of India: a review of the history and the current scenario. Int J Community Med Public Health 2016;3:2696-704 . ‹#›

38. WHO Mental Health Action Plan 2013-2020 [1] In 2013 WHO, in consultation with its member states, formulated Mental Health Action Plan 2013-2020, with the overall goal to promote mental well-being, prevent mental disorders, provide care , enhance recovery, promote human rights and reduce the mortality , morbidity and disability for persons with mental disorders. The action plan has the following objectives: To strengthen effective leadership and governance for mental health; To provide comprehensive, integrated and responsive mental health and social services in community-based settings; To implement strategies for promotion and prevention in mental health; To strengthen information systems , evidence and research for mental health. Targets for achieving these objectives and indicators to measure progress have been laid down. WHO, and all its member states, are committed to achieve these objectives. WHO Mental Health Action Plan 2013-2020. World Health Organization, Geneva 2013. [Cited 04 Feb 21). Available from http://apps.who.int/iris/bitstream/10665/89966/1/9789241506021 eng.pdf ‹#›

39. Mental Health Policy (MHP) 2014 The vision of the National Mental Health Policy is to promote mental health, prevent mental illness, enable recovery from mental illness, promote destigmatization and desegregation , and ensure socio-economic inclusion of persons affected by mental illness by providing accessible, affordable and quality health and social care to all persons through their life-span within a rights-based frame work. Goals of the policy To reduce distress, disability, exclusion morbidity and premature mortality associated with mental health problems across life span of the person. To enhance understanding of the mental health in the country. To strengthen the leadership in the mental health sector at the national, state and district levels. Objectives of the Policy To provide universal access to mental health care. To increase access to and utilisation of comprehensive mental health services by persons with mental health problems. To increase access to mental health care especially to vulnerable groups including homeless persons, persons in remote areas, educationally, socially and deprived sections. To reduce prevalence and impact of risk factors associated with mental health problems. To reduce risk and incidence of suicide and attempted suicide. To ensure respect for rights and protection from harm of persons with mental health problems. To reduce stigma associated with mental health problems. To enhance availability and equitable distribution of skilled human resources for mental health. To progressively enhance financial allocation and improve utilisation for mental health promotion and care. To identify and address the social, biological and psychological determinants of mental health problems and to provide appropriate interventions. 1. National Mental Health Policy 2014. [Cited: 04 Feb 21]; Available from https://www.nhp.gov.in/sites/default/files/pdf/national%20mental%20health%20policy%20of%20india%202014.pdf ‹#›

40. Mental Health Act 2017 Mental illness shall be determined in accordance with nationally or internationally accepted medical standards. Every person with mental illness shall have the right to make decisions concerning his/her mental health care or treatment. Every person, except a minor, will have the right to make an Advance Directive specifying the way the person wishes to be cared and treated for a mental illness . He/she will have the right to appoint a nominated representative , who is entrusted with the task of protecting the interests of the person suffering from mental illness. A person attempting suicide shall be presumed to be suffering from severe stress hence, exempt from trial and punishment. It shall be the duty of the government to rehabilitate such a person, to ensure that there is no recurrence of attempt to suicide. Every person with mental illness shall have a right of affordable, accessible and quality mental health care and treatment from mental health services run or funded by Central and State governments, without discrimination. Every person with mental illness shall have a right to live in, be part of and not be segregated from society ; and not continue to remain in a mental health establishment, merely because he/she does not have a family or is not accepted or by his/her family or is homeless due to absence of community-based facilities. In such a case it shall be the duty on the appropriate government to provide support as appropriate including legal aid and to facilitate exercising the right to family home and living in the family home . Khurana S, Sharma S. National mental health program of India: a review of the history and the current scenario. Int J Community Med Public Health 2016;3:2696-704 . ‹#›

41. Mental Health Act 2017 Every person with mental illness shall be treated as equal to persons with physical illness in the provision of all health care. Every person with mental illness shall have the right to live with dignity and also protect his/her confidentiality as regards to his/her illness and treatment as well as be provided with medical facilities. It shall be the duty of the government to plan, design and implement programmes for the promotion of mental health and prevention of mental illness in the country. The following treatments shall not be performed on any person with mental illness: Electroconvulsive therapy without the use of muscle relaxants and anaesthesia; Electroconvulsive therapy for minors; Sterilisation of men or women, when such sterilisation is intended as a treatment for mental illness; Chained in any manner or form whatsoever. Central and State governments shall establish Central and State Mental Authority as well as Mental health Review Board. ‹#›

42. Barriers to the Implementation of NMHP Poor funding Limited undergraduate training in psychiatry Inadequate mental health human resources Lack of policy driven epidemiological data and research driven mental healthcare policies Lukewarm response by mental health professionals Limited number of models and their evaluation Uneven distribution of resources across states Non-implementation of the MHA, 1987 Privatization of healthcare in the 1990s. ‹#›

43. Summary India was one of the major World Health Organization (WHO) member countries to launch its National Mental Health Programme (NMHP) in 1982. NMHP underwent major strategic revisions over its course, starting from setting a district as the unit for program planning and implementation under the District Mental Health Program (DMHP) to incorporating it with the National Rural Health Mission (NRHM) for effectively scaling up the program. The program also underwent evaluations by government bodies and independent agencies and was reviewed by many researchers. The program has been partly successful in terms of enhancing its reach to community , improving service delivery, and getting increased budgetary allocation, but at the same time, its impact was limited by financial and human resource constraints, lack of community participation, ineffective training, poor NGO/private partnership, and lack of a robust monitoring and evaluation (M and E) system. The latest National Mental Health Policy and the incorporation of its objectives have given a new impetus to the ongoing NMHP, however, its implementation needs to be monitored and the impact is yet to be evaluated. ‹#›

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