National mental health programme (nmhp)

1. NATIONAL MENTAL HEALTH PROGRAMME(NMHP) AND DISTRICT MENTAL HEALTH PROGRAMME (DMHP): WHAT HAS BEEN ACHIEVED AND FUTURE COURSE SATYAKAM MOHAPATRA JUNIOR RESIDENT –III rd Year

2. OVERVIEW NMHP AND DMHP Evolution and implementation Achievements Reasons for slow progress Future recommendations

3. MENTAL HEALTH DISORDERS IN INDIA All kinds of mental and behavioural 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 “ In developing countries basic mental health care should be decentralized and integrated with the existing system of general health services”.

4. FACTORS CONTRIBUTING TO THE DRAFTING OF THE NATIONAL MENTAL HEALTH PROGRAMME FOR INDIA 1)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. (2) Starting of “ Community Mental Health Unit ” by NIMHANS , Bangalore – 1975 SAKALWARA PROJECT : Focus on developing services and model. (3) WHO Multi-country project: “Strategies for extending mental health services into the community” (1976-1981) RAIPUR RANI PROJECT - Focus on testing and evaluating models. (4) 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. NATIONAL MENTAL HEALTH PROGRAMME ( NMHP) OF INDIA 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).

6. OBJECTIVES OF NMHP (1) To ensure the availability and accessibility of minimum mental healthcare for all in the foreseeable future, particularly to the most vulnerable and underprivileged sections of the population . (2) To encourage the application of mental health knowledge in general healthcare and in social development. (3) To promote community participation in the mental health service development and to stimulate efforts towards self-help in the community.

7. STRETEGIES FOR IMPLEMENTATION OF NMHP CENTRE TO PERIPHERY STRATEGY : Establishment and strengthening of psychiatric units in all district hospitals, with outpatient clinics and mobile teams reaching the population for mental health services . PERIPHERY TO CENTRE STRATEGY : Training of an increasing number of primary health care health personnel in basic mental health skills to provide minimum mental health care to the people. With availability of referral service.

8. APPROACHES OF NMHP Integration of the mental health care services with the existing general health services. To utilize the existing infrastructure of health services and to deliver the minimum mental health care services. To provide appropriate task oriented training to the existing health staff. To link health services with the existing community development programme .

9. SERVICE COMPONENTS OF NMHP TREATMENT REHABILITATION PREVENTION

10. INITIAL PROBLEMS FACED IN IMPLEMENTATION OF NMHP AFTER 1982 : No budgetary estimates or provisions were made for the implementation of the programme. There was a very lukewarm response to the programme by psychiatrists the country . Difficulty in implementing the programme in larger populations and in real world settings. Realizing that the NMHP was not likely to be implemented on a larger scale without demonstration of its feasibility in larger populations, the need for planning for the implementation of the programme at a district level was highlighted .

11. Development of the pilot district mental health programme at Bellary district in Karnataka : Training in basic mental health care in a decentralized manner. Provision of 6 essential psychotropic and anti epileptic drugs . Mental health team a t the district head quarters. A system of simple mental heath case records , monthly reporting, regular monitoring and feed back from the district level mental health team. 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.

12. DISTRICT MENTAL HEALTH PROGRAMME (DMHP) In 1996 the Ministry Of Health and Family Welfare, Govt. Of India formulated district mental health programme (under national mental health programme) as a fully centrally funded programme .

13. OBJECTIVES OF DISTRICT MENTAL HEALTH PROGRAMME To provide sustainable mental health services to the community and to integrate these services with other services. Early detection and treatment of patients within the community itself. To see that patient and their relatives do not have to travel long distances to go to hospitals or nursing homes in cities. To take pressure off mental hospitals. To reduce the stigma attached towards mental illness through change of attitude and public education. To treat and rehabilitate mentally ill patients discharged from the mental hospital within the community

14. IMPLEMENTATION OF DMHP The District Mental Health Programme was launched during 1996-97 in four districts. During the IX Five Year Plan DMHP was extended to 27 districts spread all across the country. 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.

15. COMPONENTS OF SERVICES PROVIDED BY DMHP (REVISED IN 11 th FIVE yr PLAN) BASIC MENTAL HEALTH CARE FOLLOW UP OF TREATED CASES INFORMATION , EDUCATION AND COMMUNICATION(IEC ) ACTIVITIES SCHOOL MENTAL HEALTH PROGRAMME COLLEGE MENTAL PROGRAMME SUICIDE PREVENTION

16. BASIC MENTAL HEALTH CARE FACILITIES Out door facilities In patient facilities Referral services Follow up services

17. STAFF PATTERN OF DMHP Nodal officer Psychiatrist Clinical psychologist Psychiatric social worker Staff nurse

18. COMPONENTS OF DMHP TRAINING Doctor Nurse Paramedical staff

19. IEC Mental health awareness programmes. A variety of educational and awareness building activities on different aspects of mental disorders and mental health. Use of local print media as well as other forms of mass media like public talks, exhibitions, street plays, use of educational slides in local movie theatres, providing information through local cable TV.

20. DMHP Currently DMHP is being implemented in 123 districts in the country .

21. MENTAL HEALTH IN 11 TH FIVE YEAR PLAN ( 2007-2013): ( GOI, 2007, Planning commission, 2006, Srinivasa murthy,2007 ) (1) FUNDING: During the 11 th Five Year plan, there has been substantial increase in the funding support for NMHP . The total amount of funding allotted is Rs.1000 crores ( a three fold increase from the previous Five Year Plan).

22. MENTAL HEALTH IN 11 TH FIVE YEAR PLAN (Contd.) (2) MANPOWER DEVELOPMENT: SCHEME (A) Establishment of 11 Centres of Excellence in the field of mental health by upgrading and strengthening existing mental health hospitals/institutes. 44 psychiatrists 176 clinical psychologists 176 psychiatric social workers 220 psychiatric nurses SCHEME (B) setting up/strengthening 30 units of psychiatry, 30 departments of clinical psychology, 30 departments of psychiatric social work, and 30 departments of psychiatric nursing with the financial support to postgraduate department . 60 psychiatrists 240 clinical psychologists 240 psychiatric social workers 600 psychiatric nurses Together, these two schemes will produce 1756 qualified mental health professional annually.

23. MENTAL HEALTH IN 11 TH FIVE YEAR PLAN (Contd.) (3) Spill over activities of the 10 th Plan : Up gradation of the psychiatric wings of Government medical colleges/general hospitals   (4) Modernizations of state run mental hospitals .     (5) To integrate NMHP with the National Rural Health Mission (NRHM ). (6) Importance on added components of DMHP i.e. Life Skills training and counselling in schools, counselling service in colleges, work place stress management and suicide prevention services .

24. MENTAL HEALTH IN 11 TH FIVE YEAR PLAN (Contd.) (7) Research -There is huge gap in research in mental health which needs to be addressed. (8) IEC -An intensive media campaign is planned for 11th Plan duration. (9) NGOs and Public Private Partnership for implementation of the Programme. This would increase the outreach of community mental health initiatives under DMHP. (10) Monitoring ,Implementation & Evaluation -Effective monitoring at Central/State/District level will facilitate implementation of various components of NMHP.  

25. DMHP EVALUATION The evaluation of DMHP carried out during 2009, by the Indian Council of Marketing Research(ICMR), New Delhi, covering 20 of the 123 districts of DMHP. 20 DMHP districts and 5 Non-DMHP districts (as control) were compared.

26. RESULTS OF THE EVALUATION 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”

27. RESULTS OF THE EVALUATION (cont.) 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 centres. “ This is because of lack of dedicated drug procuring mechanism for DMHP”  

28. RESULTS OF THE EVALUATION (cont.) 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”  

29. RESULTS OF THE EVALUATION (cont.) Awareness about the types of mental illness were found to be significantly higher in DMHP districts as compared to non-DMHP districts . Consulting traditional practitioners was suggested by only 47.3% of respondents from DMHP districts as against over 70% of non-DMHP respondents. “ This indicates that DMHP has been able to spread awareness in the districts where it was being implemented ”

30. RESULTS OF THE EVALUATION (cont.)   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”

31. RESULTS OF THE EVALUATION (cont.) TRAINING: 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”

32. MANPOWER DEVELOPMENT UNDER NMHP To increase the availability of trained personnel required for mental health care, 7 Centres of Excellence have been funded against the 11 that are to be set up during the Eleventh Plan. Support has been provided to 19 PG ( postgraduate) departments during the year 2009–10 for manpower development . ( Annual Report on Health of the Ministry of Health and Family Welfare, September, 2010, relating to mental health )

33. UPGRADATION OF THE OF MENTAL HOSPITALS (Under NMHP) T he National Human Rights Commission carried out 2 systematic reviews of mental hospitals in India in 1998 and 2008. Following the initial report, as part of the NMHP, funds were provided for upgrading the facilities of mental hospitals. This has resulted in positive changes over the past 10 years as shown by the 2008 (NIMHANS) report : Admissions through courts has decreased from about 70% to 20% Long-stay patients has decreased from 80 % to about 35 %. Rehabilitation facilities have increased from 10 to 23 institutions . Use of electroconvulsive therapy (ECT) has reduced and use of modified type ECT has increased from 9 to 27 institutions. “ Overall there were more changes in the past 10 years than in the preceding 5 decades”

34. APPRAISAL OF THE EXISTING NMHP

35. APPRAISAL OF THE EXISTING NMHP NMHP has expanded steadily across the country during the past two Five Year Plan periods, so appraisal of the existing situation is required.

36. APPRAISAL OF THE EXISTING NMHP ( 1) ASSESSMENT OF THE FEASIBILITY OF INTEGRATION OF MENTAL HEALTH WITH PRIMARY CARE : The soundness of this approach has been emphasized by several international organizations . This integration is “the only realistic option ” due to continuing resource constraints in developing countries (WHO). It will take years to place psychiatrists/psychologists in 600 districts in the country when there is not even a general physician (GP) available in those area.

37. APPRAISAL OF THE EXISTING NMHP (2) EFFECTIVENESS OF THE IMPLEMENTATION OF NMHP : Several reports on the assessment of implementation of DMHP suggest that the current implementation is far from optimal and the reasons are numerous : LACK OF MOTIVATION AND COMMITMENT OF THE STATE HEALTH AUTHORITIES (From Directorate of Health Services to chief medical officers): Partial integration Differential effectiveness

38. Limited development of the DMHP in its operational aspects by the Central agency : The core idea of integration has not been fully developed to operational level so that the states could follow the guidelines. The components of the programme like the training manuals, treatment guidelines, IEC activities have been developed to a limited extent. Limited state level capacity to implement the DMHP : In most states the mental health programme is under the responsibility of non-psychiatrists and often as one of the many other responsibilities. As a result the technical inputs required for the programme have not been invested in the programme.

39. . Inadequate technical support from professionals: At the initial stages of the programme, NIMHANS, Bangalore and few other centres provided the technical inputs (training manuals for PHC personnel) and field level experiences of implementing programme on a regular basis. All of these developments needed further field level application, modification when the DMHP moved from demonstration project to programmatic stage of expansion to a large number of centres. Location of the DMHP with teaching centres : The teaching centres did not have the knowledge of public health as well as did not work with the field level personnel to make the programme effective. Training at medical colleges without involving the DMHP team

40. Difficulties in recruitment and retention of mental health professionals in the DMHP Lack of mental health indicators: Simple indicators to address the objectives Clinical outcome Lack of monitoring: There is no central/state level technical advisory committees to monitor the programme and carry out the evaluation. Lack of emphasis on creating awareness in the community: IEC activities are the most important need and least emphasized till recent times. Lack of involvement of the non-governmental organizations (NGO) and the private sector in DMHP.

41. ( 3) EFFECTIVENESS OF PRIMARY CARE MENTAL HEALTH No adequate data on long term effects of primary mental health care are available to make meaningful interpretations. Mental health training programmes for primary care personnel has brought improvements in their mental health knowledge and diagnostic sensitivity . But there is only little evidence of changes in actual practice of health workers and better outcomes for patients.

42. (4) INDEPENDENT EVALUATION OF THE DMHP Regular independent evaluation of DMHP is lacking. Last independent evaluation was carried out by the Indian Council of Marketing Research (ICMR) during 2008-2009. Regular evaluations will provide recommendations and suggestions for improvements in implementation and future expansion of the programme.

43. Most common problems Lack of motivation and commitment Lack of manpower

44. FUTURE OF NMHP India with a population of about 1.2 billion and extremely limited number of trained mental health professionals, the basic approach of the NMHP continues to be an acceptable and feasible method of extending basic mental health services to the whole country . The main component of the NMHP namely the district mental health programme was developed more than 15 years ago and has not changed much since then. The approach needs a major technical and operational review and certain corrections following the review are necessary. The situation across the country varies significantly in different states . Local issues should be identified, and feasibility of programme implementation should assessed. Appropriate local modifications to the basic programme will have to be made in different parts of the country.

45. For more efficient and quick countrywide implementation of the programme, many of the salient recommendations of the recent independent review of the DMHP will have to be seriously considered :   1 . Strengthening of mental health services at the sub-centre, PHC and CHC levels to make the service more accessible. 2. NMHP is currently a fully centrally funded Plan programme. The financial responsibility for the programme will have to be gradually shifted to the state governments and mental health services will have to be integrated in the State and District Implementation Plan .

46. 3. To enhance the capacity in the country to train mental health professionals . Staff positions in DMHP will have to be made more attractive to motivate and retain professional staff. The DMHP staffs also require training in programme management and organizational activities. Appropriate non-pharmacological interventions will have to be introduced into the programme and the PHC staff trained adequately.

47. 4. Increase massively the IEC activities and integrate mental health messages and information as part of all community messages through mass media and local level community radios. The programme has given more emphasis on the curative services to the mental disorders and preventive measures are largely ignored.

48. 5. Detailed operational guidelines for implementation of the schemes required. There should be detailed specifications and clear instructions of what needs to be done , what the likely barriers are to implementing the proposal , h ow these barriers could be overcome and h ow progress towards specific goals could be measured. 6. A set of specific, measurable outcome indicators for the DMHP have to be developed and used for regular and continuous reporting and monitoring of the programme.

49. 7 . Collaboration and partnerships with the private and non-governmental sectors in the NMHP will have to be developed. To support NGO initiatives , especially in the areas of: Setting up of self-help groups of patients/families. Imparting public mental health education to reduce stigma. Providing financial and technical support for the establishment of a spectrum of rehabilitation facilities such as day care, long-stay homes. Promoting income-generating activities by patients and families .

50. 8 . INTEGRATION OF DMHP WITH THE NATIONAL RURAL HEALTH MISSION (NRHM): This will contribute numerous advantages to the DMHP- Optimal use of existing infrastructure at various levels of health care delivery system. An integrated IEC under NRHM. Involvement of NRHM infrastructure for training related to mental health at the district level, Use of NRHM machinery for procurement of drugs to be used in DMHP Building of credible referral chains for appropriate management of cases detected at lower levels of the health care delivery system.

51. 9 . REHABILATION : There is no provision to treat and rehabilitate mentally ill patients discharged from the mental hospitals within the community. Treatment of severe mental illness is incomplete without effective care, rehabilitation and reintegration of recovering mentally ill person into the society. Social and culturally acceptable and affordable rehabilitation measures need to be developed and implemented.

52. 10. There are areas of mental health programme that have not been given adequate attention . The life skills education for children and adolescents is still in its initial phase in few centres . In spite of the attention to suicide by farmers, the number of centres providing suicide prevention is limited to a few centres when it should be available in a few hundreds. The excellent models of disaster mental health care have not been a part of the past NMHP efforts.

53. CONCLUSION The last 29 years of NMHP can be summarized as : It is possible to develop a National Mental Health Programme but it has been a gradual process . The developments in the area of mental health has brought mental health care from the closed confines of mental hospitals to the larger community. The full potential of the DMHP has not been realised and the objectives outlined have not been achieved.

54. CONCLUSION It is important to understand the reasons for the current state of programme to be an “ extension ” service rather than “ integration” of mental health with general health care. India has the opportunity to develop a viable and effective mental health care programme by giving attention to certain areas that need attention.

55. REFERENCES Director General of Health Services (DGHS): National Mental Health Programme for India. New Delhi, Ministry of Health and Family Welfare; 1982 Gururaj G., Isaac M.K. Psychiatric epidemiology in India: moving beyond numbers. In Agarwaal S.P, Goel D.S, Ichhpujani R.L, et al ( eds ); Mental Health- An Indian perspective (1946-2003). New Delhi: Elsevier for Directorate General of Health Services, Ministry of Health and Family Welfare; 2004: 37-61. Neki J.S. Psychiatry in South-East Asia. British Journal of Psychiatry. 1973; 123: 257-269. Wig, N.N. , Srinivasa Murthy , R. , and Harding T.W. A model for rural psychiatric services- Raipur Rani experience. Indian Journal of Psychiatry,1981, 23, 275-290. Jain,S ., Jadhav,S . Pills that swallow policy: clinical ethnography of a Community Mental Health Program in northern India, Transcultural Psychiatry, 2009, 46:60-85. National Human Rights Commission (NHRC) Mental health care and Human Rights, Eds. Nagaraja.D ., Murthy,P ., NHRC-NIMHANS, New Delhi. 2008. Planning Commission. Towards a faster and more inclusive growth- an approach to the 11 Five Year Plan, Government of India, Yojana Bhavan , November 2006, P.72)

56. REFERENCES Agarwaal , S.P., Goel , D.S., Ichhpujani , R.L., Salhan , R.N., Shrivatsava , S(2004) Mental Health- An Indian perspective(1946-2003), Directorate General of Health Services, Ministry of Health and Family Welfare, New Delhi. Pages 75-91.   Government of India. Implimentation of National Mental Health Programme during the Eleventh Five Year Plan-approval of the manpower development component, Ministry of Health and Family Welfare, New Delhi.Dtd.24 April 2009. Indian Council of Marketing Research, Evaluation of District Mental health Programme-final report, 2009, New Delhi. National Mental Health Programme: Time for reappraisal; Mohan Isaac (Formerly, Professor and Head, Department of Psychiatry, NIMHANS, Bangalore) (Chapter from Kulhara P et al “Themes and Issues in Contemporary Indian Psychiatry” New Delhi, Indian Psychiatric Society, 2011). Annual Report on Health of the Ministry of Health and Family Welfare, released in September, 2010 Sinha SK, Kaur J. , National mental health programme: Manpower development scheme of eleventh five-year plan., Indian J Psychiatry 2011 , 11 Oct 31 53:261-5 mhGAP : Mental Health Gap Action Programme: Scaling up care for mental, neurological and substance use disorders. Geneva: World Health Organization; 2008.    Srinivasa Murthy R. Mental health programme in the 11 th Five Year Plan. Indian Journal of Medical Research 2007; 125: 707-711 Indian Council of Medical Research. Department of Science and Technology (ICMR-DST). A collaborative study of severe mental morbidity. Indian Council of Medical Research, New Delhi, 2005.

57. Thank You