community mental health in india -way ahead
DESCRIPTION
community psychiatry nimhans, public mental health programTRANSCRIPT
Community mental health in India- way ahead
Dr K.V.Kishore Kumar Psychiatrist
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Magnitude of mental disorders
• 10-15% of adult population affected
• 20% of patients seeking primary health care have one or more mental disorders, though not recognised
• One in four families have at least one member with a behavioural or mental disorder at any point in time.
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World Health Survey 2003 – Karnataka
• A national sample of 10,000 individuals were surveyed as part of WHS 2003
• States selected were Assam, West Bengal, Rajasthan, Karnataka and Maharasthra.
• Sample size of Karnataka was 1300• 9% of the sample were diagnosed as
depression• Psychosis was < 1%
Burden of mental disorders
6%
6%
4%
3%3%
6%7%
5%
13%
3%
10%
4%3%
12% Cardiovascular diseases
Diabetes
Malignant neoplasms
Digestive diseases
Neuropsychiatric disorders
Other NCDs
Injuries
Other CD causes
Maternal conditions
Malaria
Childhood diseases
Tuberculosis
Diarrhoeal diseases
Perinatal conditions
HIV/AIDS
Respiratory infections
Respiratory diseases
Nutritional deficiencies
Sense organ disorders
Diseases of the genitourinary systemMusculoskeletal diseases
Congenital abnormalities
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Burden of disease% attributed to mental and behavioural disorders
of total DALYs lost world-wide
• 1990 10 %
• 2000 12.3 %
• 2020 (projected) 15 %
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Global estimates
340 million Depression 45 million Schizophrenia 91 million Alcohol use disorders 15 million Drug use disorders50 million Epilepsy 29 million Dementia 8.77 lakh people complete suicide every year One out every four seeking help have mental
/behavioral / neurological- most of them untreated or undiagnosed
Global recommendations • Integrate mental health in primary care • Educate communities – mental disorders • Ensure availability of psychotropics • Involve families communities and groups • Establish policy, program and legislation at
national level.• Provide and develop human resource for mental
health • Intersectoral linkages for mental health care • Promote research and evidence
1950- Amritsar – Family involvement1960- GHPU’s
1969 - Mudaliar committee recommendation on mental health 1970 - Integration of mental health care with primary health care 1974 - Srivatsava committee recommendation on community level volunteer 1975 - Launch of community mental health services
1985- Bellary DMHP 1985 – NDPS act 1987 – Mental health act 1990 - NGO’s 1992 - Rehabilitation council of India act 1995- Disability act 1997 -Quality assurance in mental health care
1999- mental health identified as priority for the WHO 1999 – National trust act
2001- World health report 2003- world health survey 2003 – evaluation of DMHP 2007 – UNCRPD 2007-08 – Up-scaling DMHP to 123 Districts‘ 2011-12 – mental health policy initiatives 2013 – Union Cabinet clears mental health care bill
Important Milestones of Mental Health Care in India
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Community-based carebenefits
• Services close to home• Focus on disabilities as well as symptoms• Focus on the individual • Wide range of services• Ambulatory rather than static services• Partnership with carers• Better quality of life for ill persons• Prevents inappropriate admissions
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Depression
Up to 60% of patients recover
Substance Abuse
Up to 60% reduction in drug use
Epilepsy
Up to 73% of patients live free from seizures
Schizophrenia
Up to 77% of patients live without relapses
Effectiveness of Treatment
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Poor utilisation of servicesexample from Australia 1997
Table 3.1 Utilization of professional services for mental problems, Australia, 1997
Consultations for mentalproblems
No disorder Any disorder > 3 disorders
% % %
General practitioner onlya 2.2 13.2 18.1
Mental health professional onlyb 0.5 2.4 3.9
Other health professional onlyc 1.0 4.0 5.7
Combination of healthprofessionals
1.0 15.0 36.4
Any health professionald 4.6 34.6 64.0
a Refers to persons who had at least one consultation with a general practitioner in the previous12 months but did not consult any other type of health professional.
b Refers to persons who had at least one consultation with a mental health professional(psychiatrist/psychologist/mental health team) in the previous 12 months but did not consult any othertype of health professional.
c Refers to persons who had at least one consultation with another health professional(nurse/non-psychiatric medical specialist/pharmacist/ambulance officer/welfare worker or counsellor)in the previous 12 months but did not consult any other type of health professional.
d Refers to persons who had at least one consultation with any health professional in theprevious 12 months.
Source: Andrews G et al. (2001). Prevalence, comorbidity, disability and service utilisation: overviewof the Australian National Mental Health Survey. British Journal of Psychiatry, 178: 145153.
Tab
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Cost of care
753.27
997.41
352.34
476.37395.03
451.07
1554.66
1357.951278.58 1294.32
962.091001.95
1075.691016.72
884.81
295.28280.54299.75279.07
76.91.6317.416.72
83.9312.41
1556.69 1505.5
1182.76
0
200
400
600
800
1000
1200
1400
1600
1800
Baseline 3 months 6 months 9 months 12 months 15 months 18 months
Co
st in
Ru
pee
s
Service Travel & time Family Total
Leading cause of years lived with disability • Unipolar depression = 11.9%• Hearing loss adult onset = 4.6• Iron def anaemia = 4.5• Chronic obstructive airway disease = 3.3• Alcohol use disorders = 3.1• Osteoarthritis =3.0• Schizophrenia =2.8 • Injury =2.8• BPAD =2.5• Asthma =2.1
Needs of persons with mental disorders
NMHP- 1982
1. Availability and accessibility of minimal MH services for all
2. Application of knowledge to general health care and social development
3. Stimulate Community participation
Approaches:1. Diffusion of mental health skills2. Task distribution
3. Equity4. Integration of services5. Linkage with community development
National Mental Health Programme (1982
Long-Stay Facilities
&Specialist Services
Community MentalHealth Services
PsychiatricServices in General Hospitals
Mental Health ServicesThrough PHC
Informal Community Care
Self Care
highhigh
lowlow highhigh
lowlow
COSTSCOSTSFREQUENCY FREQUENCY OF NEEDOF NEED
Optimal mix of different mental health services Optimal mix of different mental health services (WHO 2003(WHO 2003))
QUANTITIY OF SERVICES NEEDEDQUANTITIY OF SERVICES NEEDED
Some important insights
• Community care is possible • Economical and effective • Non mental health professional can partner with
mental health professionals to deliver such a care.
• Community accepts the approach to care • Ineffective implementation is due to systemic,
professionals and inadequate use of resources.
IEC-Manual for Health workers
IEC-Manual for medical officers
Ten features of mental disorder- Flip charts and posters
Interactive computer-based video training modules (6 CDs)
Institutional response to mental health problems.
• Mental Health Problems are large in magnitude • Challenge of mental health care is essentially
collective responsibility of the Government, Civil society and Non-governmental voluntary agencies
• Community based approach to mental health care is critical to reach the masses
• Integrating mental health care into general health care is the key strategy
Community care in India-DMHP
• 123 DMHP as part of 10th 5 year plan.• DMHP will extended to all the district in the
country in the 11th plan period period.• A sum of 1089 crores will allocated for the
mental health program • Current approaches to provide community
care through DMHP uses restrategized methods
Mental Disorders and poverty
Mental health gap action program • WHO launched 2008• Program to reduce treatment
gap • Up Scaling of services • Asserts that with proper
care, psychosocial assistance and medication, tens of millions could be treated for depression, schizophrenia, and epilepsy, prevented from suicide and begin to lead normal lives– even where resources are scarce.
Changing paradigm in mental health • Technical – political response • Exclusion – inclusion • Individual to public health approach • Hospitalization – Ambulatory to primary
care • Individual action to team work • Hospital – community
Gaps in mental health
• Promotion and prevention • Access to quality care • Policy and financing • Human rights • Values and Knowledge
Institutional response- continued • Man power resource development –
increase in the number of psychiatrist by substantial increase in PG training centres
• Innovative approaches to fill the void- training public health personnel to provide mental health care at PHC level and to manage mental health care programs at district level.
• Deinstitutionalization (Italy, 1978)• Care in the community• Partnership with consumers• Partnership with families• Human rights
International Developments
Psychiatric beds and professional
Psych beds World S-E- Asia India
Total 1.69 0.33 0.25
MH 1.16 0.27 0.2
GH 0.33 0.03 0.05
Others 0.20 0.03 0.01
Psychiatrists 1.20 0.20 0.08
NS 0.20 0.03 0.06
P Nurses 2.0 0.10 0.05
Psychologist 0.60 0.03 0.03
SW 0.40 0.04 0.03
Beds/10T Professional One lakh
Barriers to care • Though cost effective treatments exist • Serious mental illness is not recognized• Benefits of treatment not well understood • Policy makers, insurance companies, health and
labour policies, General public all discriminate between physical and mental disorders
• LAMIC allocate less 1% health expenditure to mental health
• Consequently, community care, policy, legislation and treatment does not get the priority they deserve
Evaluation Barriers in DMHP
Administrative Barriers Lack of clarity in guidelines Lack of manpower resources Motivational barriers General Issues
Extension of DMHP • 1996-1997 = 4 Districts
• 1997-1998= 7 Districts
• 1998-1999= 5 Districts
• 1999-2000= 4 Districts
• 2000-2001= 7 Districts
• 2003-2004= 22 Districts
• 2005-2006=94 Districts
• 2007-2012=123 Districts
MENTAL HEALTH - NEW UNDERSTANDING
- NEW HOPE
WORLD HEALTH REPORT 2001
1. Provide treatment in primary care
2. Make psychotropic medicines available
3. Provide care in the community
4. Educate the public5. Involve communities, families and
consumers
RECOMMENDATIONS OF WHR 2001
6. Establish National Policies, Legislation7. Develop human resources8. Link with other sectors9. Monitor community mental health10. Support more research
WHR 2001 – RECOMMENDATIONS
LOOKING AHEADCHALLENGES
1. Very uneven distribution of resources across states / UTs.2. Low human resources for mental
health care3. Poor UG training in Psychiatry4. Lack of welfare programmes5. Public ignorance6. Growth of private sector
• Build on community resources• Community tolerance• Family commitment• Limited barriers for professional work• Partnerships with wide variety of
community resources• Integration of services• Using technology to improve access to care
OPPORTUNITIES
Conclusions • Mental Health Problems are common and
universal • There is no health care without mental
health care• Mental Disorders are disabling and
burdensome • Effective and safe interventions are
available in the country • Integrating mental health care with general
health services is an important strategy
Conclusions- continued • Strengthening medical colleges and
development of regional institutes of mental health is crucial for increase in mental health manpower resource
• Considering and implementing innovative approaches to fill the void in manpower is an important short term measure.
• Development of telemedicine facilities to disseminate knowledge , skills is of parmount importance
Conclusions- continued
• Empowering families to strengthen partnership with service providers.
• Investing on data base of people with mental health problems to facilitate accurate estimation of treatment gap.
• Intensification of IEC activities • Research to understand outcomes of
interventions. • Upgrading resource material so as to incorporate
recent developments • Professional commitment to incorporate research
evidence into service delivery.