BEDLAM, 1946

Thousands spend their daysoften for weekslocked in devices euphemistically called

'restraints: leather handcuffs, locks & straps & restraining sheets. Hundreds are confined in
'lodgesbare, bed less rooms reeking with filth & fecesby day lit only through half-inch
holes in steel-plated windows, by night merely black tombs in which the cries of the insane
echo unheard from the peeling plaster of the walls.
Bhore Committee (1946).

Before independence there were no clear plans for the care of the mentally ill persons.
The approach was largely to build asylums which were custodial rather than
therapeutic. The situation in regard to mental health services is best presented in the
Bhore Committee report:

Even if the population of mental patient be taken as 2 / 1000 in India, hospital

accommodation should be available for at least 87,00,000 patients as against the
existing provision for a little over 10,000 beds.

In India, the existing number of mental hospital beds is in the ratio of 1 bed / 40,000
populations, while in England, the corresponding ratio is approximately
1 bed /
300 populations.

Moore Taylor Report It is as if time had stood still

The Mudaliar Committee (1962).

Reviewed the progress made subsequent to the Bhore Committee:

Reliable statistics regarding the incidence of mental morbidity in India are not
available. It is believed that enormous number of patients requires psychiatric
assistance and service As against the total need of the number of beds available in
mental hospitals in India are only 15,000. There is hardly any provision for the
treatment of psychosomatic disease in general hospitals.

An important outcome of these Committee recommendations was the setting up of a

number of district psychiatric units in the different parts of the country and creation of
a mental health advisory group at the Ministry of Health

The Srivastava Committee (1974)

Reviewed the progress of health in the country and suggested plans for the future.
One of the important outcomes of this committees recommendation was the
Community Health Volunteer (CHV) scheme. The CHVs were expected to be from
the committee and provide services to about 1000 population. The training of CHVs
contained a component of mental health

Community Psychiatry
1. Community psychiatry comprises the principles and practices needed to provide
mental health services for a local population by:
(i)
(ii)

establishing population- based needs for treatment and care

providing a service system linking a wide range of sources of adequate
capacity, operating in accessible locations and
(iii)
Delivering evidence-based treatments to people with mental disorders.
Principles of Community Psychiatry
1.
2.
3.
4.
5.
6.
7.

responsibility to a population, usually a catchment area defined geographically

treatments close to the patients home
multi-disciplinary team approach
continuity of care
consumer participation
Comprehensive services.
The inspiration for the community mental health movement comes from 3 factors.

8. The first is the realization that the treatment of mentally ill patients in mental hospitals
might be counterproductive.
9. Second is the realization that institution based psychiatry through trained
professionals is very expensive and that countries like India will not have sufficient
manpower and facilities to deliver services through conventional methods.
10. The third was the happy discovery that professionals could after undergoing simple
and short innovative training, delivers reasonably adequate mental health care.
Burden of Mental Illness

Mental disorder account for 12% of the global burden of disease.

Nearly 10% of total population suffers from these disorders

In India alone about 100 million people are in need of mental health services.

(WHO 2001).

Need for Care & the Treatment Gap

Total persons with severe mental disorders > 10 million & Common mental disorders
> 50 million

Requiring hospitalization > 3-5 million

Requiring long term care > 3 million

At district level nearly 100,000 persons require mental health services

Enormous burden of mental illness in the community, and the inadequacy of mental
health care infrastructure in the country

Mapping Mental Health Resources

Total no. of govt MH beds > 20,000

Other beds ~ 9000 (Private MH 5000 & GH beds 4000)

Total psychiatrists ~ 4000

Most (80%) of them in urban locations

About 50- 90 % of mental disorders do not access services

Mental Health Resources

110 psychiatrists graduate every year and sizeable number migrate

Almost half the districts lack psychiatrists

Psychiatrist per unit of population 25 times lower than developed country

Modest estimates need 1 per 1 lakh & Clinical Psychologists & Psychiatric Social
Workers 1.5 per 1 lakh population

Deficits in MH Resources

The current number should increase by 3 folds

Psychiatrists 7000 (at 1 per 1lakh pop)

Cl psychologists 12000( 1.5 per 1lakh)

Psych Social Workers 17000 (2 per 1 lakh)

Psychiatric Nurses not known(1 per 10 beds?)

Hospital Beds & Long term care & rehab

Problems /Barriers to care

1. Poor access to health services, transportation and poverty
2. Poor knowledge, negative attitudes and stigma towards the mentally ill
3. Inadequate facilities (numbers and poor facilities)
4. Resources for mental health are inadequate, insufficient and inequitably distributed
5. Non-implementation of Mental Health policy, programs, laws and statutes

Community Psychiatry in India

The story of community psychiatry in India begins with Dr. Vidya Sagar who in the
late 1950s began to involve family members in the treatment of mentally ill patients
who were admitted to the Amritsar Mental Hospital.

The exercise results in reduced hostility in the minds of the patients for having been
abandoned in a strange place; helped to remove the age old myths about the
incurability of mental illness; the relatives learnt the essential principles of mental
health care and were thus motivated towards improvement in their own ways of life

General Hospital Psychiatric Units

The next phase in de-institutionalization was the establishment of the GHPUs. These
provided a big push for the greater acceptance of psychiatric services by the public
without fear of social stigma. Most such units came up in the 1960s, because of the
availability of antipsychotic drugs which dramatically controlled the agitation,
aggression and withdrawal tendencies of patients, making it possible to treat the
mentally ill in general hospitals. These units have brought a change in the mental
health training of professionals a research.

In the last three decades more and more centers have come up all over the country.
Most of them are 30-50 bed units. As of now there are about 4,000 beds under this
facility in different parts of the country. It is estimated that 75% of the research work
done comes from professionals working in these units. An extension of these units has
been the setting up of district hospital psychiatric units. The work has been taken up
systematically in at least two states, namely Kerala & Tamil Nadu and at present there
is a psychiatrist in each district in these two states

Community care

The next phase of development of mental health services has been the community
care approach. The impetus for this approach has come from the following sources.

the commitment of the country to provide health services to all.

the extension of a large infrastructure of general health services (PHC system)

the approach to utilize Multipurpose Worker and rural doctors to provide health care
to rural people.

realization of the magnitude of severe mental disorders in the community (at least
1%) and availability of simple interventions for these conditions.

Bangalore model

The programme of Community Psychiatry was launched in 1976 at the NIMHANS.

The aim was to develop suitable training programmes for the doctors and the
multipurpose workers from the various PHCs in Karnataka, so that after their training
PHC personnel could provide basic mental health care.

The team initially studied the needs of the rural population in one PHC (1975-1980).
This was carried out by identifying the mentally ill persons in their homes through
key informants and those attending the general health facilities.

These efforts of understanding the needs and methods of care in the community were
followed by pilot experiment to integrate mental health with primary health care in
one PHC with a population of 1,00,000 (1980-86).

Following this a model programme covering a district with a population of 2 million

was developed.

Chandigarh model

The Chardigarh efforts were initiated in 1975. This effort was the outcome of the
observation of the limited utilization of psychiatric service from the hospital.

The aim was to develop a model for rural psychiatric services.

The basic approach adopted in this model was to integrate mental health with general
health services and provide basic mental health care as part of psychiatry health care.

At Chandigarh Centre this project provided opportunities to understand the needs of

the rural mentally ill and methods of providing care to them utilizing the existing
primary health workers and physicians.

The Barwani Experiment

This study used a three-tier model for the delivery of mental health services.

The first tier was the outpatient programme.

The second tier employed mental health workers drawn from local community.

The third tier consisted of family members and key people in the community who
formed the local health groups.

The compliance with treatment rate was much higher (63%) compared with another group,
who used only the outpatient service (46%). The mental health workers, being members of
the local community communicated effectively with patients and their families used shared
cultural idiom, thus promoting greater adherence to treatment.
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

Rural Psychiatric Services

The organization of essential mental health services as an integral part of primary

health care has been a major development in the country. The efforts were started by
two centers in the country namely, Bangalore and Chandigarh.

Currently, the programme is covering over 25 districts, in 22 states of the country

providing services to over 40 million of the population.

The Evidence for Community Mental Health

Studies show that adequate, accessible, quality mental health services can be provided
with community based interventions using lay health workers

The Bellary model of the DMHP by NIMHANS

Recent studies from India, Africa, Brazil

Recent DMHP research

DMHP at Thirthahalli taluk -Shimoga district

Despite 6 psychiatrists being available, 25% psychotics were never treated.

55% of patients were not on treatment currently

All the patients were initiated on treatment after training HW and Doctors

95% of patients improved with treatment

QOL increased, disability and burden reduced significantly with continued care in the
primary care settings

The Revitalized 11th 5 year plan

1. Focus on almost all districts. Equity in mental health care- 75% covering rural
population and 25% urban population.
2. Provision for medication and treatment
3. Improvement in manpower-training of personnel
4. Skills Training & Stress Management- School, adolescent, college mental health
programs
5. Suicide prevention
6. Public education
7. Research

8. Delivery through public-private participation

9. Central & State Monitoring committees
10. Mental Health Authority

Revitalized strategy: 11th plan Manpower development

Short term and long term plan to develop mental health man power

Development of regional institutes of mental health and neuro-sciences

Clear targets

IEC activities

Active public-private partnerships in all areas of DMHP to optimize care

NHRC Meeting NLSIU Total 57 slides

Strategy to meet the challenge- Manpoower shortage
Short term

Training PHC doctors

Program officers

1-yr certificate course

GP training

CME for other specialists

Long term

Strengthen UG education

Start new PG centers

Increase PG seats

Uniform PG syllabus

Regional institutes

Improvement in manpower

Proposed to facilitate 120 MD seats, 60 DPM seats in the teaching colleges

Train 500 program officer over 5 years
1-year certificate course in mental health for doctors to work in DMHP
Such training should occur in all regional centers
Rs.100 crores budget under this head
Outcome of the implementation

Annual evaluation

Program indicators

Input indicators

Process indicators

Output indicators

Mid course corrections to made after evaluation.

WHR 2001- Need of the ill

Conclusion

The observations in the World Health Report 2001 about status of Mental Hospitals in
India can be summed up as under:
-

geographical and professional isolation of

repeated cases of ill treatment to patients;

weak reporting and accounting procedures;

bad management;

ineffective administration;

poorly targeted financial resources;

lack of staff training;

inadequate inspection & quality assurance;

poor living conditions;

chronic human rights violations.

institutions

and their staff;

Dehospitalization is ultimate solution to the problem of mental health.

Dehospitalization does not mean closing down the mental health hospitals.

It means a progressive replacement of hospital services by a more cost effective

community based mental health care services.

This is the only way that scarce resources can be optimally utilized. While it costs Rs.
500/- per day in the minimum the per capita national expenditure on health is only Rs.
200/- per annum.

In addition to a vibrant community based mental health care services what we need
are Mental health institutions which will function as centres of excellence and not of
maladministration and maltreatment of patients and human rights abuse.

Experience gained through these extension services has confirmed that majority of the
psychoses & epilepsy can be managed on OPD basis without sophisticated
investigations.

Involvement of NGOs has helped in eradicating the misconceptions, stigma and

provides better awareness regarding mental illness.

This has also proved that crucial aspects of management of these patients are
continuous, uninterrupted, prolonged medication and the involvement of family
members in the management process.

Under the existing circumstances & poor resources the professionals can provide
services to the neglected population in rural areas by starting extension services as
one of the approach.

Professionals can spare one day in a week for extension services and can easily take
up four rural areas in a month by fixing up regular & continuous services.

It has been clearly shown that monthly follow up is adequate. There is no need of
more frequent follow-ups.

By this approach services can be made available and accessible to the majority of the
population.