Community Psychiatry

By
Dr Jateen Ukrani
DNB Resident, VIMHANS Hospital
Chairperson Dr Santosh Goud DPM,DNB

Definition

Psychiatry focusing on detection, prevention, early

treatment,

and

rehabilitation

of

emotional

and

behavioural disorders as they develop in a community.

It refers to a system of care in which the patients

community, not a specific facility such as a hospital, is
the primary provider of care for people with a mental
illness.

Treating within the community

2

World scenario(1900 1950)

Philippe Pinel

William
Tuke

Benjamin
Rush

Mental Hygiene Movement

Adolf
Meyer

Three Revolutions in Psychiatry

The age of enlightenment following the
middle ages, when mental illness was
1st
viewed as a consequence of sin and
revolution
witchcraft
the development of psychoanalysis
which offered hope for a causative
2nd
revolution explanation of psychiatric disorders.
Born in 1963, the community psychiatry
movement has been hailed as the third
3rd
revolution psychiatric revolution.

But
The community psychiatry movement was
made possible by another revolution, the
advent of psychopharmacology.
So it may be more appropriate to refer to
community psychiatry as the fourth psychiatric
revolution.

Deinstitutionalization

The period following 1955 was an era of

deinstitutionalisation in USA and other
Western countries, consisting of discharging
mentally ill patients from mental hospitals, to
be cared for in the community supported by
community mental health centres.
This provided an impetus to the development
of community psychiatry.

Deinstitutionalization

Deinstitutionalization

1962 - Ken Kesey publishedOne Flew

Over the Cuckoo's Nest

A fictional story
about abuses in a
mental hospital.
It dramatized
conditions and
helped turn public
opinion against
electro-shock
therapy, commonly
used at the time

The Community Mental Health Act of 1963

I am proposing a new approach to mental illness and Mental retardation.

This approach is designed, in large measure, to use federal resources to
stimulate state, local, and private action. When carried out, reliance on the
cold mercy of custodial isolation will be supplanted by the open warmth of
community concern and capability.

The rise & fall of Community Mental Health

Movement
As a part of this approach beds in state psychiatric hospitals
reduced from 5,60,000 in 1955 to 61,000 in 1992.
But, over a period of time this approach fell into disrepute due
to the following reasons:
1.Severely ill patients who were released from the hospitals
didnt go to CMHCs. They were not accepted by their families..
This resulted in trans-institutionalization & were neglected.
2.The staff couldnt convince the authorities that the preventive
measures led to decrease in the morbidity.
3.Cost-effectiveness was not proved.
4.Confusion existed regarding the responsibility.

As a result the community psychiatry movement in USA

had its rise & fall between 1950s & 80s.

Attitude towards Family

1970 -Family as cause of relapse (EE)

1980 Family as care taker
1990 - Family as partners in
treatment

Development of Community
Psychiatry in India

BHORE COMMITTEE REPORT 1947

.even if the
proportion of patients be
taken as 2 per thousand
population in India, hospital
accommodation should be
available for 8,00,000
mental patients as against
the existing provision for a
little over 10,000 beds for
the country as whole

Quantitative Gap

Formation of AIIMH to reduce Quantitative

Gap

In 1954, the All India Institute of Mental Health was

established which, in 1974, became an autonomous
Institute called NIMHANS.

Condition of Mental Hospitals

Away from the community

Dumping ground for the mentally ill
Custodial rather than therapeutic
Run by wardens rather than doctors
Later observations- Poor human rights record

Qualitative Gaps

16

Dr Vidya Sagar and Amritsar Family

Involvement

Historically, in India,
families were part of the
treatment process at a
time when family
involvement was
considered as toxic in
many other parts of the
world.
Dr Vidya Sagar initiated
the trend at Amritsar
Mental Hospital, who is
acclaimed to be the father
of family therapy in India.

MUDALIAR COMMITTEE REPORT 1964

.

Reliable
statistics regarding the
incidence of mental
morbidity in India are
not available. as
against the total need
of the number of beds
available in mental
hospitals in india is
only 15,000

MENTAL HEALTH DISORDERS IN INDIA

All kinds of mental and behavioral disorders were
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
They Concluded that
In developing countries basic mental health care
should be decentralized and integrated with the
existing system of general health services.

FACTORS CONTRIBUTING TO THE

DRAFTING OF THE NATIONAL
MENTAL HEALTH PROGRAMME FOR
INDIA

Recommendation From WHO

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 nonspecialized health workers at all levels.

Starting of First Community Mental

Health Unit by NIMHANS , Bangalore

SAKALWARA PROJECT
model.

: Focus on developing services and

Raipur Rani Project

Chandigarh Program:
Was carried out in Raipur rani block, Ambala
district of Haryana state during 1975-1982
It was a part of WHO project titled Strategies
for extending mental health care
System of priority selection to train the
existing primary health care personnel
This experience resulted in the practical
manual of Mental disorders and Mental health
education materials.

Focus on testing and evaluating

models.

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Aimed to achieve Health for All by

2000 by universal provision of
primary health care

Collaboration with ICMR

To evaluate the feasibility of training of PHC staff to provide

mental health care as part of their routine work

NATIONAL MENTAL HEALTH

PROGRAMME (NMHP) OF INDIA

1980

Government of India felt the necessity of evolving a

plan of action aimed at the mental health component of
the National Health Programme.

drafting committee met in Lucknow and prepared the

first draft of the NMHP. This was presented at a
February
workshop at New Delhi on 2021 July 1981.
1981
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
August
implementation of National Mental Health Programme
1982
(NMHP).

National Mental Health Program, 1982

27

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.

Aims of NMHP

To ensure treatment and prevention of mental

and neurological disorder.
Use of mental health technology
Application of mental health principles in total
national development to improve quality of
life.

Strategies 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.

Service Components of NMHP

TREATMENT

village and sub center

-Primary health center
-District hospital
-Mental hospital and teaching
psychiatric units.

REHABILITATION
PREVENTION

Approaches
1.

Diffusion of mental health skills to the periphery of the health

services system

2.

Integration of basic mental health care into general health

services.

3.

Appropriate allotment of tasks in mental health care for different

levels of health personnel.

4.

Equitable and balanced territorial distribution of resources.

5.

Linkage to community development.

6.

Improve mental health training in all institutions, where medical

and paramedical workers are trained.

Achievements in Initial Years:

Workshops for mental health professionals,
health directorate officials were held,
sensitization to mental health issues
Preparation of support materials in form of
manuals, health records and health education
materials with inputs from NIMHANS, CIP and
PGIMER
Training for teachers in psychiatry

Weaknesses
Emphasis on curative rather than promotion or
preventive aspects of mental health
Community resources like family was not given
due importance
No clear cut model for macro implementation

What happened after 1982??

Adoption of the national mental health programme was a great

achievement
Issues left unclear

No budgetary estimates or provisions

Lack of clarity regarding who should fund the programme

Central government or the state governments who perpetually
had inadequate funds for health care.

A very lukewarm response / almost rejection of the programme

by psychiatrists.

Doubts were expressed about the feasibility of 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.

Barriers to the Implementation of NMHP

Limited

undergraduate training in psychiatry

Inadequate mental health human resources
Lack of policy driven epidemiological data and
research driven mental healthcare policies
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.

District Mental Health Program(19821990)

NIMHANS ,District Health and Family
Welfare Personnel, and District
administration of Bellary jointly
launched a pilot model program to
implement NMHP at a district
level In Bellary
population of about 20 lakhs,
located about 350 kms away from
Bangalore
chosen for the pilot development of
a (DMHP)

DISTRICT MENTAL HEALTH

PROGRAMME (DMHP)
Components of the DMHP at Bellary were:
training for all primary care staff(in a decentralized manner)
provision of 6 essential psychotropic and anti epileptic drugs
(chlorpromazine, amitryptiline, 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
was reviewed every month at the district level by the
district health officer during the monthly meeting of primary
health centre medical officers.

DISTRICT MENTAL HEALTH

PROGRAMME (DMHP) in 9th five year
plan (1997-2002)
In 1996 the MOHFW,Govt. Of India formulated district
mental health programme (under national mental
health programme) as a fully centrally funded
programme.
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.

DISTRICT MENTAL HEALTH

PROGRAMME (DMHP)

Launched in 199697 in four districts, one each in

Andhra Pradesh, Assam, Rajasthan, and Tamil
Nadu
Expanded to 27 districts by end of 9 th five year
plan
At present the program is in place in 127
districts(2012)
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
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DMHP Objectives:
1.

2.
3.
4.
5.
6.
7.

To Provide sustainable basic mental health

services in community and integration of these
with other services
Early detection and treatment in community
itself
To ensure ease of care givers
To take pressure off mental hospitals
To reduce stigma
To rehabilitate patients within the community
To detect ,manage & refer cases of epilepsy

Components of DMHP
1.

Training of medical, paramedical personnel

and community leaders

2.

Community Mental Health care through

existing infrastructure of the health services

3.

Information, Education and Communication

(IEC) activities

Services Offered under DMHP

District Mental Health Team will provide services
to the mentally ill and their families as follows: Daily Out-patient (OPD) services
Ten bedded in services facility (IPD)
Referral service
Liaison with Primary Health Center (PHC)
Provide follow up service
Community Survey if feasible
Remove stigma of mental illness by creating
awareness in the community

Progress of Community Psychiatry

1995-2002

Extension of DMHP to 25 states

Fully centrally funded
Mental Health care as part of Primary health
care.

Lessons from the Erwadi Tragedy

Stigma

& Belief in Supernatural

Concept
Lack
Lack

of incurability

of services

of recognition of human
rights

SUPREME COURT INITIATIVES N

Ramdass Committee Report

Enlarge the scope to whole country

Emphasis on human rights

Responsibility of the state for mental health

care

RECOMMENDATIONS OF WHR 2001

1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Provide treatment in primary care

Make psychotropic medicines
available
Provide care in the community
Educate the public
Involve communities, families
and consumer
Establish National Policies,
Legislation
Develop human resources
Link with other sectors
Monitor community mental health
Support more research

Report identified that one person

in every four will be affected by a
mental disorder at some stage of
life

2002 to 2007 10th Five Year Plan

period
The NMHP was re-strategized in the year 2003 (in X
Five Year Plan) with the following components:
1. Extension of DMHP to 100 districts
2. Up gradation of Psychiatry wings of
Government Medical Colleges/ General Hospitals
(New component)
3. Modernization of State Mental hospitals (New
Component)
4. IEC
5. Monitoring & Evaluation

Re-stratezisation
Re-designation DMHP around nodal institution
Strengthening Medical Colleges
Streamlining and Modernizing Mental Hospitals.
Strengthen Central & State Mental Health
Authorities
Research & Training
Funding 1900 millions in 10th Five Year Plan
50

Revised Goals

Strengthening Community and Families

Mental Health Initiatives to support individuals

and families

Rebuilt social cohesion, community development;

rights of Mentally Ill.

51

Modernization of State Run

Mental Hospitals

The assistance under this scheme is provided for

modernization of state run mental hospitals from custodial
care to comprehensive management.

A one-time grant with a ceiling of Rs.3.00 crores per hospital

is provided.

The grant covers activities such as

construction/repair of existing building(s),

purchase of cots and equipments,

provision of infrastructure such as water- tanks and toilet

facilities etc.

Does not cover recurring expenses towards running the

mental hospitals and cost towards drugs and consumables.

Grant is for modernization of the mental hospitals only and

any increase in the number of beds in the hospital is not
permitted.

Up gradation of Psychiatric Wings of Medical

Colleges/General Hospitals

Every medical college should ideally have a Department of

Psychiatry with
minimum of three faculty members
inpatient facilities of about 30 beds as per the norms laid
down by the MCI
scheme for strengthening of the psychiatric wings of
government medical colleges/hospitals which provides for a
one-time grant of Rs.50 lakhs for up gradation of
infrastructure and equipment as per the existing norms.
aim of the scheme is to strengthen the training facilities for
UG& PG at Psychiatry wings of government medical
colleges/hospitals.
grant covers construction of new ward, repair of existing
ward, procurement of items like cots, tables and equipments
for psychiatric use such as modified ECTs.

IEC Activities

NMHP has dedicated funds for IEC activities for the purpose
of
increasing awareness and

removal of stigma for mental illness.

The funds are allocated at central and state levels for IEC
activities.

An amount of Rs. 25 crore is allocated for the purpose of

IEC activities at central level.

2007 -2012 11th Five Year Plan

In the XI Five Year Plan, the NMHP has the following

components/schemes:
1. District Mental Health Programme (DMHP)
2. Manpower Development Schemes - Centers Of
Excellence And Setting Up/ Strengthening PG
Training Departments of Mental Health Specialities
(NEW COMPONENT)
3. Modernization Of State Run Mental Hospitals
4. Up gradation of Psychiatric Wings of Medical
Colleges/General Hospitals
5. IEC
6. Training & Research
7. Monitoring & Evaluation

Centres of Excellence (Scheme A)

Under Scheme-A:
at least 11 Centres of Excellence in mental health were
to be established in the IXth plan period by upgrading
existing mental health institutions/hospitals.

A grant of up to Rs.30 crores is available for each centre

The commitment to take over the entire funding of the
scheme after the 11th five year plan period from the
state government is required.
The proposal of the State Governments for these
centres must include definite plan with timelines for
initiating/ increasing PG courses in Psychiatry, Clinical
Psychology, PSW and Psychiatric Nursing.

Setting Up/ Strengthening PG Training Departments

of Mental Health Specialities (Scheme B)

To provide further impetus to manpower development in

Mental Health, Government Medical Colleges/ Hospitals are
supported to start PG courses in Mental Health or

to increase the intake capacity for PG training in Mental

Health.

The support involves capital work for

establishing/improving mental health departments

(Psychiatry, Clinical Psychology, Psychiatric Social Work, and
Psychiatric Nursing),

equipments, tools and basic infrastructure,

support for engaging required/deficient faculty for

starting/enhancing the PG courses.

The support of up to Rs. 51 lacs to Rs. 1 crore per PG

department is available.

Strategies 11th Five Year Plan

DMHP- All Districts of all States

Direct funding of Districts

Private Medical Colleges as Nodal Institutions

Training District Medical Officer in Mental Health &

Administration

Encourage Private Psychiatrists/ Practitioners in

Psychiatric Care.

Public Private Participation

Increase Budget 10% of total Health Budget.

58

School mental health program

In 2010, this program has been sanctioned to

be implemented in all DMHP districts in the
country

Aims of the SMHP

Provide Class Teachers with Knowledge and Skills to

Identify Emotional, Conduct Problems in their students
Provide Class Teachers with a system of referral for
students with psychological problems to the District
Mental Health Team for inputs and treatment.
Provide Class Teachers with Facilitative Skills to
Promote Life Skills among their Students.

Missing links from NMHP till 11th five

year plan

1. Inadequate provision of care for full range of mental

illness: no provision for child , adolescent and substance
abuse cases
2.Crisis management and in patient service: There was
also a near total absence of any crisis intervention services in
the DMHP Other services such as ambulatory services, day
care, mental health first aid are non-existent in the DMHP
programme.
3. Continuing care in the community: The DMHP does not
provide any form of continuing care in the community.
Consequently, the DMHP has failed to address the ongoing
health and social care needs of persons with chronic and
severe mental illness.

Missing links from NMHP till 11th five

year plan

4.Homeless and mental illness: Except in a few

places(eg. Delhi), the DMHP has not addressed the
needs of the homeless persons with mental illness.
5.Lack of involvement of users and care-givers:
There was a near total absence of users and caregivers in the design, implementation and monitoring of
the DMHP
6.Poor NGO and private sector participation
7. Disability certification: While persons with mental
illness received disability certification, the coverage
was patchy and in majority of the cases, no Disability
Allowance (DA) was given. The DA was also not
synchronous with time and not adjusted for inflation.

Principles of NMHP 12th five year plan

(2012-2017)

The key principles underlying the programme components are as

follows :
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 1
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.

Goals & Objective of DMHP 12th five

year plan (2012-2017)

The goal of the DMHP is to improve

health and social outcomes related to
mental illness
The primary objective of the District
Mental Health Programme is 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 XIIth Plan period,
particularly the most vulnerable and
underprivileged sections of the population.

Other objectives of the DMHP are:

a) To reduce the stigma attached towards mental illness;

b) To promote community participation in the mental health service development
and to stimulate efforts towards self-help in the community;
c) To increase access to preventive services to the population at risk, in
particular, addressing the risk of suicide and attempted suicide;
d) To inform the person with mental illness,their care givers, professionals and
other stakeholders of the rights of persons with mental illness and ensure that
rights are respected during the provision of care and services;
e) to broad base mental health into other related programs such as RCH, SSA,
work place intervention and similar;
f) to ensure a motivating and empowering work place for staff by allowing an
opportunity to improve their skills and recognition of their work;
g) to generate knowledge and evidence related to the delivery of mental health
care and services;
h) to improve the infrastructure for mental health service delivery;
i) To establish governance, administrative and accountability mechanisms to
realise the above objectives;

Future of Community Psychiatry

Present situation in the country - 9million psychotics & severely mentally

retarded
1 bed for 40,000 people

Time for non-institutional, community based mental health care

Limited mental health man power not going to increase in required

proportion is an indication to involve non specialists and paraprofessionals

in care of mental ill and handicapped

Fortunately, dependable family support system

Good future for CP
Political will to give funds
Professional will to implement NMHP
Social will to accept the ill and provide them opportunities to lead an useful
life
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Thank You for your

Patient Listening
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