COMMUNITY MENTAL HEALTH A PERSPECTIVE OF DMHP THIRUVANANTHAPURAM 2012
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- COMMUNITY MENTAL HEALTH A PERSPECTIVE OF DMHP THIRUVANANTHAPURAM 2012
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Community Mental Health
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DISTRICT MENTAL HEALTH PROGRAMME (DMHP)
Thiruvananthapuram
Phone 0471-2435639, Mob 9495123999
Website: www.dnihptvpm.org, E-mail: dmhptvpm@gmail.coni
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TABLE OF CONTENTS
1. Community Psychiatry
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2. DMHP Thiruvananthapuram
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3. Problems faced in Community Psychiatric Care
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4. Strategies adopted by DMHP Tvpm
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5. Primary Care Integration in Phases
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6. Role of Primary Care Doctors
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7. Role of Health Workers
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8. Present Status
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9. Functional levels of primary care
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10. Rehabilitation in Primary Care
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11. Suggestions and recommendations
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12. Acknowledgements
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: Dr. Kiran PS
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! Dr. Anju Lijin
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Prepared and Edited By
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aWe believe each of us as waves andforget we are also the ocean"
Community Psychiatry
Evolution of Mental Health Care can be best described through 5 ‘C’s, namely Confinement,
Caring, Curing, Chemicals, & Community. In early and medieval periods, mental patients
were mostly Confined or chained, as their behaviors were believed to be due to evil spirits,
witchcraft or black magic. But in 18th century, these symptoms and behaviors were started to
be considered as part of a disease, and thus the concept that these people need to be Cared
for, emerged. In late 19th century attempts were made to Cure these symptoms, and many
psychological methods were developed. But still crude methods including torturing were in
vogue in different parts of the world. Using Chemicals to cure mental illness found success
with the discovery of Chlorpromazine in 1956. Thus began the era of psychopharmacology
which drastically reduced the morbidity associated with the illness. But still the benefits were
narrowed to a selected few for whom these treatments were accessible and affordable. Thus
came the 5th revolution in mental health namely Community Psychiatry in 1960s.
Community psychiatry in India
WHO strongly recommended the delivery of mental health services through primary health
care systems as a policy for developing countries, as most developing countries including
India did not have adequate number of institutions to care for the mentally ill.
The seven reasons given by World Health Organization (WHO) for integrating mental health
into primary care are: 1. The burden of mental disorders is great.
As they produce significant economic and social hardships that affect society as a whole.
2. Mental and physical health problems are interwoven.
As many people suffer from both physical and mental disorders, integrated primary care
services help ensure that people are treated in a holistic manner.
3. The treatment gap for mental disorders is enormous.
There is a significant gap between the prevalence of mental disorders and the number of
people receiving treatment and care. Primary care for mental health helps close this gap.
3
4. Primary care for mental health enhances access.
People can access mental health services closer to their homes, thus keeping their families
together and maintaining their daily activities.
5. Primary care for mental health promotes human rights.
Mental health services delivered in primary care minimize stigma and discrimination and can
also remove the risk of human rights violations that can occur in psychiatric hospitals.
6. Primary care for mental health is affordable and cost effective.
Costs in seeking specialist care in distant locations are avoided.
7. Primary care for mental health generates good health outcomes.
Especially when linked to a network of services in the community.
Over the last few decades, community psychiatry in India has made substantial advances.
National Mental Health Programme (NMHP) was established in 1982.
Attempts to develop models of psychiatric services in the PHC setting were made nearly
simultaneously at PGI, Chandigarh in 1975 and NIMHANS, Bangalore in 1976.
Aims of NMHP
1. Prevention and treatment of mental and neurological disorders and their associated
disabilities.
2. Use of mental health technology to improve general health services.
3. Application of mental health principles in total national development to improve quality of
life.
Strategies adopted
1. Integration of mental health with primary health care.
2. Provision of tertiary care institutions for treatment of mental disorders.
3. 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).
District Mental Health Programme (DMHP)
DMHP was started as a component of NMHP with the following aims:
1. To provide sustainable mental health services to the community and to integrate these
services with general health services.
4
2. Early detection of the patients within the community itself
3. To see that the patient and their relatives do not have to travel long distances to go to
hospitals or nursing homes in their cities
4. To take pressure off the mental hospitals and medical colleges
5. To reduce the stigma attached towards mental illness through change of attitude and public
education
6. To treat and rehabilitate mental patients discharged from the mental hospital within the
community.
The components of DMHP
1. Training of medical, paramedical personnel and Health workers in mental health skills.
2. Community Mental Health care through existing infrastructure of the health services
3. Information, Education and Communication activities.
4. Community oriented Rehabilitation Services.
DMHP Thiruvananthapuram
❖ DMHP Tvpm was established in 1999 as first in Kerala.
❖ DMHP office is situated in the campus of Mental Health Center, Thiruvananthapuram,
which is also the Nodal Center of the programme.
❖ Selected as the most successful and model DMHP in India by WHO.
❖ Total number of registered patients as on 2012 is 14,357.
DMHP Tvpm -Staff pattern
Nodal Officer
(Psychiatrist)
Clinical Psychologist
Psychiatric Social worker
Staff Nurse
Clerk cum DEO
Attender
5
Activities of DMHP Tvpm
Clinics
> PHCs*, CHCs**
> Taluk hospitals
> After Care homes
*
J
Mental health
Training
DMHP
Tvp m
Targeted
interventions
programmes
> Primary Care Doctors
> Paramedical staff
> Health Workers
>
>
>
>
>
>
>
School Mental Health
Geriatric Mental Health
Suicide Prevention
Stress Management
Substance Abuse Prevention
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IEC
Activities
> Awareness classes:
Govt.Servants, Media
Persons, Local Self Govt.
Representatives, ASHA,
Anganwadi, Kudumbasree
workers & General Public
Rehabilitation
Activities
> Community Based
Occupational Therapy
Units
*PHC- Primary Health Centre (6 sub centres, population- 30,000)
**CHC-Community Health Centre (First referral centre, population-1, 40,000)
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Problems faced in Community Psychiatric Care
1. Lack of Awareness
Regarding symptoms-physical symptoms of depression and anxiety disorders like body
pain, aches, impaired sleep and appetite, are usually considered as that of physical illnesses
(even after physical examination and investigation results are negative and assurance from
physician) and repeatedly seek treatment or take analgesics and other medications by self.
Regarding treatment. Most people are ignorant regarding psychiatric treatments available,
mental health professionals, and where to approach. So they may prefer religious forms of
treatment which are easily available. Also, misconceptions regarding psychiatric treatments
especially pharmacotherapy and ECT, keeps patients away from seeking proper treatment.
These can be addressed through increasing awareness regarding mental illnesses and
treatments. Conducting regular IEC Programmes in community will help in achieving this
aim.
2. Resources
Resources are limited. Number of mental health professionals especially Psychiatrists are few
compared to the growing population and demand.
Available resources are concentrated in urban areas, leaving psychiatric care scarcely
accessible to majority
Lack of mental health skills in primary health care professionals and workers
Quacks thriving in many rural areas due to lack of qualified mental health professionals.
These can be addressed to a large extent through integration of mental health into Primary
care system.
3. Stigma
There is stigma associated with mental illness, because of which people try to ignore the
symptoms, or keep it to themselves. They may opt for religious forms of treatment or black
magic for cure.
Stigma can be reduced by increasing awareness through IEC programmes. Integration with
Primary Care will also help in the process.
4. Follow-ups
Cost of treatment, especially when multiple drugs are needed.
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•
Long duration of treatment needed as in schizophrenia
•
It may be difficult to bring the patients for long distances in public transport system,
especially if the patient is symptomatic.
Can be addressed to a certain extent through Primary Care integration of Mental Health.
5. Other patient related factors
•
Poor drug compliance:- mostly patients relate the treatment with that for acute physical
illnesses and discontinue drugs as soon as symptomatic improvement occur.
»
Expressed emotions;- hostility, over-involvement, and critical comments towards the patient
from care givers and family members often increase relapse rates.
Repeated and regular psycho-education for patients, caregivers and other family members
should be given to ensure compliance to treatment and address expressed emotions.
5. Attitude of General public
Even though health is defined as physical, mental and social wellbeing, majority considers
physical wellbeing as the only criteria for health. People tend to seek treatment for even
minor physical ailments while a severe mental stress or illness is kept to themselves without
seeking any help, even though the stress created by the latter is far greater. This attitude of
general public may be due to a combination of factors like stigma, lack of awareness, and
lack of easy accessibility to treatments. But this forms the leading limitation in the concept of
psychological wellbeing to all, as we assume that five sixth of those requiring psychiatric
intervention (constituted mostly by depressive disorders, anxiety disorders, OCDs and
somatoform disorders ) still remain untreated in the community.
Strategies adopted by DMHP Tvpm
As a unit of National Mental Health Programme, DMHP works within the framework of
NMHP guidelines. Being a national programme, it allows enough flexibility for regional
variation in strategies to be adopted (especially the Revised NMHP guidelines). For example,
while providing funds in a head like IEC, it suggests measures like school mental health,
stress management etc. The strategies to be adopted in each head and subheads can be
decided by the concerned DMHPs depending on the regional requirements. This may vary
from state to state, between districts or even within a district.
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Strategies adopted in each (IEC, Training, Clinics & Rehabilitation)
Targeted interventions - help in channelizing the awareness activities to selected target
groups. So they become more effective and ensures easy follow up of actions.
Resource Persons-With 22 clinics, 8 aftercare homes and Training programmes in hand, its
impractical for DMHP Team to conduct awareness programmes in the entire community.
NMHP guidelines give us scope for creating resource persons for IEC programmes. DMHP
Tvpm created resource persons for each Targeted interventions by conducting Training for
Trainers (TOT). They are given remuneration for the number of classes they conduct.
Another scope provided in NMHP guidelines is tie up with Psychology or sociology
departments of colleges in the district. Even though no tie-ups have been made with any
departments, students (mostly MSW) of Sociology departments of Kerala University and
Loyola College of Social Sciences undergo community psychiatry training in DMHP Tvpm
as part of their fieldwork. They form a workforce as most of them continue their work as
voluntary trainees or resource persons even after their placement. With this workforce in
hand DMHP Tvpm implemented targeted interventions which include:-
i.
School Mental Health Project (Thaliru): Aims at the holistic development of mental health
of school children. Through awareness classes, distribution of booklets, posters, leaflets,
counselling sessions and other psychiatric services, DMHP makes sure that the aim is being
achieved. (Utilizing the lack of co-ordinated services, several unqualified people have gained
access in this area, posing as mental health professionals, which has brought in more severity
to the basic problems of school mental health.)
For creating a link between DMHP and schools in the district, 64 School Counsellors, and 38
School JPHNs were trained in school mental health issues and incorporated into this
programme. ‘Thaliru’ focuses on 5 aspects of school mental health namely
a) Behavioural and emotional problems
b) Substance abuse
c) Suicide prevention
d) Stress management
e) Life skill education
Once awareness classes are conducted, cases requiring counselling are identified following
which counselling camps are conducted in the school with regular follow ups. Those
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requiring pharmacotherapy are referred to the nearest DMHP clinics. Till date the programme
has covered 26 schools and 7,208 students in the district.
ii.
Geriatric mental health (Thanal): Through this project, DMHP conducts camps in
community or Old age homes. Screening is done for dementia (MMSE), depression, anxiety
disorders and adjustment disorders. Awareness classes are given and counselling sessions are
conducted for the necessary. Those who need further treatment are referred to nearby DMHP
clinics.
iii.
Substance abuse (Mukthi) and Suicide prevention (Jeevaraksha): In these projects
DMHP enlisted the support of NSS (National Service Scheme) Volunteers from different
colleges of the district. A seminar and street play writing competition were conducted in first
phase to help them understand the gravity of the situation and different aspects of the
problem in society. In the next phase these volunteers perform street plays, distribute leaflets,
conduct awareness class in colleges and help identify those in need.
iv.
The same volunteers or students from Sociology or Psychology departments will be
managing ‘Bodhana’, the Stress management units DMHP plans to start in colleges across
the district.
In addition to this DMHP has started stress management programme in Government Offices
in the district. Awareness classes and interactive sessions will be followed by counselling
sessions for those in need.
Other Target groups:
LSG members- DMHP Tvpm conducts mental health awareness programme for Elected
representatives of LSG- Grama, Block and Jilla Panchayats, Municipalities and Corporation.
It focuses on 5 components:-
1.
2.
3.
4.
5.
6.
Importance of mental health in public health scenario
Problems faced in mental health especially community mental health
Common symptoms and disorders
Removing misconceptions regarding psychiatric treatments
Pension schemes and other benefits available to psychiatric patients.
About the help they can provide in rehabilitation of these patients, especially with
regard to Mahatma Gandhi National Rural Employment Guarantee Scheme
(MNREGS).
ASHA, Anganwadi, and Kudumbasree workers: form a suitable link for mental health
awareness and activities to reach the grass root level. For this, DMHP started a programme
for these workers. Resource persons were created, and they conduct awareness classes and
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interactive sessions in batches of 50-100. These workers in turn arrange classes in the
community. This ensures an even distribution and maximum outreach in the community.
Residence Associations and Youth Clubs: forms another mode to reach the community.
Through awareness classes, counselling sessions, street plays, painting competitions and
other activities based on mental health, the aim is being achieved.
NGOs: DMHP Tvpm has tie ups with NGOs like Sacred Heart Charity, Providence Home,
Mahila Samakhya Society, BUDS (of Kudumbasree) and SSREE Foundation for
rehabilitation and occupational therapy of the mentally ill patients.
Posters and Leaflets: Taking a cue from other health programmes (Immunization
program, RNTCP, Family planning etc),which owe a part of its success to wide campaign
through posters and leaflets, DMHP Tvpm prepared 7 sets of posters and leaflets and is
distributing these to be displayed in Hospitals, Govt. Offices and Public places. Themes
include:
1. Reduction of Stigma associated with mental illness.
2. Common signs and symptoms, in particular the somatic symptoms.
3. Treatments available and removing misconceptions regarding it.
4. Alcohol abuse
5. Stress management in school children.
6. Substance abuse in school children
7. Life skills to be developed.
These have helped in extending our campaign throughout.
Street Play: For the past few years DMHP Tvpm is using the appeal and minimalism of
Street Play as a tool for mental health promotion. It has been conducted in 58 locations in the
district and focuses on awareness regarding symptoms, common illnesses, treatments
available, stigma and misconceptions in mental health. Information leaflets are distributed
after each play. It has been found to a very effective tool as it draws large crowds and huge
response in the form of clearing doubts directly and through phone calls.
Mass media: The extensive range of mass media is regularly utilized in the form of Mental
Health Articles in Newspapers, and Talk shows in Doordarshan, and Radio Health. This
further helps in mental health awareness campaign to reach a wider population.
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Primary Care Integration
From its onset in 1999, DMHP Tvpm has been conducting clinics directly in selected PHCs,
CHCs & Thaluk hospitals. During the initial periods clinics were conducted every two weeks,
and later on, as number of clinics increased, they were conducted monthly.
Table- Clinical attendance (%) at DMHP clinics in January 2012
Clinics (N)
Schiz
BPAD
Epil*
Dep
Dem
ADS
Anx. dis
Others
Poovar (139)
46
32
2
7
0
1
1
4
Vakkom (96)
41
37
6
4
0
1
0
5
Kanyakulangara (81)
49
27
10
4
0
0
0
3
Aryanadu (73)
43
18
16
7
1
0
0
1
Pallichal (38)
47
24
8
0
0
0
0
0
Vellarada (123)
37
27
19
7
1
1
0
6
Puthanthope(63)
38
29
10
11
2
2
0
5
Kilimanoor (51)
47
31
6
10
0
0
0
4
Malayankeezhu (134)
41
16
16
8
1
1
0
1
Kattakkada (101)
41
28
16
4
1
0
1
5
Neyyatinkara (163)
57
31
5
1
0
1
0
1
Kesavapuram (146)
40
39
5
5
1
1
0
6
Vamanapuram (93)
40
31
8
4
0
1
0
9
Vcllanadu (41)
17
24
46
2
0
2
0
0
Vilappil (65)
52
22
15
2
0
0
3
3
Vizhinjam (71)
41
20
23
1
0
0
0
4
Vithura (70)
41
27
11
6
3
0
0
4
Perumkadavila (74)
35
41
16
0
1
0
0
3
Kallara (171)
32
44
7
6
2
1
0
3
Mangalapuram (86)
40
37
5
5
1
2
1
5
Palode (90)
40
33
8
8
0
0
0
4
AshaBhavan(F)(63)
51
48
0
2
0
0
0
0
AshaBhav (M)(57)
72
23
2
0
2
0
0
0
Total (2089)
42
31
10
5
1
1
0
4
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There has been a steady increase in the number of patients and is about 2000 per month now.
This amounts to about 100-180 patients per clinic. But the availability of only a single
Psychiatrist began affecting the quality of care given. Moreover, the other components of
DMHP namely IEC activities, training programmes, rehabilitation work etc. were also
affected. It was the case till 2010. Also, the National Mental Health Programme meeting of
Nodal Officers of Southern states at NIMHANS in July 2011 gave emphasis on the need for
integrating mental health with primary care. It was in these circumstances that DMHP Tvpm
decided to start the process of Primary Care Integration in August 2011. This was to be done
in 3 phases.
PHASE I (Initiation)
1. Training for Doctors, Nurses, Pharmacists, Health workers, and ASHA workers of hospitals
where DMHP conducts clinics (22 in number)
2. Trained doctors to conduct Psychiatry OP in each hospital.
3. Psychiatric drugs to be dispersed by concerned trained pharmacist of each institution.
4. Case sheets to be prepared for each patient to be kept in concerned PHCs & CHCs.
PHASE II (Consolidation)
1. Consolidation of the integration process
2. Assigning follow-up cases to weekly psychiatry OP conducted by trained primary care
doctors.
3. Preparation of Case taking Performa and Treatment protocol for Doctors.
4. Preparation of Case detection forms and Follow up form for Health workers.
5. Preparation of Posters and Leaflets on signs and symptoms of mental illness and treatments
available, to be distributed and displayed in Primary care institutions across the district.
PHASE III (Extension)
1. Extending the integration process to all other PHCs & CHCs in the district.
2. Doctors, Pharmacists, Nurses and Health workers in these institutions to be trained in primary
mental health care.
3. Weekly Psychiatry O.P to be conducted in all PHCs & CHCs by trained doctors.
4. Follow-up cases in the first 22 clinics (of Phase -I) to be re-assigned to their nearest PHCs or
CHCs.
5. This will reduce the number of follow-up cases in each institution to 10-50 (from the current
100-180 patients)
6. DMHP team will conduct clinics in 22 CHCs.
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7. New cases and follow-up cases which are symptomatic to be referred by primary care
doctors to nearest DMHP clinic. After regular follow-ups, once these patients become stable,
they will be referred back to the doctor of concerned PHCs.
8. Mental Health Awareness and orientation regarding primary care integration to be given to
all staff members of PHCs, CHCs and also to elected representatives of Local Self
Governments.
Training in Mental Health
Doctors: Training in mental health skills were imparted to 48 primary care doctors in
three batches. Training modules were prepared focusing on familiarization of psychiatric
symptoms, identification of common psychiatric illnesses in primary care, its management,
and psychopharmacology.
They were also given awareness regarding their role in community mental health. For
Doctors, DMHP Tvpm conducts an initial Five day training programme followed by Two
day Review trainings every 6 months.
Resource personnel for Training Programmes of DMHP
•
Dr. Veena G Thilak, Retired Consultant Psychiatrist, Mental Health Center, Tvpm.
•
Dr. Vidhukumar, Addnl. Prof, in Psychiatry, Medical College Hospital, Tvpm.
•
Dr. Jayaprakash, Psychiatrist, Mental Health Center, Tvpm.
•
Dr. Indu V Nair, Psychiatrist, Mental Health Center, Tvpm
•
Dr. Jayaprakash KP, Associate Prof in Psychiatry, Medical College Hospital, Tvpm
•
Dr. Anish NRK, Psychiatrist, Mental Health Center, Tvpm.
•
Dr. Sheena G Soman, Psychiatrist, Mental Health Center, Tvpm.
•
Dr. Arun V, Psychiatrist, Mental Health Center, Tvpm.
•
Dr. Arun B Nair, Asst. Prof in Psychiatry, Medical College Hospital, Tvpm.
•
Mr. Ajith R, Clinical psychologist, Mental Health Center, Tvpm.
•
Ms. Nanda, Psychiatric Social Worker, Mental Health Center, Tvpm.
•
Ms. Sandhya Sony, Psychiatric Social Worker , Mental Health Center, Tvpm.
•
Dr. Kiran PS, Nodal Officer, DMHP, Tvpm.
•
Ms. Amrutha R, Clinical psychologist, DMHP, Tvpm.
•
Mr. Vinod MD, Psychiatric Social Worker, DMHP, Tvpm.
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Role of Primary Care Doctors in Community Mental Health
As primary care givers, delivering mental health care through primary care doctors, makes it
more accessible and affordable and also reduces stigma to a certain extent as they are treated
by general care physician.
Doctors in PHCs & CHCs can play an active role in Primary Mental Health Care by:-
> Patient care - treat psychiatric patients in weekly clinics or along with general O.P.
[During Training, most Primary Care Doctors expressed reservations regarding examining
psychiatric patients in general O.P, as number of General cases are very high and mostly only
a single doctor is available to manage. Also psychiatric patients may have to wait in long
queues of general care patients to be examined. This is also the case with Pharmacists who
have to dispense multiple psychotropic drugs for one month to each patient. Hence weekly
clinics are preferred in all PHCs. Another advantage with weekly clinic is that the detailed
case sheets prepared by DMHP team for each patient can be referred to by doctors, and also
Psychiatric O.P register provided by DMHP can be maintained ].
Doctors can examine follow-up cases and can adjust dosage of drugs if patient is
symptomatic, and can refer them to DMHP Clinic if there is no improvement. They should
enquire about side effects of drugs if any, improvements made, whether patient is going for
work or household jobs etc.
They can also examine new psychiatric cases or can refer them to DMHP Clinic. It is
preferable for primary care doctors to attend DMHP Clinic so that they can get an overview
of psychiatric diagnosis, first line psychiatric drugs and can also clear doubts about the cases
they referred.
> Case detection & Psycho-education- As general care physicians, they can detect
psycho-somatic, somatoform, dissociative-conversion disorders, and physical symptoms of
anxiety disorders and can give individual psycho-education regarding the psychological
factors in the causation of these symptoms and disorders.
> Awareness Classes -mental health topics can be included in the awareness classes they
conduct in community. Focus should be on causes of mental illness, common symptoms,
treatments available, whom to approach, need for regular follow-ups and treatment
compliance.
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> Supervision - can enquire about the number of cases identified and referred by health
workers. In addition they can be asked to follow up drop out cases if any. One trained JHI can
be entrusted with co-ordination of community mental health activities. Number of cases
attending the primary care clinics are to be reported to DMHP by month end.
Other Health Professionals -Training was imparted to 34 Pharmacists and 39 Staff
Nurses, focusing on psychopharmacology. They were familiarized with psychiatric drugs and
their common trade names. DMHP will provide drugs to pharmacists of PHCs & CHCs, to be
dispensed to psychiatric patients in their clinics.
Table: Training for Health professionals
Date
Participants
No. of participants
06.08.11
JPHN & JHI
30
29.09.11
JPHN & JHI
32
30.09.11
JPHN & JHI
,35
07.11.11
LHI
21
26.11.11
HI
24
20.01.12 to21.01.12
Pharmacists
24
27. 01.12 to 30.01.12
Doctors
18
Doctors
21
31.07.12
Pharmacists & Staff Nurse
27
20.08.12
Pharmacists & Staff Nurse
22
16.10.12 to 20.10.12
Doctors
8
23.02.12 to 28.01.12
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As part of its efforts to bring mental health care to community, Health Workers (JHI, JPHN,
HI, & LHI) were given mental health training. 142 Health Workers were trained in 5 batches.
They were taught about common psychiatric illnesses, epilepsy, mental retardation, dementia,
identification of common symptoms, referral and follow up of mentally ill.
They were given information about Expressed Emotions in caregivers, and ways to reduce it
through psycho-education.
DMHP Tvpm has included ASHA workers in the process of referral and follow - up of
mentally ill patients. Awareness classes of 2 hours duration were intended to alleviate the
misconceptions regarding mental illness, inform them of the treatments available for mental
illnesses, and about primary care integration and their role in it. 626 ASHA workers have
been included in the process till date.
Table:-Awareness programme for ASHA Workers.
No. of participants
Date
Place
06.09.11
R.H.C Vakkom
69
26.09.11
P.H.C Perumkadavila
21
03.10.11
C.H.C Aryanadu
27
07.10.11
P.H.C Pallichal
12
12.10.11
P.H.C Mulakkalathukavu
30
24.11.11
C.H.C Palode
42
08.12.11
P.H.C Malayankeezhu
30
15.12.11
C.H.C Vellarada
23
23.12.11
C.H.C Vithura
32
27.12.11
C.H.C Kallara
28
28.12.11
P.H.C Mangalapuram
33
02.01.12
C.H.C Poovar
31
04.01.12
C.H.C Kanyakulangara
27
16.01.12
C.H.C Kattakada
38
13.02.12
C.H.C Vellarada
27
15.02.12
P.H.C Vamanapuram
47
20.03.12
C.H.C Kesavapuram
79
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Role of Health Workers in Community Mental Health
Active involvement of Health Workers is essential for successful implementation of
community mental health programme. They can play active role in:-
1. Case detection
As health personal who are in constant touch with community, and
conducting house visits, they help detect untreated psychiatric cases in the community. Cases
thus detected should be promptly referred to Medical Officers of concerned PHCs or CHCs.
2. Follow-up - For dropout cases, health workers as part of their home visits can persuade and
educate the patients and family members to ensure regular follow ups and drug compliance.
3. Awareness classes - Health workers should include mental health topics in the awareness
classes they conduct in community. Also, they can arrange for DMHP team members and
resource persons to take mental health classes in community.
4. Reporting - just as they report Communicable disease to District Medical Office, total
number of mental health cases seen in one month in the hospital is to be reported to staff
nurse of DMHP by month end.
Present Status
Now weekly Psychiatric clinics are conducted in Government Hospitals under DMHP
Thiruvananthapuram. Of the 4 weekly clinics every month, one clinic is directly conducted
by DMHP while other 3 are conducted by trained medical officers of the concerned
institution. DMHP clinics examine new cases and those referred by Medical Officers
conducting the other three clinics. Psychotropic medicines are provided to the respective
pharmacists, to be supplied to the patients. A register for the Psychiatry OP is also provided
by DMHP. The programme ensures that the patients are monitored regularly and all
medications given free of cost.
18
Functional levels of Primary Care under DMHP Tvpm
Monthly DMHP clinics
Referral
For follow ups
Medical officers of concerned PHCs, CHCs
Reporting drop out cases
Bringing them to
Health workers (JHI, JPHN, HI, LHI)
Asha and
anganwadi
workers
Ensuring regular follow
ups and helping in
rehabilitation.
Case
detection
.................... . •
Mental health issues and cases in
community
J
Prepared by DMHP Tvpm 2011
19
Community based Rehabilitation - Occupational therapy Units
at primary care settings
Rehabilitation and mainstreaming of patients with severe psychiatric illness are key issues while
focusing quality health care to all. There are many patients under treatment for mental illness who do
not have active illness and are in remission. These patients need not be in hospital but should be cared
for at home so that they can slowly be brought to the mainstream. But very often, after being
discharged, these patients end up being a burden on their families. Unemployment and rejection could
drive them to alcohol or drugs; they could miss medication and finally end up in hospital again.
Occupational therapy helps them to build their self-esteem, confidence and also help them to come into
the main stream of life like any other individual.
Objectives
> To rehabilitate the patients who are under treatment but in remission.
> To provide occupational opportunities so that the patients can be gainfully employed.
> Help patients acquire the skills to care for themselves.
> To impart basic skill so that the dignity and self-worth of the individual can be sustained
through receiving remuneration for the skilled work done.
This is best achieved by establishing occupational therapy units in Primary Care Settings. DMHP Tvpm
started the first community based Occupational Therapy unit in Kerala at PHC Mangalapuram, Tvpm
onl9th march 2012. Similar units are being planned to be started in 3 other zones of the district at
Primary Level.
In addition to this, patients not going for work are given psycho-education and enrolled in
MNREGS. For this DMHP makes regular contacts with Local Self Government
representatives and officials of their concerned Panchayat. For the past 2-3 years DMHP
Tvpm has obtained help from many Panchayat members for registering our patients in this
scheme, and we feel that the work is well suited to our patients as it is done in groups and
under supervision. Once they get registered they can re-join work even if there is relapse and
hospital admissions and so it provides a constant source of income. Now most of our patients
with working capacity (without any prior job) is employed in this scheme.
20
As on November 2012 we have completed the Phase -II of Integration process, and is
entering the final phase.
Phase -II
Integration process has been consolidated. Training for 39 staff nurses and 10 pharmacists
were conducted in August& September. Third batch of Doctors Training was conducted from
16th to 20th October. Posters and leaflets on mental health awareness, Case detection and
follow-up forms for health workers have been prepared and released. A book on mental
health care for primary care doctors including treatment protocol is under preparation, to be
distributed by November 2012. DMHP is also starting a monthly magazine on mental health
awareness and activities to be distributed among doctors, paramedical staff and health
workers in the district.
Case sheets
Case sheets have been prepared for each patient by interviewing the patient and family, and
kept in concerned PHCs and CHCs for the purpose of verification and follow up by the
medical officers. A soft copy of each will be kept in DMHP. Till now, 2026 case sheets have
been prepared and kept in concerned PHCs & CHCs for this purpose.
Future Plan (Phase-Ill)
For integration of mental health into primary care to become complete, doctors, pharmacists
and health workers in all PHCs and CHCs should be involved in the process. Starting in
November 2012 (Phase-III), DMHP is starting training to Health Professionals in all PHCs
and CHCs in the district. By this, Psychiatry Clinics can be conducted in every PHCs and
CHCs in the district by the trained doctors, under supervision of DMHP Tvpm. Symptomatic
cases and new cases can be referred to DMHP in nearest CHCs, for which DMHP will be
conducting monthly clinics in 22 CHCs across the district. This makes sure that patients have
to travel least distance to get mental health care, so it becomes most accessible and affordable
to them. Case detection and follow-ups by health workers will cover the entire district, so
most of the undetected and untreated mentally ill patients can be brought to treatment. DMHP
Tvpm has also included Local Self Government officials and elected representatives in this
process by conducting awareness programmes for them, which will make it more effective;
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Suggestions and Recommendations
Successfill implementation of programmes in community requires certain rules and
enforcements.
1. Mental health training should be made compulsory for Doctors, pharmacists and health
workers in PHCs, and CHCs, as less than 50% of those called, attend the training process. It
would be better if a list of 25 doctors were given from DMO office to DMHPs after each
Medical Officers Conference (5th working day every month).
2. Weekly Psychiatric Clinics should be conducted in every PHC and CHC by the trained
doctors. This is essential because even after training is given, there is no rule that they need to
see psychiatry cases or conduct weekly psychiatry clinics.
3. It should be made mandatory for Health workers to report mental health cases, drop out
cases, and relapses in monthly meetings. Also total number of cases attended the weekly
clinics should be reported to DMHPs by month end.
4. A scheme similar to DOTS (for TB) should be implemented to ensure treatment
compliance which will minimise drop out cases and relapses.
5. As in general health care different levels of care should be implemented in mental health.
DMHPs should be the first referral units, District Hospitals the second referral units, while
Mental Health Centres and Medical Colleges should be made the third referral units. This
requires strengthening of Psychiatry Units at District Hospitals, but ensures that only the
needed cases reach Medical Colleges and Mental Hospitals.
6. It should be made mandatory for Casualty Medical Officers of Taluk and District Hospitals to
undergo training in emergency psychiatric managements. This will limit referrals to only
those requiring restraining or expert evaluation to mental hospitals.
7. ASHA workers should be incorporated into community mental health activities and
provisions should be made to provide remuneration to the worker for bringing untreated
cases.
8. MNREGS work is well suited to our patients as it is done in groups and under supervision.
Once they get registered they can re-join work even if there is relapse and hospital
admissions and so it provides a constant source of income. So it will be better if preference is
given for mentally ill patients in MNREGS.
I
22
9. Targeted intervention programmes of mental health should be implemented through
Primary care settings, which include:
i.
School Mental Health,
ii.
Geriatric Mental Health,
iii.
Substance abuse prevention,
iv.
Suicide prevention,
v.
Stress management, and
vi.
Community based rehabilitation
10. General cadre doctor (preferably with Public health training) should be posted in each
DMHP through NRHM. The functions will be:
To assist the Nodal Officer in the supervision of clinics, which are to be
extended to all the PHCs, CHCs and After Care Homes under public sector in
the district.
11.
Liaison with the offices of the District Medical Officer (DM0 office) and
District Program Manager (DPM office) for conducting mental health training
to Doctors and Health workers in health services.
iii.
To assist the Nodal Officer in implementation of specific target programmes at
primary care level.
iv.
Research on the effectiveness of clinics, targeted interventions and mental
health training programmes in order to make any modifications if indicated.
11. Research- funding should be allocated for research purpose particularly with regard to the
1.
requirement in the community and the activities being implemented therein.
12. The DMHPs presently functioning as attached units to District hospitals, Mental Hospitals or
Medical Colleges often produce administrative delay and difficulty in implementing the
program effectively. This has resulted in the program becoming ineffective or stagnant in
many districts. It would be better if DMHPs could be made independent units of
community mental health in each district similar to the district units of other National
Programs such as the RNTCP. Overall Supervision should be by the State Nodal Officer of
NMHP. This makes the movement of files faster and the implementation of the program
more effective.
13. DMHP should function as a supervisory body for Community Mental health in each district
as stated as one of the aims of NMHP, and not merely as a treatment team as it presently
operates in some districts.
14. Rehabilitation assistants should be posted in each DMHP to coordinate the community
based rehabilitation and occupational therapy units.
t
23
Proposed Model: Levels of Mental Health Care
Third Referral
Mental Health Center & Medical College
Unit
Second
District Hospital
Referral Unit
First Referral
Monthly DMHP clinics
Unit
Referral
For follow ups
Medical officers of concerned PHCs, CHCs
Reporting drop out cases
Bringing them to
Health workers (JHI, JPHN, HI, LHI)
Reporting
Asha and
Anganwadi
Ensuring regular follow ups
Case
detection
and helping in
rehabilitation.
workers
Mental health issues and cases in
community
Prepared by DMHP Tvpm 2011
k
24
Acknowledgements
DMHP Tvpm likes to express its sincere gratitude to the support & guidance provided by Dr.
PK Jameela, Director of Health Services; Dr. D Raju, Secretary, State Mental Health
Authority; Dr. Prabhachandran Nair, Addl. DHS; Dr. SunilKumar, Superintendent, Mental
health Centre, Tvpm; Psychiatrists of MHC, Tvpm; faculty of Dept. Of Psychiarty, Medical
College, Tvpm and Indian Psychiatric Society (IPS).
Also we would like to thank the Clinical Psychologists, Psychiatric Social Workers and all
the supporting staff of MHC, Tvpm.
Success of community mental health activities is largely owed to the dedicated and sincere
efforts from:-
Ms. Amrutha R, Clinical Psychologist, who co-ordinates the IEC programmes and also
helped in preparing more than 2000 case sheets within 4 months as part of primary care
integration.
Mr. Vinod MD, Psychiatric Social worker, who organizes and coordinates the Training
Programmes for Doctors, Pharmacists, Nurses and Health workers, and does liaison work
with various departments.
Mr.Santhosh R, Psychiatric Nurse, who helped in designing and printing of Posters and
leaflets, organising street plays and also in assigning patients to weekly psychiatry clinics of
concerned PHCs & CHCs.
Ms. Megha BS and Mr. Padmarajan, staff members of DMHP assist us earnestly to attain the
goal.
MSW trainees and MSc Psychiatry Nursing trainees also help us in our effort.
These strategies adopted by DMHP Thiruvananthapuram have been proved to be effective
in mainstreaming many of the undetected and undiagnosed mentally ill patients in the
community. It has also helped in ensuring better treatment compliance as Psychiatric care
and medicines become easily accessible and affordable to them. We hope that this
community initiative will bring about an absolute change in the entire mental health
scenario.
Dr. Kiran PS
Nodal Officer
DMHP, Tvpm
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