RESEARCH MATERIAL ON MENTAL HEALTH
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RESEARCH MATERIAL ON MENTAL HEALTH
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Research methods in psychiatric epidemiology: economic analyses
Daniel Chisholm
Centre for the Economics of Mental Health. Institute of Psychiatry
(Forthcoming in International Review of Psychiatry, Autumn 1998)
OSJEC3WES
This session sets out to provide increased understanding and new insights into the
following areas:
«
The rationale for a health economics perspective
> the social and economic burden of mental disorders
> policy and practice uses for health economics
•
Key economic concepts and principles relevant to health care decision-making
> economics: the science of scarcity
s
> economic objectives: efficiency and equity
•
Different modes of economic evaluation
> cost-minimisation analysis
\\
> cost-effectiveness analysis
> cost-utility analysis
> cost-benefit analysis
•
Design and measurement issues in economic evaluation
>
>
>
>
'J
•
a hierarchy of economic evidence
statistical power and sampling size
stages of economic evaluation
the identification and measurement of resource utilisation and costs
The uses and limitations of economic analyses
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ECONOMIC ANALYSES IN MENTAL HEALTH CARE
The rajiGnate for a health economics perspective
The social and economic burden of mental disorders
Ah accumulating body of epidemiological evidence has emerged, particularly over the
last five years, which points to the massive burden that mental disorders impose upon
societies throughout the world. To take a notable example, a recent collaborative
report, the Global Burden of Disease (GBD), compiled by the Harvard School of
Public Health, the WHO and the World Bank, estimated that the proportion of GBD
caused by neuropsychiatric disorders was over 10% (Murray & Lopez. 1906).
Psychiatric disorders account for five of the ten leading causes of disability - unipolar
depression, alcohol abuse, bipolar affective disorder, schizophrenia and obsessive
compulsive disorder. This burden is projected to increase to 15% of GBD by the year
2020, largely as a result of demographic trends such as the increased number of
elderly individuals and consequent cases of dementia.
The clinical and social burden imposed on individuals, families and communities by
mental health problems contains an economic dimension. Mental disorders exact
costs - often in a financial and invariably in an economic sense - at all levels of
society, either directly through expenditure (or unpaid time spent) on providing health
and social care and support, or indirectly in terms of lost opportunities (such as for
leisure or work). Other ‘intangible' costs include deficits in well-being (foi example.
the anguish and anxiety experienced by people with mental health problem: and their
families or carers). Some examples of these costs are given in Figure 1.
Figure 1:
The economic burden of mental disorder
Examples of impact
Level
Direct costs
Indirect costs
Intangible costs
Patient
Service fees
Lost employment
Qualit) of life
Family
Travel costs, fees
Lost employment
Carer burden
Service system
Psychiatry
Criminal justice
Staff morale
Wider society
Tax burden
Personal safety
Fear
Pcficy and practice uses for health economics
Thie increasing interest and apparent need for health economics contentions to
mental health policy and practice stems from a number of sources. Like epidemiology.
these contributions are geared towards population-level concerns. Much of the need
i
for a health economics perspective arises out of the scarcity of resources relative to
needs, which translates into a requirement to make choices about how these scarce
resources should be most appropriately allocated. At the most aggregated level, a
government could decide, say, to double its budgetary allocation to mental health
care: while this undoubtedly would have many positive impacts, there would in all
likelihood remain an outstanding pool of unmet mental health need in the population.
Moreover, the decision to allocate a greater volume of resources to mental health care
- in a constrained, publicly funded system, at least - impacts on the resources
available for other health or welfare programmes that may equally deserve greater
investment. At the level of mental health purchasers, resource scarcity piompts rhe
need to gather data or evidence with which to evaluate the clinical and cost
effectiveness of new and current therapies, in order to improve or maximise the health
gain of their local populations. Finally, there are regulator}' requirements for health
economics data. For example, pharmaceutical companies in Australia ard Canada
must provide cost-effectiveness data before licensing new products, a trend that is
likely to be increasingly pursued in Europe.
Key economic concepts and principles relevant to health care decision-makiim
Economics: the science ofscarcity
As indicated above, the notion of resource scarcity is key to an understanding of the
economic approach towards mental disorder, since this necessarily prompts the
requirement to make choices between different courses of possible action or
investment. Making a choice implies in turn the sacrifice or foregoing of the
alternative action or investment. The economic approach therefore attempts to value
the worth of a particular resource, decision or strategy with reference to its
‘opportunity cost’, namely the value attached to the next best alternative. To give an
example, the opportunity cost of an acute psychiatric bed is (theoretically) derived
with reference to the alternative use with which those resources could be pl.t to. such
as within another medical speciality, outside medicine completely, or even investment
into an interest-bearing savings account.
A further important principle of economic analysis is that it takes a broad, societal
perspective, such that account is taken of costs falling to all relevant parties. For
instance, allowance should be made for inputs of impaid volunteers/family carers as
well as formal care inputs, as should any losses of productivity. (For mor; detailed
elucidation of these evaluative principles, see Knapp, 1995, Hargreaves el al. 1998.')
Economic objectives: efficiency and equity
It is not the aim of health economics to cut health spending or to pare down costs, bui
to improve both the efficiency with which health care resources are employed and the
targeting of those resources on needs and demands (the equity objective).
Efficiency is first and foremost concerned with establishing that heilth care
programmes are worthwhile, in the sense that their benefits exceed their costs
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(allocative efficiency); at a technical level, efficiency is concerned with ensuring that
best use is made of the scarce resources channelled into these worthwhile
programmes. Efficiency therefore provides a framework with which to de ermine an
optimal allocation of resources to various programmes of health care expcnc iture.
Equity considerations revolve around the ideas that each person must be given their
due and equals must be treated as equals. Discussions about justice or equity at a
policy level have typically concentrated on the distribution or redistr button of
(scarce) resources, which in the context of mental health care is typically c etermined
by need and expressed in terms of access to or utilisation of services.
Different modes of economic evaluation
A core response to the demands for health economics made by decision-makers at a
mmber of levels in the mental health care system is through the conduct of economic
evaluation. Economic evaluation is specifically concerned with addressing the
relationship between the costs and, outcomes of an intervention, and there arc a
ntrnber of ways in which these costs and outcomes data can be combined for
analytical purposes (see below).
Responding to scarcity, however, does not just mean conducting economic
evaluations of alternative treatments, but requires examination of. for example, the
patterns of employment, the forces of demand and supply, the roles of markets in
resource allocation, and the incentives and disincentives to better practice (?rank and
Manning, 1992; Chisholm and Stewart, 1998).
Cast minimisation analysis
The simplest of cost evaluations is commonly referred to as cost-mir imisation
analysis, which either does not take account of treatment outcomes or assumes that
they are identical for both alternative interventions under investigation. In other
wards, the task is merely to establish the least cost method of achieving these
(identical) outcomes. Since outcomes are invariably a key concern in mental health
care evaluation, yet can rarely be assumed to be the same for two groups, cost
minimisation analysis is seldom used.
Cost-effectiveness analysis
The large majority of economic evaluations in the field of mental health care are
examples of cost-effectiveness analysis, which assesses not only the costs but also the
outcomes of an intervention, expressed in terms of reduced symptoms, mproved
functioning/quality of life etc. Since clinical evaluations commonly involve a wide
range of outcomes, it is necessary to either focus on a primary measure for
establishing cost-effectiveness ratios or to analyse the relationships between costs and
outcomes using multivariate analyses.
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An example of a cost-effectiveness study is that by Knapp et al (1998), whc compared
home-based versus hospital-based care for serious mental illness. The Dt.ily Living
Programme (DLP), as it was called, consisted of intensive home-based care with
problem-centred case management for seriously mentally ill people facing crisis
admission to the Maudsley Hospital, London. A randomised contro led study
examined the cost-effectiveness of the DLP versus standard in/outpatient hcspital care
over 20 months (phase 1), followed by a randomised controlled withdrawal of half the
DLP patients into standard care (months 30-45; phase 2). Over phase 1, the average
weekly costs of home-based DLP care (£282) were significantly less costly than
standard inpatient-based care (£518) - although this difference narrowed appreciably
over this period. Taken together with the significantly improved symptomatology.
social adjustment and satisfaction of the DLP group, this indicates the cost
effectiveness of the DLP over the short-term. In phase 2, there were few tdvantages
in symptoms or social adjustment for DLP compared to control patients -■ although
satisfaction continued to be significantly better - and there were no statistically
significant cost differences between either the continuing-DLP or ex-DL 3 controls
and the original control group. The authors therefore concluded that whilst the home
based DLP was cost-effective in the short term - and indeed over the full 45 month
period as a whole - it appeared to 16se its advantage in the final year of the research
period.
Cdst-utility analysis
A particular form (and extension) of cost-effectiveness analysis is cost-utility analysis.
developed by health economists in the search to make explicit comparisons between
interventions or even conditions. This approach has considerable appeal for decision
makers since it generates equivalent and therefore comparable study data ('utilities’.
expressed by a combined index of the mortality and quality of life effects of. an
intervention). The end result is a series of cost-utility ratios, which reflect the relative
change in costs and outcomes for the alternative interventions under study, and upon
which priorities can then be based. However, there are conceptual and technical
difficulties with the application of utility measurement to mental health (see Chisholm
et al, 1997 for a review), which has restricted its use to date.
An example of cost-utility analysis in mental health is that by Revicki et al (1997).
who compared treatment for major depression with i) newer antidepressants
(nefazodone and fluoxetine) ii) tricyclics (imipramine) and, for treatment fa lures. i:i)
a step approach involving initial treatment with imipramine followed by nefazodone.
A clinical decision analysis model was developed to simulate the clinical management
pathways and pattern of recurrences of major depression for these alternative
treatment strategies in order to estimate lifetime medical costs and health outcomes
(expressed as quality adjusted life years or QALYs). There were only minor
differences in costs and QALYs between nefazadone and fluoxetine, and both these
newer antidepressants were cost-effective compared to imipramine treatment and 'die
imipramine step approach. The ratios of cost to QALYs gained for these newer
antidepressants were deemed to be sufficiently low (below $20,000 per QALY
gaihed) to merit adoption of these treatments into the health care system. For example.
the extra lifetime cost of nefazadone over imipramine (S1.321) resulted in 0.32 added
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QALYs, giving a ratio of $4,065 per QALY gained. Since decision models and their
findings are only as good as their underlying assumptions and the quality of the data
used to estimate key model parameters, extensive sensitivity analyses were conducted,
but these did not alter the basic findings and conclusions. However, the rest Its did not
include indirect costs - important for a societal perspective - and are rot readily
generalisable to groups other than the targeted population (in this study, 30-year old
wonsen with one previous depressive episode).
Ctofitenetfit analysis
The final mode is cost-benefit analysis, which refers to a particular form of evaluation
in which all costs and outcomes are valued in monetary units, thereby allowing
assessment of whether a particular course of action is worthwhile in terms cf a simple
decision rule that benefits must exceed costs. This approach, whilst the most
attractive to economists, is very labour-intensive, beset with valuation difficulties in
relation to the quantification of outcomes, and is consequently found very rarely in
mental health care evaluation.
However, new valuation techniques such as
‘willingness to pay’ - where an individual states the amount they would be prepared to
(hypothetically) pay to achieve a given health state or health gain - suggest a potential
rekindling of this mode of analysis.
One notable example of cost benefit analysis, also in the area of hospital diversion,
was conducted by Weisbrod, Test and Stein (1980) as part of the Assertive
Cdmnumity Treatment (ACT) programme in Wisconsin, USA (a precursor, in fact, to
the DLP). 130 patients were randomly assigned to either the experimental 'Training
in Community Living’ (TCL) group or a control group that received inpatient hospital
treatment and community aftercare. Over a 14 month period, a range of input costs
(spanning hospital, social services, criminal justice, social security services, plus
informal carers foregone earnings) were compared to the monetarised benefits of care
(patient earnings). The authors found that the additional benefits of the experimental
programme ($1200 per patient year) were greater than the additional costs incurred
($800 per patient year), providing a clear cost-benefit advantage of $400 (per patient
year). Non-monetarised indicators of patients’ mental health (sympoms and
satisfaction) were also significantly better in the TCL group.
Dflaian, mCTSUTgmgnt and statistical issues in economic evaluation
A hierarchy ofeconomic evidence
Ast in clinical evaluation, an important consideration for the review, assessment and
interpretation of economic evidence is the design of the research study (for example,
is it a prospective, controlled trial or a retrospective study with no contro group?).
Two further features can be added to this for economic studies, namely the type of
economic evaluation, and the scope or perspective of the study (Figure 2). The merit
or value of an economic study in terms of its coverage and generalisability is
determined to a significant extent by these three parameters.
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The ideal type of study upon which to base decisions on eost-elTecli\eness and
resource allocation is one that is conducted prospectively with two (or more)
costs and outcomes arc measured in n common currency. Such :i study, ns s.’en above.
is extremely demanding to undertake, largely due to the requirement to convert all
costs and consequences into monetary units. Most studies are in fact instances of cost
effectiveness analysis, employing the cost perspective of the formal service sector
only.
Figure 2
Economic evaluation - the hierarchy of evidence
Parameter 1
Parameter 2
I’arnmcte • 3
Type of clinical data
(what ratings are based on)
Type of economic evaluation
(how costs & outcomes combined)
Costing scope/pcrspective
(what costs are included)
Non-empirlcal
(e.g administrative database)
Cost-minimisation analysis (CMA)
(outcomes are the same)
Direct costs - single agency
(e.g. health service only)
Observational
(e.g. cross-sectional study)
Cost-effectiveness analysis (CEA)
(e.g. change in level of depression)
Direct costs - all agencies
(e.g. informal care included)
Quasl-experlmental
(e.g. retrospective study) ‘
Cost-utility analysis (CUA)
(e g. quality adjusted lite year)
Direct and indirect costs
(lost productivity included)
Experimental
(e.g. RCT)
Cost-benefit analysis (CBA)
(all costs and outcomes monetised)
Intangible costs
(e.g. anguish, side-effects)
Statistical power and sampling size
A further requirement for economic evaluation is recruitment and retention of a
sufficient sample of patients and/or facilities to show statistically significant changes
between groups. Many economic evaluations in the past have been under-powered.
mainly due to the skewed distribution of costs among subjects. Gray et al 11997), for
example, showed (retrospectively) that at 80% power, their case managerrent study
(n=30) was sufficient to detect between-group differences of approximately 30% for
total costs, but to detect a 20% difference in health care costs alone over 7C 0 subjects
per arm would have been required! This raises a number of questions, inch ding what
constitutes a worthwhile difference in costs, and what is the additional resea'ch cost of
basing sample size estimates on economic (as opposed to clinical) variab cs. What
remains clear, however, is that the uncertainty introduced into economic findings by
the variability of costs must be addressed not only by sensitivity analysis t ut also by
the sufficient powering of the study at the design stage.
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PAGE
Stages of economic evaluation
There arc a number of stages that typically comprise the conduct of an economic
evaluation, all of which need to be pursued in order to obtain a valid and idiable set
of findings:
i)
definition of the alternative interventions to be evaluated (design);
ii)
identification of the costs and outcomes to be included in the study (scope);
iii)
quantification of these identified costs and outcomes (valuation):
iv)
comparison of costs and outcomes (analysis);
v)
revision of findings in the light of uncertainty and sensitivity (qualification):
vi)
examination of distributional effects (equity).
The identification and measurement of resource utilisation and costs
The collection of service and other resource utilisation data at the le''d of the
individual service user enables the generation of detailed information on the
consumption of a wide range of resources. Opportunity cost estimates can be applied
subsequently to these data in order to calculate the overall economic costs associated
with an individual’s care, or at a more aggregated level, a particular intervention or
strategy for a group of individuals.
An initial stage in the recording of resource utilisation data is the identi ication of
relevant components of potential service receipt by users (see Figure 3 for a list of
examples). The range of service components to include in a study differs with
respect to a number of evaluative concerns, including the scope, objectives and setting
of the study, as well as the particular service needs of the client group(s). For
example, users with more severe or enduring mental disorder, such as people with
schizophrenia, are likely to need a much wider range of services than people with
common mental disorders such as depression and anxiety.
Figure 2
Example, of service utilisation items
Hospital services
Ambulatory services
inpatient - psychiatric
inpatient - general medical
outpatient - psychiatric
primary care doctor / GP
primary care nurse
psychiatric nurse
jcnrial wnrtar
psychiatrist
day care - medical/surgical
8
11
Resource utilisation data relating to identified service components can be collected
coverage/extent of service components and the access to service provider da:abases:
• study design: economic analysis carried out alongside clinical evaluatio is offers a
number of assessment points for the collection of individual service utilisation
data. Individual profiles of service use can be constructed over a defined
retrospective period via tine administration of a service receipt schedule.
Prospective studies offer the potential to collect resource utilisation da:a through
the keeping of a diary of any contacts made, rather than the completion of a formal
interview-bused schedule.
• service provider databases: an alternative method for eliciting data on individual
service contacts is through the examination of patient records kept by service
providers - particularly if these records are computerised - including hospitals.
primary care providers and social services. Sole reliance on these data sources is
made difficult by the multiplicity of databases on which an individua’s service
contact(s) may appear and the potential for non-completeness and under-1 eporting.
• service coverage: the extensive range of services that people with mental health
problems may take up means that most evaluations need to adopt a wide coverage.
which again points to the usefulness of an instrument or schedule that pulls these
disparate service components together in a single form.
For each item of resource utilisation, a unit cost estimate is required, such as a cost per
inpatient day, day care attendance, or GP contact. In some countries and for certain
services, these data may already have been calculated (in the UK, for example, see
Netten and Dennett (1998) Unit Costs of Health and Social Care). Otherwise, it will
be necessary to compute these estimates using a range of data sources, including
national/local government statistics, health authority figures and specific facility or
organisation revenue accounts. In practical terms, the main categories o' cost that
typically need to be quantified for each service are:
•
Salaries / wages of staff employed in the direct care and management of patients
•
Facility operating costs where the service is provided (( leaning, catering etc.)
•
Any overhead costs relating to the service (personnel, finance etc.)
•
The capital costs of the facility where the service is provided (land, builc ings etc. )
Tte.tMes.HMi limitations of economic analyses
Economic evaluation provides a means of comparing the costs and outc ames of a
mental health care intervention or programme together in an explicit I'ramev'ork. 1'his
in turn enables decision-makers to assess the extent to which the intervention or
strategy offers a good use of (scarce) resources. An analysis of costs alone, or indeed
of outcomes alone, does not provide such information. The results of well-conducted
economic evaluations can be channelled into decision-making processes at a
succession of levels:
• users and carers; economic evidence can complement clinical decision-making at
tins level in terms of comparison of the costs and consequences of alternative
treatment strategies, particularly in relation to new psychotropic drugs. For
example, are the additional acquisition costs (to GPs and others) associated with
the newer anti-depressants or atypical anti-psychotics worth it in terns of the
potential for reduced side-effects, enhanced compliance and less hospital sation? In
the absence of prospective, controlled cost-effectiveness trials, decision modelling
techniques have been employed to explore these complex inter-relationships
(Revicki et al, 1997).
• purchasers and providers; as well as specific therapies, purchasers need data on
mental health strategies for their local populations. A core element of local needs
assessment and strategic service development concerns the resource implications of
changes to, for example, the hospitakcommunity balance or the
statutory:independent sector interface. Au extensive literature on the cost
effectiveness issues surrounding these concerns now exists (Knapp, 1995).
• government and society; at the most aggregated level of mental hea th policy.
decisions, lor example with respect to tire rcpruviaiun ul vaic lot me long-term
mentally ill from hospital to community settings (Hallam et al. 1.994).
an extra dimension that offers a wider assessment of the implications of new or
existing courses of action, it is important to mention some of the limitations of the
of sample size, or comprehensiveness of cost and outcome measurement. Conclusions
based on a small RCT with less than 50 subjects per arm can often only be tentative.
while the failure to measure the indirect costs associated with two alternative
treatments may give rise to misleading results. There are also a number of ongoing
methodological debates with respect to certain aspects of economic evaluation, such
as the alternative techniques available for measuring health, state preference* (essential
for both cost-utility and cost-benefit analysis). In this context, it is worth noting that
economic evaluation is no panacea for making difficult allocative and policy
decisions; rather, it is one additional tool that together with clinical and social
dimensions can facilitate explicit, evidence-based decision-making.
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References
Chisholm D, Healey A, Knapp MRJ (1997). QALYs and .mental health cere. Social
Psychiatry anti Psychiatric Epidemiology, 32, 68-75.
Chisholm D, Stewart A (1998). Fxonomics and ethics in mental health care:
traditions and trade-offs. Journal ofMental Health Policy and Economics, 1. 55-62.
Frank RG, Manning WG (eds) (1992). Economics and Mental Health. John Hopkins
University Press, Baltimore.
Gray AM, Marshall M, Lockwood A, Morris J (1997). Problems in conducting
economic evaluations alongside clinical trials. British Journal of Psychiatry. 170, 47-
52.
Hallam A, Beecham JK et al. (1994). The costs of accommodation and care:,
J
.........A..
A.........................
1.
------- 1-1-.-.
-
Archives of Psychiatry and Nearulvgical Sciences, 243, 304-310.
Hargreaves WA, Shumway M, Hu T, Cuffel B (1998). Cost-outcome muhods for
mental health. Academic Press. London.
Pvliupp, JVJLIVJ
\L77Jji J ne kluhcwjv owuuhvu <.//•
Aldershot.
Mnrraj, C r.njwz AD
t'1996'i. 771.! Cllahal Burden of Disease: a comprehensive
assessment of mortality and disability front diseases, injuries and risk factors in 1 UM
and projected to 2020. Harvard University Press, Cambridge, MA.
\
A. r->«tnr>«TT J (1OQR) rfnti ao.vA- /j/*huulfh unt.1 xmiu! • ‘
<*■«.£ V"Mvtf, f'onfprknrj;
I I Inivr.r.nity
Revicki D, Brown R, Keller M, Gonzales J (1997). Cost-effectiveness of newer
antidepressants compared with tricyclic antidepressants in managed cars settings.
Journal ofClinical Psychiatry, 58, 47-58.
Weisbrod BA, Test MA, Stein LI (1980) Alternatives to mental hospital treatment: 11.
Economic benefit-cost analysis. Archives of General Psychiatry, 37, 400-405.
11
14
MW'.G-
THE LANCET, DECEMBER 13, 1969
dermatitis after taking calcium cyclamate but not after
taking saccharin. The skin reaction was eczematous,
and histology showed subacute dermatitis with mild
otdcma of the epidermis and a moderate mononuclear
cell infiltrate in the dermis. A month after stopping
the cyclamate, post-inflammatory hypopigmentation
appeared in the affected skin.
Renal and myocardial damage have been reported by
Bajusz 10 who injected 0-2 g. of calcium cyclamate a
day into hamsters for 6 days. Histological examination
showed cortical nephrocalcinosis in most of the animals,
but an equivalent amount of calcium chloride, acetate,
aspartate, or ascorbate did not produce these lesions.
With calcium cyclamate there was also myocardial
degeneration, focal calcification, and coronary-artery
calcification. The lesions resembled those seen in
hypervitaminosis D in man. Nees and Derse11
observed similar but less striking effects on rats given
calcium cyclamate by mouth. The acute tubular
acidosis seen in our patient is thus analogous to. the
tubular damage seen in these animals. Of interest is the
high serum-calcium (taking in to account the severe
acidosis) which fell with recovery and the very low
scrum-inorganic-phosphate probably indicates failure
of tubular reabsorption. Another unusual feature was
the hypokalatmia in the presence of hyperchloratmic
acidosis.
Constipation may have caused an increase in absorp
tion of cyclamate. Normally, increasing tire cyclamate
intake to 12 g. per day causes diarrhoea,8 thus limiting
absorption. Three bottles of soft drink can contain a
total of 4 g. of cyclamate 11 so our patient was probably
consuming 12 g. daily. Almost all the ingested dose is
excreted in the fatces or urine.18'13 In Britain, one
person in eight excretes cyclohexylamine ’ in the urine
after taking cyclamates but 100% of Japanese subjects
excrete this cyclamate metabolite.8 Cyclohexylamine
and dicyclohexylamine are both very toxic; both are
strongly alkaline and cause skin necrosis when applied
locally.6'14 Cyclohexylaminc also causes degenerative
changes in the heart and kidneys and may produce
methatmoglobinsmia.
No cyclohexylamine was found in our patient’s
urine, but this was 3 days after stopping the intake of
cyclamate. It is possible that the relative frequency of
photoallcrgy in Japan may be related to the production
of cyclohcxylamine and to the abundance of strong
sunlight.
1275
Preliminary Communications
MENTAL-HOSPITAL ADMISSIONS
AND AIRCRAFT NOISE
I. Abey-Wickrama
York Clinic, Guy's Hospital, London S.E.1
M. F. A’Brook
Belmont Hospital, Sutton, Surrey
F. E. G. Gattoni
Department of Statistics, London School of Economics and
Political Science, London W.C.2
C. F. Herridge
Springfield Hospital, London S. W.l 7, and Health Department,
London Borough of Hounslow
A retrospective study covering two
unimary yCars of admissions t0 a psychiatric
hospital shows that there is a significantly higher rate
of admission, especially in certain diagnostic categories,
from inside an area of maximum noise arising from
Heathrow Airport than from outside this area.
INTRODUCTION
The effect of aircraft noise on health is continually
being discussed as a result of controversy over the
siting of new major airports. Atherley 1 has stated that,
despite much popular feeling associating noise with
mental breakdown, it is very difficult to find good
scientific evidence of adverse effects of aircraft noise on
mental health. In 1963, the Wilson report - concluded
that it was extremely unlikely that an investigation into
the effects that noise might have on people living near
Heathrow Airport would produce meaningful results.
Since the London Borough of Hounslow is par
ticularly exposed to aircraft noise from Heathrow, and
since it was possible to obtain full details of admissions
to one psychiatric hospital from a major part of that
borough, we decided to see if a retrospective study of
admissions over a two-year period would reveal any
differences between populations exposed to two differ
ent levels of aircraft noise.
METHOD
Most patients requiring inpatient treatment for psychiatric
illness and living in the Borough of Hounslow arc admitted
to Springfield Hospital, which lies several miles to the
south-east of the borough. A number are admitted to general
and teaching-hospital units, and those from the Feitham
area arc admitted to another psychiatric hospital. This area
REFERENCES
has not been considered, since figures arc not available; and
Tatsu/i, K-, Toshie, A. Med, Culture, 1963, 5, 795.
such checking as was possible indicated that admissions to
Kobori, J., Arabi, II. 1963. Cited in reference 8, p. 12.
the other units are uniform from throughout the borough.
Kobori, J., Araki. H. J. Astlmta Res. 1966, 3, 213.
The population under study consists of some 124,000
Boros, E. J. Am. Med. Ass. 1965, 194, 572.
Lemberg, S. 1. ibid. 1967, 201, 747.
persons over the age of fourteen. These people live either
Kojima, S., Ichibagase, H. Chern. Pharm. Bull. 1966, 14, 971.
Leahy, J. S., Wakefield, M.,Taylor,T. B.I. B.R.A. Bull. 1966, S, 669. inside or outside a maximum noise area (m.n.a.) caused by
British Sugar Bui eau. Cyclamate Sweeteners: a review of metabolism, aircraft movement at Heathrow or by aircraft approaching
toxicology, and usage. London, 1967.
to land. The m.n.a. is defined as that where sound levels
Lancer, 1969, ii, 361.
arc above 100 PNdb (Board of Trade figures) or where the
Bajusz, E. .Ve.’urr, Loud. 1969, 223, 406.
N.N.I. (Wilson report) is over 55:
Nees, P. O., Derse, P. H. ibid. 1967, 213, 1191.
We thank Dr. G. L. F. Pawan for estimating cyclohexylaminc,
Prof. A. C. Dornhorst for helpful advice, and Dr. M. I. A. Hunter
for giving us the opportunity of investigating this patient.
Requests for reprints should be addressed to J. M. Y.
I.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Taylor, J. D., Richards, R. K., Davis, J. C. Proc. Soe. exp. Biol. Med.
1951, 78, 530.
Miller, J. P., Crawford, L. E. M., Senders, R. C., Cardinal, E. V.
Bioehem. Biophys. Res. Comm. 1966, 25, 153.
Lomonova, G. V. Fedn Proc. 1965, 24, part 2, T 96.
The N.N.I. (noise and number index) is a composite measure,
defined for purposes of the Wilson report, taking into account
the average peak noise level (at.n.) as well as the number of
aircraft (N) heard in a specific period (e.g., one day or one night).
aa2
1276
THE LANCET, DECEMBER 13, 1969
3RENTF0RD &CHISWICK M.B.
ISLE WORTH
NORTH
1 > .i .j
CENTRAL
HEATHROW
AIRPORT
Hl.'I i.-isi o
HOUNSLOW
FELTHAM U.D
JIIUIll'Himtl AREA STUDIED
rELTHAM
CENTRAL
rLLTHAM SOUTH
Map or London borough of Hounslow showing maximum noise
area and study area.
The numerical value is given by:
N.N.I.=A.P.N.+15 log 10 N —80.
PNdb. (perceived noise in decibels) is the unit of perceived
' noise level measured by a sound-level meter.
These levels have been chosen since McKennell and
Hunt3 state that a peak noise level of over 93 PNdb is of
major importance as a source of complaint, whilst the Wilson
report considered that exposure to aircraft noise reaches an
unreasonable level in the range 50-60 n.n.i. The m.n.a. is
shown on the map and contains a population of approxi
mately 54,000 (figures supplied by the housing department,
London Borough of Hounslow).
A demographic analysis was carried out to ensure that the
population of the m.n.a. and the rest of the area under study
were reasonably comparable in terms of age, sex, marital
status, population density, migration and socioeconomic
group. This was done by studying the 10% sample of the
1966 census for four wards lying almost entirely inside the
m.n.a., five wards lying outside it and, five wards lying
partly outside the m.n.a., known as the “ mixed ” wards.
This analysis (not shown here) confirmed that the borough
is fairly homogeneous in respect of these factors. However,
although there is no great social difference between the two
populations, the socioeconomic status is lower and density
and migration higher outside the m.n.a., suggesting that
this population is, if anything, more at risk from psychiatric
TABLE II—DIAGNOSTIC CATEGORIES (FEMALES ONLY)*
TABLE 1—TABLES OF SIGNIFICANCE
Category*
M.N.A.
Noh-m.n.a.
o 1— 1 o
E
All admissions:
Total ..
245
First
96
Female admissions:
Total ..
147
First ..
.. 54
Male admissions:
Total ..
98
First ..
42
Females aged > 45:
Total ..
96
First
36
Females (married):
Total ..
68
First
24
Females (otherf):
Total ..
79
First
30
Females (widows,
separated, divorced):
Total ..
44
First
21
Females (widows):
Total ..
36
19
Significance
X*
212-9 243 275-1
78-1 83 100-9
8-58 0005>P>0-001
7-28 0-01 >p> 0-005
125-7 143 164-3
41-2 41 53-8
6-37 0-025>p>0-01
7-02 0-01>P>0-005
87-1 100 110 9
36-9 42 47-1
2-44
1-30
'
N.S.
N.S.
75-4
22-8
79
17
99-6 9-98 0-005>P>0-001
30-2 13-42
P< 0-0005
61-5
19-8
69
20
75-5
24-2
1-30
1-70
N.S.
N.S.
62-3 74
20-75 21
90-7 7-55
30-25 6-92
38-5
15-5
33
10
38-5
15-5
1-57
3-90
0-05>P>0-01
27-5
13-0
19
7
27-5
13-0
5-26
5-60
0-05>P>001
005>P>0-01
0-01 >P >0-005
0-01>P>0-005
• The following categories were also analysed but nothing significant
was found: males <45, males >45, females <45, males married,
males other.
t Single, widowed, separated, or divorced.
O ^observed. E=expected.
Category
Non-
M.N.A.
X*
Significance
5-19
1-02
0-05 >p> 0-01
N.S.
E
0
“ Neurotic
Total
26 18-6
First
9 6-9
Organic mental illness:
Total
35 24-3
22 12-1
First
17
7
24-4
9-1
21
6
31-7 8-33 0-005 >p >0-001
15-9 13 94
P<0-0005
O
E
’ Affective, schizophrenic, “ psychopathic ”, and “ epileptic, alcoholic,
&c.” groups were analysed for females and all six diagnostic categories
were analysed for males, but in all instances either p was >0-05 or
the numbers were too few for analysis.
illness than that living inside the m.n.a.'-8 Since admissions
are largely channelled through one of us (C. F. H.), it is
probably safe to say that, in the relevant parr of Hounslow,
the policy of inpatient or community treatment is fairly
uniform over all the N.H.S. practices in the area.
We examined the records of all patients admitted to
Springfield Hospital from the area of study from July 1,
1966, to June 30,1968. Admissions were divided into “ first
admissions ” (those patients who had apparently never had
inpatient psychiatric treatment before) and “ total person
admissions ” (all patients who had one or more admissions
during the period). Details of age, sex, marital status, and
diagnosis were recorded, and the patient’s address was
plotted on a large-scale map. All persons of no fixed abode
who happened to be admitted from the area were excluded.
THE LANCET, DECEMBER 13, 1969
1277
RESULTS
fibroblasts, confirming the in-utero diagnosis of
type-ii glycogenosis.
These are presented in detail in tables I and n. It
should be noted that populations at risk have had to be
estimated from 1966 Census data for everything but
total person admissions because the exact distribution
in terms of age, sex, and marital status of the popula
tions in the M.N.A. and non M.N.A. areas is unknown. In
all, 42 tests of significance were done on the data; not
all the negative results are shown in the tables. 14 7/
values were significant at the 5% level compared with
2 positives which would be expected by chance alone.
CONCLUSIONS
This is a retrospective study, which measures only
admissions to a psychiatric hospital, and makes no
attempt at exploring mental illness in the community.
A further more detailed prospective study is planned.
Several factors can govern whether a patient is
admitted to hospital or treated in the community, and
we do not suggest that aircraft noise itself can cause
mental illness. The results clearly show, however, that
admission-rates to Springfield Hospital are significantly
higher from the M.N.A. than from outside it, both for
total person admissions and for first admissions.
Furthermore, the type of person most affected is the
older woman who is not living with her husband and
who suffers from neurotic or organic mental illness.
We conclude that the high intermittent noise levels
from aircraft using Heathrow Airport may be a factor
in increased rates of admission to Springfield Hospital.
INTRODUCTION
Type-h glycogenosis (Pompe’s disease) is inherited
as an autosomal recessive disorder characterised by
intractable cardiac failure progressing to death within
the first year of life.1 a-l,4-glucosidase activity is
deficient in the liver,2 and leucocytes and cultivated
fibroblasts 3 of patients with this disorder. Since this
enzyme can be detected in cultivated1 and non-cultivated5 amniotic-fluid cells and since in a number of
other heritable disorders in-utero detection of an
affected fetus has been accomplished using cultivated
amniotic-fluid cells,0-11 we set out to evaluate amnioticfluid analysis in the management of pregnancies of
women who had previously delivered children with
type-n glycogenosis.
METHODS
Amniotic fluid was obtained by transabdominal amnio
centesis performed between the fourteenth and sixteenth
week of pregnancy from five women (eight pregnancies)
who had previously delivered children with type-n glyco
genosis and from twenty controls. 10-15 ml. of amniotic
fluid was divided into roughly equal parts and centrifuged,
and the supernatant was removed for analysis of a-1,4glucosidase activity. One cell pellet was used for enzyme
analysis (non-culturcd amniotic-fluid cells). The remain
ing cell pellet was suspended in 100% fetal calf scrum,
placed in two Falcon pctri dishes, immobilised under
coverslips, F-10 medium supplemented with 15% fetal
calf scrum was added and placed in 5% carbon-dioxidc
We thank the London Borough of Hounslow for a grant
towards this study, and some of its officers, in particular Mr.
atmosphere at 37°C. The cultures .vere fed every other
M. W. Langford and Mr. K. J. Rowlands, for their valuable help.
day until the time of subculture (10-25 days). 4-7 days
Requests for reprints should be addressed to C. F. H., Spring
after subculture, the cells were removed by trypsinisation
field Hospital, London S.W.17.
(0-25% trypsin), rinsed with Hanks’ balanced salt solution,
REFERENCES
suspended in .0-5 ml. of 0-25 M sucrose and mechanically
1.
Athcrley, G. R. C. in Documenta Geigy: Noise; p. 4. Manchester, disrupted. a-l,4-glucosidase activity was determined by
1968.
the method of Nitowsky and Grunfcld.3
2.
3.
4.
5.
6.
Committee on the Problem of Noise: final report. H.M. Stationery
Office, 1963.
RESULTS
McKenncll, A. C., Hunt, E. A. Noise Annoyance in Central London.
The activity of <z-l,4-glucosidase in amniotic fluid,
H.M. Stationery Office, 1966.
Schneider, E. V. Inter Relations between Social Environment and non-cultured amniotic-fluid cells, and cultivated
Psychiatric Disorders. New York, 1953.
amniotic-fluid cells are shown in the table.
Tictze, C., Lemkau, P., Cooper, M. Am. J. Sociol. 1941, 47, 167.
Tictze, C. ibid. 1942, 48, 29.
In six cases (1, 2, 3, 5, 6, and 7) healthy children
were delivered at term and in the first 8 months of
life, none has any evidence of type-n glycogenosis.
In babies 1, 3, 5, and 7 a-l,4-glucosidase activity
IN-UTERO DETECTION OF TYPE-II
GLYCOGENOSIS (POMPE’S DISEASE)'
H. L. Nadler
A. M. Messina
Department of Pediatrics, Northwestern University and
Children’s Memorial Hospital, Chicago, Illinois 60614, U.S.A.
Summary a’)>4‘8'ucos*dase activity was detery mined in amniotic fluid, amnioticfluid cells, and cultivated amniotic-fluid cells obtained
between the 14th and 16th week of pregnancy. Eight
pregnancies were monitored for women who had pre
viously delivered children with glycogen-storage dis
ease type II (Pompe’s disease). In one case, amniotic
fluid, amniotic-fluid cells, and cultivated amnioticfluid cells were found to be deficient of «-l,4-glucosidase activity. The pregnancy was terminated and
examination of the fetus revealed an absence of
a-l,4-glucosidase activity in all organs and cultivated
«-1,4-clucosidase activity in amniotic fluid* and outcome
OF PREGNANCY
Amniotic- Cultivated
Case Amniotic
fluid cells amniotic
fluid
fluid cells
2
3
4
5
8
7-8
3-7
11-2
0-4
40
2-4
12-3
132
5-6
51
0
36
4-3
8-1
8-2
0-3
6-5
3-2
Outcome Enzyme level
of
in infant
pregnancy | (or fetus)
Normal
Normal
Normal
Therapeutic
abortion
Normal
Normal
Absent
Normal
Normal j|
Spontaneous I
abortion
Normal
Con- i
trol ;
mal) 11-9 ±3-6
values:
4-2 ±1-6
7-8 ±2-3
7-6 ±2-0
* ixmolcs maltose hydrolysed per minute per g. protein.
1278
TIIE LANCET, DECEMBER 13, 1969
was normal while in babies 2 and 6 reduced levels
were found. In amniotic-fluid analyses a-l,4-glucosidase activity has been readily demonstrable in
cell-free amniotic fluid, non-cultured and cultured
amniotic-fluid cells.
In case 8, the pregnancy ended one month after
amniocentesis in a spontaneous abortion, presumably
related to the development of an incompetent cervix.
Pathological examination (Dr. Kurt Benirschke)
revealed minimal and recent chorioamnionitis with no
apparent relationship between the amniocentesis and
the abortion. <x-l,4-glucosidase had been detectable
in all amniotic-fluid analyses.
In case 4, a-l,4-glucosidase activity could not be
detected in non-cultured amniotic-fluid cells and was
barely detectable in amniotic fluid and cultivated
amniotic-fluid cells. On the basis of these findings,
the parents elected to terminate the pregnancy.
Abdominal hysterotomy was done at 19 weeks of
pregnancy. The fetus had no a-l,4-glucosidase
activity in liver, spleen, kidney, or cultivated fibro
blasts, confirming the diagnosis of type-n glycogenosis.
DISCUSSION
We suggest that examination of amniotic fluid
obtained between the 14th and 16th weeks of preg
nancy can be reliably utilised for the in-utcro detec
tion of type-n glycogenosis.
Examination of non-cultured amniotic-fluid cells
permits rapid identification of the affected fetus,
strikingly reduces the interval between amniocentesis
and diagnosis, and obviates the need for highly special
ised tissue-culture techniques. Amniotic fluid should
be obtained before the 20th week of pregnancy, since
enzyme activity in non-cultured amniotic-fluid cells
tends to be extremely low or absent after this period.5
Direct enzyme assay of non-cultured amniotic-fluid
cells has permitted the in-utero identification of a
presumed heterozygote of Tay-Sachs disease.12
In our experience, neither maternal nor infant
mortality has been observed in over 150 cases in which
transabdominal amniocentesis has been done between
the 12th and 20th week, as part of the management of
genetic “ high-risk ” pregnancies.13
We thank Elvira Shannon and Marilyn Swae for technical
assistance, Dr. Kurt Hirschhorn (case 3) and Dr. Richard
Waters (case 8), for permitting us to study their patients, and
Dr. Albert Gerbic and other obstetricians for performing the
amniocenteses. These studies were supported by U.S. Public
Health Service National Institutes of Health grants 7 R01
HD04339 and 1 R01 HD04252, and the National Foundation
March of Dimes.
Requests for reprints should be addressed to H. L. N.
REFERENCES
Pompe, T. C. /Inn. Anar. Path. 1933, 10, 23.
Hers, H. G. Biochcm.J. 1963, 8G, 11.
Nitowsky, H. M., Grunfcld, A. J. Lab. din. Med. 1967, 69, 472.
Nadler, I I. L. IHochem. Genet. 1968, 2, 119.
Nadler, H. L., Gcrbic, A. B. Am. J. Obstet. Gynec. 1969, 103, 710.
Fujimoto, W. Y., Seegmiller, J. E., Uhlcndorf, B. W., Jacobson,
C. B. Lancet, 1968, ii, 511.
7.
Nadler, H. L. Pediatrics, Springfield, 1968, 42, 912.
8.
DeMars, R., Sarto, G., Felix, J. S., Benke, P. Science, 1969, 164,
1303.
Frantantoni, J. C., Neufeld, E. F., Uhlcndorf, B. W., Jacobson,
C. B. New Engl. J. Med. 1969, 280, 686.
10. Nadler, H. L., Swae, M. A., Wodnicki, J. M., O’Flynn, M. E.
Lancer, 1969, ii, 84.
11. Nadler, H. L., Egan, T. J. New Engl. J. Med. (in the press).
12. O’Brien, J. S., Okada, S. Paper read at a meeting of the American
Society for Human Genetics, held in San Francisco, Oct. 1-4, 1969.
13. Nadler, H. L. Unpublished.
1.
2.
3.
4.
5.
6.
EFFECT OF CORTICOTROPHIN ON
PLASMA LEVELS OF HUMAN GROWTH
HORMONE
Gaston R. Zaiind
Andre Nadeau
Karl-E. von Muhlendahl
Department qf-Medicinc, University of Geneva, Switzerland
Plasma concentrations
of human growth
Summary ,
.
,
, r
hormone (h.g.h.) were measured after
acute administration of corticotrophin (a.c.t.h.) and
insulin to normal subjects. Both stimuli evoked an
equally significant secretory response of H.G.H. It
seems that corticotrophin may be a physiological
mediator of stress-induced h.g.h. release.
INTRODUCTION
Human-growth-hormone (h.g.h.) secretion may be
elicited during states of deficient glucose metabolism in
the brain,1-2 by aminoacid infusions
as well as by a
number of stressful conditions?-8 Absolute or relative
hypoglycarmia is generally considered to act speci
fically on the mechanisms controlling the pituitary
release of h.g.h. Noxious stimuli including anxiety,
physical trauma, or acute administration of agents such
as pyrogen or vasopressin are suspected of promoting
elevation of plasmarH.G.H. through non-specific path
ways attributed to “ stress ”,
This investigation was undertaken in an attempt to
assess the possible role of corticotrophin (a.c.t.h.) in
the regulatory control of h.g.h. secretion.
SUBJECTS AND METHODS
Six healthy volunteers (five males, one female) of normal
body-weight, aged 24-27, were investigated after an
overnight fast. The subjects were allowed to rest for half
an hour prior to the test procedure. A needle was then
inserted in an antecubital vein and kept permeable with a
slow drip of physiological saline solution. After collection
of three basal blood-samples, 1-0 mg. of lyophilised syn
thetic p1-21 corticotrophin (‘ Synacthcn ’, Ciba) dissolved in
5 ml. of saline was injected intravenously. 90 minutes later
the subjects received a short-acting insulin (‘ Actrapid ’,
Novo), in a dose of 0-1 unit per kg., by the same route.
Blood-samples were obtained every 15 minutes during a
total period 210 minutes. After each blood-sampling 2 ml.
of saline solution was injected, the subjects being in most
instances unaware of the moment when corticotrophin or
insulin were administered. Particular care was taken to
avoid any exterior cause of distress for the volunteers
throughout the test.
H.G.H. in the plasma was measured by a modification of
the solid-phase radioimmunoassay,0 using antibody-coated
polystyrene tubes and an immunochemical grade h.g.h.
preparation of A. E. Wilhelmi (‘ HS U82B ’) for labelling
with 1WI and for standards. Blood-sugar was estimated by
the method of Nelson-Somogyi,10 plasma-cortical colorimetrically.11
RESULTS
Three subjects described a slight and transient
abdominal discomfort shortly after the injection of
corticotrophin, whereas all of them developed mild
symptoms and signs of hypoglycaemia after insulin
administration. A more profound reaction was
observed in one (no. 2).
Individual plasma H.G.H. and glucose responses to
corticotrophin and insulin administration are shown in
the accompanying figure. The accompanying table
Ini. J. Mint. Htalxk, Vol 19, No. 2, pp. 30-35
M. E. Sharpe, Inc, 1990
riH
R. Srinivasa Murthy
Bhopal
On the night of 2/3 December, 1984, about 40 tons of methyl iso cyanate (MIC)
from tank 610 of the Union Carbide India Limited factory at Bhopal (central India)
leaked into the surrounding environment This leak of an “extremely hazardous
chemical,” which occurred over a short span of a few hours, covered the city of
Bhopal in a cloud of poisonous gas. Following the gas leakage, at around midnight,
people living in the direction of the gas leakage woke up with feelings of suffoca
tion, intense irritation, and vomiting.
Initially most people thought that a neighbor had “burnt chillies.” However, as
they realized the real cause of their symptoms, panic struck the population. People
ran to escape from the gas, often without concern for their family members. Many
died on the spot; others fell while running to escape; and many others reached safe
places only after hours of running. The number of dead has been estimated to be
around 2,500. Of the total population of Bhopal (0.7 million), about 0.3 million
were exposed to the poisonous gas [1],
The Bhopal disaster is of importance in the relevant literature for a number of
reasons. First, it is one of the largest man-made disasters in a developing country.
Second, the disaster effects were a combination of both the chemical substances
inhaled and the psychological effects. Third, no formal mental health infrastructure
was available to provide postdisaster mental health care, and this led to the develop
ment of innovative approaches to care. Fourth, this disaster has been the subject of
intense study, both cross-sectionally and longitudinally, from physical and mental
health viewpoints.
This report deals with the magnitude of the mental health problems and the
mechanisms developed to provide mental health care.
G-2>
BHOPAL
31
and examinations of those attending the medical facilities. These initial observations
placed the magnitude at 50% of those in the community and about 20% of those
attending medical facilities [1].
Following these observations, systematic studies were carried out by a KGMC
team [2]. As a first step, ten general medical clinics in the disaster-affected area
were chosen. A team consisting of a psychiatrist, a clinical psychologist, and a
social worker visited one clinic a day, by rotation in a randomized fashion, on three
occasions and screened all the newly registered adult patients with the help of a
self-reporting questionnaire (SRQ) [3]. Subjects identified as probable psychiatric
patients were then evaluated in detail by the psychiatrist with the help of a standard
ized psychiatric interview, the Present State Examination (PSE) [4], Clinical diag
noses were based on the International Classification of Diseases (9th revision)
(ICD-9).
During a period of 3 months (February-May 1985), of the 855 patients screened
at the 10 clinics, 259 were identified, on the basis of their SRQ scores, as having a
mental disorder. Of these potentially mentally ill'people, 44 could not be evaluated,
and 215 were given the PSE. The final number of psychiatric patients was 193,
yielding a prevalence rate of 22.6%. Most of the patients were females (81.1%)
under 45 years of age (74%). The main diagnostic categories were anxiety neurosis
(25%), depressive neurosis (37%), adjustment reaction with prolonged depression
(20%), and adjustment reaction with predominant disturbance of emotions (16%).
Cases of psychosis were rare, and they were not related to the disaster.
Subsequendy, the same team conducted a detailed community-level epidemio
logical study, beginning in June 1986. The results of the first-year survey involved
4,098 adults from 1,201 households. A total of 387 patients were diagnosed to be
suffering from mental disorders, giving a prevalence rate of 94/1,000 population.
Most of the population consisted of females (71%); 83% were in the age group
16-45 years. Ninety-four percent of the patients received a diagnosis of neurosis
(neurotic depression, 51%; anxiety state, 41%; and hysteria, 2%) and had a temporal
correlation with the disaster [1], For the last three years, the KGMC team has
repeated annual surveys and follow-up of the initial patients identified by the com
munity survey. Detailed case vignettes and descriptive accounts of the patients from
the Bhopal disaster are also available [1].
Magnitude of the mental health problems
Training in mental health care
Information is available about the mental health problems from a number of
sources. The initial assessments were made in the first week of February 1985
(about eight weeks after the disaster) by Professor R. Srinivasa Murthy, of the
National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore,
and Professor B. B. Sethi, of K. G. Medical Collegee (KGMC), Lucknow. Their
observations, over a week’s time, were based on visits to affected people at home
Dr. Srinivasa Murthy is Professor and Head of the Department of Psychiatry and officer in ,
charge of the ICMR Centre for Advanced Research on Community Mental Health, National ,
Institute of Menial Health and Neuro Sciences, Post Bag No. 2900, Bangalore, 560 029, India. '
The initial visit of two psychiatrists eight weeks after the disaster revealed a large
number of people with emotional reactions and a lack of mental health services to
care for them. The team therefore recommended rapid organization of mental health
services utilizing the existing medical personnel.
In April 1985, a second visit was made to develop a training program, including
instructional audio and video materials, and to finalize the arrangements for the
Gaining. The actual training was given from 22 April to 4 May 1985.
About fifty medical officers were working in the various health facilities in the
32
R. SRINIVASA MURTHY
gas-affected area. Most of these doctors had had no training in mental health as pan
of their initial medical education, and this was reflected in their poor perception of
the emotional needs of the disaster victims. The basic orientation of these doctors
was highly medical/biological. In pretraining interviews, most of them expressed
the view that distribution of monetary compensation would solve the physical com
plaints of many of their patients. Some thought that the free rations provided by the
state were the reason for the weaknesses and inability to work of which most
patients complained. The medical officers believed that the “lethargy” of their
patients would disappear not thanks to medical care or the use of drugs, but by
stopping the distribution of free rations and compensation money.
The basic aim of the training was to enhance the sensitivity of the medical
officers to their patients’ emotional needs and their skill in recognizing, diagnosing,
treating, and referring (when required) people with mental health problems. The’
period of initial training was six working days. It was decided that the training
should be as practical as possible, and should be imparted to groups consisting of no
more than twenty persons. The training methods took into account principles of
“adult learning,” viz., an open learning environment in which participants were
free to share their needs and experiences, with considerable stress on interactive
learning. A predominantly lecture approach was changed to one consisting of case
studies and group discussions, facilitated by audiovisual, taped material of the af
fected population, with maximum learner involvement [5].
The actual training was carried out in two groups by two consultant psychiatrists.
A manual was prepared for this training on the basis of our experience in training
medical officers at NIMHANS, Bangalore [1],
Each morning, the two faculty members visited the different health facilities and
worked with the medical officers in order to help them leant interview techniques;
and counseling methods. This “hands-on” experience was considered very useful
by the medical officers, 38 of whom took part in the training.
Day 1: The main objectives of the first session were to form the group, facilitate
interaction of the faculty and the participants, and enable all to become well ac
quainted with each other. The trainee doctors were asked to share their expectations
concerning the program. The pretraining views of all the doctors were obtained on a
structured response sheet
Day 2: The aim of the second session was to give the doctors an understanding
of normal and abnormal behavior. Patients with different symptoms and presenta
tions were shown via videotapes. Types, features, and causes of mental illnesses
were outlined.
Day 3: Discussion centered on the approach to patients with emotional distur
bances, recording the history of such patients, and the mental examination (inter
viewing) of patients. This was facilitated by audiotaped and videotaped interviews.
Day 4: This session was considered to be a crucial one, as the problems faced by
the trainee doctors daily in their outpatient clinics were discussed. The training
during the first three days provided the basic background required to understand the
psychological nature of many of the patients’ complaints. Various clinical presenta
BHOPAL
33
tions of the gas-affected patients were discussed. In this session all the audio and
zideo material used pertained to the patients seen in the various clinics in Bhopal.
Since the emotional reactions of people to disasters, irrespective of the nature of
the disaster or where it occurs, follow a similar pattern, some of the classic docu
ments on psychological sequelae of disasters were reviewed and discussed. Many
children were brought for consultation for various kinds of compliants, and some
time was therefore devoted to discussion of the emotional reactions of children to
sudden, severe stress. Many interviews with children, both on audiotape and video
tape, were presented.
Assessment of people with varying degrees of physical disability due to proven
gas-related physical illnesses (such as fibrosis of the lungs) posed a problem for
many doctors: hence, emotional responses to physical disability and chronic physi
cal illnesses were covered. The availability of patients (on videotape) from the local
clinics for discussion greatly enhanced the interest and involvement of the partici
pants. The emotional dimension of patients’ complaints was completely new to
most of the participant doctors.
Day 5: By the 5th day of training, most of the participants were able to recognize
and appreciate the emotional disturbances in a great many of the patients attending
their clinics. The participants were able to elicit, in many patients, various mental/emotional symptoms. At this stage of training, we considered it appropriate to
discuss the approaches to management of such patients. This session therefore
emphasized the importance of psychological management
After an initial introduction by the faculty, the session proceeded with a role-play
exercise in which interviewing a patient was simulated. The basic principles of
psychological management, the importance of appropriate interview techniques in
establishing a satisfactory doctor-patient relationship, and the methods of reassur
ance, suggestion, and psychological help were discussed. Audio recordings of psy
chotherapy by the faculty with some of the local patients were used to illustrate the
techniques.
Day 6: During the last session, pharmacological management and other ap
proaches to patient care were covered. A good part of the time was taken up by
discussion of “implementation of the mental health care program” among the
affected population in Bhopal. The last 30 minutes were devoted to obtaining post
training responses from the participants.
Some of the comments of the participants in the post-training evaluation con
firmed the utility of the training. Most of them felt that with this training, they
would be able to provide much more help to patients with mental illness and to
others with physical problems as well. Some doctors confessed that earlier they had
been accustomed to giving their patients only symptomatic treatment, but that after
the training, they were able to consider and diagnose conditions also in terms of a
psychiatric approach. Some mentioned that they had not been aware of any mental
problems and had thought that patients were malingering and presenting vague
symptoms to evoke a sympathetic response and get more medicines. All the doctors
who took pan in the training agreed that there were needs for privacy for interviews.
BHOPAL
34
35
R. SRINIVASA MURTHY
6. Kinston, W., & Rosser, R. (1974) Disaster: Effects on mental and physical stare
support from a psychiatrist for difficult cases, and psychotropic drugs.
Discussion
The studies of the Bhopal disaster population illustrate both the needs for mental
health care and the scope for utilizing existing resources. In most developing coun
tries, formal mental health resources are extremely limited, and the focus has to be
on including mental health components in the training of the “helping groups”
working with a disaster population.
Kinston & Rosser [6] in 1974 expressed the view that the general field of inquiry
loosely encompassed by the term disaster has not yet found an established position
in the psychiatric canon. There seem to be theoretical, practical, and emotional
reasons for this. The situation has been gradually changing in the last 15 years.
There is a vast literature on the mental health aspects of disasters [7], but experience
from developing countries is limited [8,9]. Still more limited is experience in inter
vening to provide mental health care by utilizing the resources available.
The Bhopal disaster, being a major man-made disaster, provides an opportunity
for understanding mental health needs and developing culture-specific interventions
in such situations.
Acknowledgment
The intervention program was undertaken with the support of the Indian Council of
Medical Research, New Delhi, India. We offer our sincere thanks to Dr. G. N.
Narayana Reddy, Director, NIMHANS; Dr. V. Ramalinga Swamy, Director-Gen
eral, ICMR (1985—1989); Dr. A. S. Painthal, Director-General (1987- ), and Profes
sor Usha K. Luthra, Additional Director-General, ICMR, New Delhi.
References
1.
Srinivasa Murthy, R., Isaac, M.K., Chandrashekar, C.R., & Bhide, A. (1987) The
Bhopal disaster—Manual of menial health care for medical officers (ICMR-ACMH, No. 4).
Bangalore: ICMR Centre for Advanced Research on Community Mental Health, National
Institute of Mental Health and Neuro Sciences.
2.
Sethi, B.B., Sharma, M., Trivedi, IK, & Singh, H. (1987) Psychiatric morbidity in
patients attending clinics in gas affected areas in Bhopal. Indian Journal of Medical Re
search, 86, SuppL, p. 45.
3.
Harding, T.W., DeArango, M.V., Battazar, I, Climent, C.E., Ibrahim, H.H.A., Ignacio,
LI*, Srinivasa Murthy, R., & Wig, NN. (1980) Mental disorders in primary health care: A
study of their frequency and diagnosis in four developing countries. Psychological Medicine,
10,231.
4. Wing, IK, Cooper, IE., & Sartorius, N. (1974) The measurement and classification of
psychiatric symptoms. London: Cambridge University Press.
5. Srinivasa Murthy, R., & Isaac, M.K. (1987) Mental health needs of Bhopal disaster
victims and training of medical officers in mental health aspects. Indian Journal of Medical
Research, 86, SuppL, p. 51.
Journal ofPsychosomatic Research, 18,437.
7. National Institute of Mental Health (1984) Disaster and menial health: An annotated
bibliography (DHSS Publication No. [ADM] 84—1311). U.S. Department of Health, Educa
tion. and Welfare. Rockville, MD: ADAMHA. [See pp. 87-88 of VoL 19, No. 1, of this
journal.]
8. Narayanan, H.S., Sathyavathi, K, Nardev, G, & Thakrar, S. (1987) Grief reactions
among bereaved relatives following a fire disaster in a circus. NIMHANS Journal, 5,13.
9. Lima, B.R., Pai, S„ Santacruz, H., Lozano, I, & Leena, I (1987) Screening for the
psychological consequences of a major disaster in a developing country. Armero, Colombia.
Acta Psychiatrica Scandinavica, 76,561.
C.M.R.
I.
Bulletin Vol.18, No.12, December, 1988
SEVERE MENTAL MORBIDITY
Mental health and care of the mentally ill have
generally been neglected areas in the field of health
care. Ignorance and widely prevalent misconceptions
about various aspects of mental illnesses have contri
buted to this neglect, poor demand for modern services
and underutilisation of the available services. Health
planners, administrators and medical professional also
have no access to data on the prevalence and suffering
caused by mental illnesses. Most of the currently avail
able, limited services are institution-based and situated
in urban areas, either in large custodial mental hospi
tals or in psychiatric units attached to general hospi
tals.
As service, training and research in the field of
mental health have steadily grown during the past
three decades in our country, many psychiatrists have
selected epidemiology of mental illness as a research
area. In the earliest account of mental illness in India
by Overbeck-Wright1 a prevalence figure of 0.26 per
thousand is mentioned, based on the census report of
1911. Dube2 refers to an effort by Govindaswamy (the
first Director of the then All India Institute of Mental
Health—now known as the National Institute of Men
tal Health & Neurosciences-NIMHANS) in Banga
lore, who conducted a survey through questionnaire
but his results were inconclusive. In the earliest
reported field survey of mental morbidity in India,
Surya et al} surveyed a population of 2731 from 510
households in the Kurchikuppam locality of Pondi
cherry during June to September 1962 using a simple
screening questionnaire with one informant per house
hold. All these informants were asked if they knew
anyone with any of the listed 25 symptoms. All the>
reported persons were identified and clinical inter
views were carried out by Surya himself. Twenty six
persons were found to be suffering from neuropsychi
atric illness, and the rate was 9.5 per thousand. Epi
lepsy accounted for 2.2, schizophrenia 1.5, alcoholism
3.6 and mental defect 0.7 per thousand respectively.
Depression was not represented and no one appeared
to be in need of institutional care.
Subsequently, several mental morbidity surveys
in the general population were carried out in different
parts of the country. These surveys demonstrated that
all types of mental illness are common in India as
elsewhere in the world and are equally common in
rural areas. Notable amongst these are surveys by
Dube2 in Agra (23.7 per thousand), Verghese et aP in
Vellore (66.5 per thousand), Sethi et al5>6 in Lucknow
(39 per thousand and 72.7 per thousand), Elnagerer aP
in Hooghly district, West Bengal (27 per thousand),
Carstairs and Kapur8 in Kota village of South Kanara
district, Karnataka (369 per thousand) and Nandi etaP
in villages near Calcutta (102.8 per thousand). The
wide range of prevalence rates of mental illnesses
found by these workers in different parts of the country
is probably because of a number of reasons viz diversi
ties of the scope of the surveys, variations in methodo
logy, differences in statistical manipulation of the data,
lack of uniformity in classification of the data, prob
lems of population definition and sampling procedures
and problems of case definition, identification and
classification.
The Present Study
In June 1976 a collaborative study on severe men
tal morbidity was initiated by the Indian Council of
Medical Research (1CMR) and the Department of
Science and Technology (DST) as the first major mul
ticentric study in this field. Although the ICMR had
earlier supported a few major psychiatric epidemiolog
ical researches2.4.6 to estimate the prevalence of mental
disorders in the country, their rates and results were
not comparable as they used different methodologies.
The present study was aimed to estimate the preval
ence of psychiatric morbidity at different selected cen
tres in the country and to investigate the
socio-demographic correlates of this morbidity. It was
generally felt that the information that would accrue
from the study should be such, as to help in improving
the delivery of mental health care to the people
through the existing channels of welfare, keeping in
mind the paucity of resources in the country. Therefore
it was decided to limit the scope of the study to ‘severe
mental morbidity’, and to couple it with an interven
tion programme for this morbidity and also to evaluate
the efficacy of the intervention. It was decided to carry
out the study at 4 centres in the country viz Bangalore,
Baroda, Calcutta and Patiala.
At about the time, experiments on various
methods of extending mental health services to the
community were being carried out at the Community
Psychiatry Unit at NIMHANS,.Bangalore. A WHO
multinational project on ‘Strategies for extending
Mental Health Care’was also ongoing in several devel
oping countries with a centre at the Department of
Psychiatry, Postgraduate Institute of Medical Educa
tion and Research, Chandigarh. Isaac and Kapur10 at
Bangalore showed that all the adult epileptics and all
but one of the adult psychotics in a population of
roughly 5000 were picked out by a method which in
terms of effort, time and funds, cost one-fifteenth of
that necessary to carry out a full survey of the adults in
that population. Pilot programmes to train primary
health centre doctors and multipurpose health workers
to carry out simple mental health care tasks along with
their routine activities were also being carried out at
Bangalore11*'2.
126
Earlier, in 1975,'a WHO expert committee on
mental health13 made specific recommendations on
organisation of mental health services in developing
countries. The Committee advocated the policy of
decentralization and integration of basic mental health
care with existing general health care infrastructure
and provision of this care by primary health workers
following a short term task oriented training. The
Committee specifically recommended that “countries
should, in the first instance, carry out one or more pilot
programmes to test the practicability of including
basic mental health care in an already established pro
gramme of health care in a defined rural or urban
population”and that “training programmes, including
a simple manual for the training of health workers
should be devised and evaluated”.
In planning the ICMR study, these national and
international developments in the field of Mental
Health were taken into account.
Objectives
The specific objectives of the collaborative study
were the following:
I.
To determine the prevalence of severe mental
illness in the community with focus on psychosis
and epilepsy—at 4 different centres in the coun
try.
2.
To study the feasibility and effectiveness of
involving the multipurpose workers (MPWs)and
primary health centre (PHC) doctors:
3.
(i)
for detection and management of all psy
chotics and epileptics in rural areas.
(ii)
for bringing changes in attitudes towards
mental health in the rural community.
To estimate the cost of training and management
of the programme in B&l areas.
Study Design
The essential core of the study was the training
and intervention by the primary health care personnel
(ie identification and management of severe mental
illness and epilepsy) and the evaluation of the interven
tion by a final field survey. During the intervention
phase, initially, the study areas had to be identified at
all the 4 centres—preferably, rural areas around a
primary health centre, covering roughly a population
of 40,000. Following the selection of the study areas
and population to be covered, the personnel delivering
primary health care to this population had to be given
in-service training in basic mental health care, without
disturbing their routine tasks and activities, after
which, for a year, they would be expected to identify
and manage severely mentally ill persons and epileptics
in their respective catchment areas and maintain sim
ple case records. During this period the research staff
would examine every patient identified and managed
by the PHC team and in addition, also carry out an
attitude survey, interviewing one adult member of
every twentieth household in the study areas. At the
end of a year of intervention by the PHC team, the
research team would carry out a survey of severe men
tal morbidity and all patients on treatment assessed in
detail again. The survey would be a two stage proce
dure, wherein initially, one adult member of every
household would be interviewed using a questionnaire
to detect ‘possible cases’ following which all the nomi
nated suspects would be assessed in detail. The attitude
survey would be repeated during the final field survey.
A simple costing of the training as well as management
of the programme was also to be carried out. For the
purpose of training, intervention and survey, several
research instruments had to be selected, modified or
developed and translated into the vernacular. Inter
investigator and inter-centre reliability of the tools had
to be checked too. Instruments for measuring psychi
atric symptomatology, social functioning, and attitude
towards mental illness had to be either selected from
existing available ones or newly developed. Training
manuals, schedules for evaluation of the training and
simple case records and follow up sheets had to be
developed.
Instruments used
Two kinds of instruments were required for the
study, one for survey ie measuring psychiatric mor
bidity, social functioning and attitudes and another,
for the intervention phase ie training of personnel,
evaluation of training and simple case records to be
maintained by the PHC personnel.
For measuring psychiatric morbidity, the Indian
Psychiatric Survey Schedule (1PSS) was used14. This is
a structured interview schedule developed and stand
ardized in India and had already been successfully used
in a major field survey in the country8. It is an exhaus
tive instrument designed to enquire about the presence
of 124 psychiatric symptoms and 10 items of historical
information through a multistage procedure and using
multiple sources of information.
The IPSS was used for the detailed assessment, of
all the patients who were detected and regularly man
aged at the PHC by the PHC team, both initially as
well as at the end of the intervention phase. It was also
used in the final two stage field survey for the assess
ment of the nominated cases. The 1PSS was already
available only in one of the Indian languages—
Kannada, and hence had to be translated into various
other Indian languages for use in the different centres.
To measure the social dysfunctioning of those
assessed in detail with the I PSS, a complementary
instrument viz. Katz’s Social Adjustment Scale (KAS
Behaviour Inventories: R2 Form) was used15. This
instrument was suitably modified for use in the Indian
setting.
A subsection of the preliminary section of the
Indian Psychiatric Survey Schedule termed the ‘Symp
toms in others’ questionnaire was used as the initial
proforma for screening the population. After getting
the socio-demographic details of every family on a
household card from either the head of the family or
one adult male, this questionnaire was administered to
the same person. This questionnaire with 15 questions
was designed to elicit from the respondent information
which might indicate serious psychiatric illness or epi
lepsy in members of his family or neighbourhood. This
simple questionnaire takes only a few minutes to com
plete and can be easily administered by any trained
non-professional. The usefulness of this instrument in
picking up serious psychiatric illness like psychosis and
epilepsy had been validated in an earlier Indian field
survey10.
To find a suitable instrument for measuring atti
tudes towards mental illness and epilepsy, several atti
tude questionnaires were examined in detail. The
investigators of the study jointly developed a short 15
item questionnaire which was simple enough to be
used with the villagers. Since this was a simple questi
onnaire with ‘Yes’ and ‘No’ response, the face validity
was considered sufficient.
Training programmes and separate manuals of
instruction in mental health care for PHC doctorsand
multipurpose workers developed by the Community
Psychiatry Unit at N1M HANS were used for the train
ing of PHC personnel. These manuals were prepared
127
by the staff of the Unit based on the broad recommen
dations of WHO1’ and the objectives of the ongoing
work of the Unit primarily aimed at integrating mental
health with primary health care. These manuals were
pilot tested earlier11'12.
training and intervention by PHC personnel and final
field survey were—
(i)
The training for the PHC doctors consisted of 15
sessions of 2 hours each, in the form of lectures, discus
sions, examples of cases and actual demonstration of
cases. Flexibility was permitted to suit the local situa
tion. The training for the health worker was carried out
in the vernacular and in 11 sessions of two hours each
in the form of lectures, discussions, examples of cases
and actual demonstration of cases.
The training was evaluated by an assessment of
the theoretical knowledge gained by the trainees and
enquiring into any attitudinal change which occurred
due to the training. This was achieved by comparing a
simple post-training assessment of the health person
nel’s attitudes and knowledge regarding mental health
with their pre-training performance. The schedules
consist of two parts. The first part is a questionnaire
which inquires into the health personnel’s knowledge
and attitude regarding causation and management of
severe mental illness and epilepsy. This part is identical
for both doctors and health workers but the doctors
questionnaire contained in addition a section on inves
tigations needed for the diagnosis and management of
mental illness and epilepsy. The second part of the
assessment for doctors consists of presenting them
with a series of simple clinical histories of different
neuro-psychiatric conditions. They were then required
to answer certain questions based on these clinical
histories on diagnosis, and management of the condi
tion. Definite answers for all the questions on all the
clinical stories were formulated and the credit for each
correct answer determined. The second part of the
assessment for MPWs consists of seven open-ended
questions on types and management of mental illness
and epilepsy.
Simple case history and follow up records to be
maintained by the PHC doctors and MPWs, during
the intervention phase, developed by the Community
Psychiatry Unit at N1MHANS and modified by the
investigators, were used in the study.
The Initial Phse of the Study
The various activities completed during the initial
phase of the study in preparation of the actual work of
128
(ii)
Translation of 1PSS into different Indian lan
guages: The IPSS was translated into Tamil and
Telugu at the Bangalore centre, into Punjabi at
Delhi initially, and later at the Patiala centre, into
Bengali at Calcutta centre, and Gujarati at Bar
oda centre. These translations were made by
either mental health professionals who were wellversed with the colloquial use of the language
concerned or those who were well-versed in the
languages, in consultation with mental health
professionals who knew the respective languages.
Translation of all these vernacular versions into
English was done, again by people who were
well-versed in the colloquial use of these lan
guages but different from those who took part in
the original translation.
Inter-investigator reliability studies of vernacular
versions of the IPSS.
(iii)
Validation of the modified version of Katz’s
Social Adjustment Scale: The Katz’s Social
Adjustment Scale (KAS Behaviour inventories:
Form R2)ls lists 16 items of activities which a
normal individual is expected to perform. These
activities are fairly basic and would be expected
in any culture. Katz’s scale modified by the inves
tigators, was validated for grading severity of the
illness16.
(iv)
Inter-centre reliability check of IPSS and Katz’s
Social functioning scale.
(v)
Pilot training programme for PHC personnel:
Pilot training programmes for PHC personnel
were carried out at the Bangalore and Calcutta
centres. At Bangalore, 2 doctors and 11 MPWs of
the Anekal PHC (a PHC situated about 40 km
away from Bangalore) were trained in mental
health care17.
Training of PHC Personnel and Intervention by
Trained Personnel
Delineation of study areas and population
Primary health centres which were typical of the
large number of PHCs in the country, were selected for
the intervention phase of the study. In all 4 centres,
PHCs situated not very far away from the participat
ing institution were selected. Efforts were made to
(H
ensure that medical officers and multipurpose health
workers of the PHC, who were to undergo the training
in basic mental health care would not be transferred
from the PHC for a minimum period of I'/j years. A
predominantly rural area of the PHC comprising
about 40,000 population was designated as the ‘study
area’ in each of the PHCs and the health workers in
these areas were given the training. Solur, Padra,
Amdanga and Ajnanda were the PHCs thus selected in
Bangalore, Baroda, Calcutta and Patiala centres,
respectively. The various general characteristics of
these study areas are given in Table I.
in Baroda and Patiala, respectively and hence had
teams of specialists visiting them regularly, every week.
A large part of Padra population was semiurban and
easily reachable. The study population was typically
rural in Amdanga (Calcutta)and Solur (Bangalore). In
Amdanga, the population was predominantly Muslim
and in Ajnanda, Sikh. Ajnanda PHC had a dental
surgeon working and Padra had 5 doctors in the PHC.
The average daily attendance in the PHC was maxi
mum in Amdanga. All the PHCs had inpatient facili
ties as well as quarters for the doctors and in two of
them the MPWs scheme had not started yet.
Table I. General characteristics of the study areas
Bangalore
Baroda
Calcutta
Patiala
1
Name of the PHC
Solur
Padra
Amdanga
Ajnanda
2.
Location
50 Km. from
Bangalore
22 Km. from Baroda
45 Km. from Calcutta
25 Km. from Patiala
Over 150,000
Over 100.000
56, 000
3.
Total population coverage 80,000 (approx)
of the PHC
4.
Study area
8 Blocks—124 villages
about 40,000
2 sections—6 villa
3 Anchals—33 villages 51 villages
ges each, about 40,000 about 40,000
about 43,000
5.
General characteristics
of the population
Rural
Semiurban
Rural
Rural
6.
Major religion
Hindu
Hindu
Predominantly
Muslim
Sikh
7.
Special activities, if any.
conducted in the PHC
Nil
—Weekly psychiatric
Nil
clinic by specialist for few
years.
—One of the PHCs
adopted by Medical
college.
—regular visit by
Medical College teams.
-Weekly visit by
specialists.
8.
Economic activities
Farming, rearing silk
worms, beedi rolling
9
No. of doctors in the PHC 2
10.
Inpatient facilities
Available (12 beds)
II.
Whether MPW scheme
has started.
Yes
12.
No. of health workers
II
Farming
Farming—rice, jute,
sugercane, mango,
coconut.
5.
2
Available
Available (15 beds)
Available (12 beds)
Yes
No
•No
9
20 (+27 CHVs)
10
Farming, Farm
labourers
3+1 dentist
CHV - Community health volunteer
MPW - Multipurpose worker
While there were several similarities in these
PHCs there were few striking differences too. The total
population coverage of the PHCs varied from a low
56,000 in Ajnanda to over l'/2 lakhs in Padra. Padra
and Ajnanda were PHCs attached to medical colleges
Training of the PHC personnel in basic mental health
care
The training for the medical officers of the PHCs
and the health workers working in the designated
129
Evaluation of the training
study area at all the 4 centres was carried out by the
investigators and the research officers (1-medical and
1-non medical) appointed at each centre. At all the
centres, the doctors and MPWs were trained separ
ately. The training was carried out as far as possible
without disturbing the existing routine of the PHC.
The details of the time-table for the training were
worked out at each centre in consultation with the
medical officers and other staff of the PHC. The actual
training was carried out in the premises of the PHC in
all the centres. The doctors were taught in English,
while the health workers were taught in the vernacular.
For the training of health workers the ‘Manual of
instructions in mental health for health workers’ was
translated into the local languages and used as a guide
line. In addition to the lectures on various topics,.based
on the manuals of instructions, group discussion and
case demonstration were important components of the
training. At Baroda and Patiala, simple flow charts
were developed and used for the training. Active par
ticipation by all the trainees was sought. The sessions
were informal and good rapport was established
between the trainers and trainees.
The results of evaluation of the training for health
workers in the two parts of the pre - and post- training
assessment are shown in Table II. It was found that the
attitudes and knowledge of health workers with regard
to mental health is far from satisfactory before the
training, as assessed by the schedules. They showed a
satisfactory change in the positive direction after tfje
training. Average pre-assessment scores which ranged
from 30 to 50 per cent improved after training to over
70 per cent at all centres. In Baroda, since the post
assessment scores were not satisfactory initially, the
training period was extended. Those portions of the
curriculum found to be deficient in the trainees were
covered again and the assessment repeated. At the
Calcutta centre, the chief investigator was forced to
impart the training to the community health workers
as he found the MPWs were leaving fnost of their
peripheral work to the community health workers.
At all the centres, the pre-training assessment of
the doctors showed that they had poor knowledge of
the clinical features, diagnosis and management of
common psychiatric conditions and epilepsy. Their
basic knowledge and attitudes towards mental illness
was reasonably satisfactory even before the training.
Hence there were no marked changes in the scores for
part I between the post - and pre - training assessments.
There was remarkable improvement in their post
training performance in part II of the assessment. This
meant that the doctors ability to correctly diagnose
and manage common psychiatric conditions had
improved considerably.
The interest shown by the health staff in the train
ing at all the centres was satisfactory. The doctors
realized that while mental health care was never taught
to them during their undergraduate courses, it was an
important component of general health care which was
grossly neglected. The range and variety of questions
asked by the health workers was an indication of their
ignorance as well as interest in mental health. At all the
centres, the health workers would have liked to know
more than what was taught to them.
Table II. Evaluation of training—health workers
O'
Baroda
Bangalore
Calcutta
Post ■ training
I
II
Patiala
Pre
training
Post
training
Pre
training
Mean score obtained by
HW for Part 1
77
94
49
78
92
for Part II
33
63
8
39
' - 71 . '
33
72
20
58
Parts 1 & II
55
78
29
58
82
43
78
46
73
HW- Health worker
130
Pre
training
Post
training
53
85
Pre
training
Post
training
72
88
Intervention by PHC team of doctors and MPWs
The intervention period was 12 months from the
completion of training for the PHC personnel. During
this period, the health workers were expected to detect
priority disorders like psychosis and epilepsy in their
respective areas of work during their field visits, fill up
a short case record, refer the detected patients to the
PHC doctors, carry out the follow up of these patients
as per the instruction of the doctors and maintain a
short follow up record. The doctors were expected to
examine the patients, diagnose and initiate the man
agement. In addition, they were also expected to main
tain simple case records and follow up information for
every patient from the study area, managed at the PH C
during the intervention period. During the initial part
of the intervention period, the research team at all the
4 centres carried out an attitude survey using the
simple 15 items attitude questionnaire on one adult
member from every twentieth household in the study
area. The research team also examined every case
detected and managed by the PHC team, in detail
using the IPSS. Such cases were examined in detail
again during the final survey.
The pre- and post- training assessments had
shown that the knowledge gain of doctors and health
workers after the brief training at all the 4 centres was
satisfactory. The intervention by them was indeed a
test of their ability to translate the new knowledge into
action. It is quite well known that in regard to health
related problems and with health personnel, ‘knowing
more’ did not necessarily mean ‘behaving differently’.
. Table III shows that 72,36,58 and 66 patients suffering
from severe mental illnesses (schizophrenia, mania,
depressive psychosis, organic brain syndrome) and
epilepsy from the respective study areas in Bangalore,
Baroda, Calcutta’and Patiala centres were on manage
ment by the PHC teams. Of these while 41, 28, 0 and 8
cases were identified and referred to the PHCs by the
trained health workers, the remaining cases came to
the PHCs directly after hearing about the mental
health care services in the PHC through others in that
village. If one includes all the patients on management
at the 4 study centres (ie in addition to patients of
severe mental morbidity, other types of psychiatric
patients also) then the numbers are 107, 117, 75and96
respectively at Bangalore, Baroda, Calcutta and Pati
ala.
At all the 4 centres, the intervention phase
helped the investigators to gain an understanding of
the functioning of the general health care infrastruc
ture, the performance of the health care services in
general and the various national programmes in par
ticular. It also clarified issues related to the back
ground, training and morale of the PHC personnel,
both doctors and health workers and the target
oriented approach of the health care administration. It
was noted that the main thrust of the health care
administration and hierarchy was for performance in
the family welfare programme. The PHCs and staff
were assigned targets as well as incentives for perfor
mance. This emphasis on the family welfare pro
gramme influenced the entire health care services,
often at the cost of other programmes. Next to the
family welfare programme, priority was assigned to
the malaria control programme. In comparison, how
ever, various other programmes like tuberculosis and
leprosy control programmes, expanded programme of
immunization, prevention of blindness programme
etc, were accorded lower priority. It was doubtful
whether the original unipurpose workers in a vertical
subsystem had truly become multipurpose workers in
areas where the scheme was introduced. There was
absence of a well-knit back-up of referral services. The
Table III. Cases detected and managed at the PHCs during the intervention phases
Calcutta
Bangalore
Baroda
No. of patients of severe mental morbidity detected and
referred by the health workers to the PHC
41
28
-
8
No. of patients of severe mental morbidity (from the study
areas) on management at the PHCs
72
36
58
66
Total number of patients managed at the PHCs (includes
patients from outside study area)
107
117
75
96
Patiala
absence of community support and participation in the
various health programmes was most striking. There
was suggestion of underutilization of the PHCservices
which primarily appeared to arise out of a lack of faith
and confidence in the system. The mental health care
programme inherited all these inherent qualities of the
primary health care infrastructure.
Against the foregoing background, the mental
health care programme appeared too peripheral to the
health personnel. Poor performance in this pro
gramme did not encounter any admonition from their
superiors. At all the centres, it was the impression of
the Investigators that the morale at the PHC was poor
and the health workers did not make field visits as
frequently as they were expected to. Many of the
workers accepted this and stated that they found it
difficult to visit the families which demanded medi
cines for the illnesses and which the health workers
were unable to provide. Some of them even said that
they were called as ‘fever doctors’ as all that they could
do in villages was to distribute chloroquin tablets for
reported cases of-fever. Many who had not carried out
satisfactory work complained of a heavy work, load,
while a few others raised the issue of lack of incentives
for additional work. Some of the health workers
frankly stated that they had no ‘prestige’amongst the
villages they worked with and that the villagers had
little faith and confidence in them. This lack of confi
dence was observed not only in case of the health
workers but also in the entire PHC system. While the
workers knew of “patients” or cases in their own areas
of work, they were unable to convince the family
members to seek help from the PHC. Thus, it was
found that the poor rate of detection and management
during the intervention phase was due to several rea
sons. It was a general observation that most health
workers who performed well in any one programme
tended to do well in all other programmes, including
mental health care. These workers were also quite
popular with the villagers amongst whom they
worked.
Fora programme like the mental health care pro
gramme, a period of 1 year is too short for evaluating
the efficacy, as the positive aspects of the programme
are more likely to be cumulative. Considering the over
all efficiency of the health care infrastructure and the
performance of the health personnel in the various
national programmes which have been in existence for
longer periods of time, the performance of the PHC
teams at the 4 centres in mental health care interven
tion has been, by and large, encouraging. In consider
ing their effectiveness in mental health care work, it
should also be borne in mind that the inputs for this
programme have been quite minimal (short training
for doctors and health workers in basic mental health
care) and these did not interfere with their existing
work.
Field Survey
Prevalence of severe mental morbidity
At the end of the intervention phase, a field survey
was carried out by the research team at all the 4 centres
to estimate the prevalence of severe mental morbidity.
It was a two stage survey. During the initial stage,
trained research investigators administered a simple 15
questions screening proforma to one adult member of
every household in the study areas after collecting
certain basic socio-demographic information about
the household. This ‘symptoms in others’ question
naire asked them if they knew anybody who suffered
from one or more of the 15 symptoms either in their
families or in their villages. During the second stage, all
such nominated probable cases were assessed in detail
using the 1PSS based on the symptoms recorded by the
IPSS, and the patients were diagnosed. The ‘symptoms
in others’ questionnaire is essentially an instrument
which detects severe mental morbidity particularly dif
ferent forms of psychoses and epilepsy. Table IV gives
the overall results of the survey ie the prevalence of
severe mental morbidity at tRe 4 centres while their
diagnostic categorization is given in Table V.
There are certain interesting differences in the
characteristics of the population studied at the 4
centres. While at all the centres, males outnumbered
females and the age structure was largely similar, the
Patiala centre had only about 3 per cent population at
income of less than Rs.300/- per month, the percen
tage for the same at the other centres being 26.2,74 and
73 per cent at Bangalore, Baroda and Calcutta, respec
tively. Calcutta has predominantly Muslim population
and Patiala has over 70 per cent Sikh population.
Although the survey has used similar methodology at
the 4 centres, there are striking differences in the
prevalence rates. While Baroda and Calcutta have low
rates of epilepsy (1.28 and 1.71 per thousand), it is
higher in Patiala (3.17 per thousand) and highest in
Bangalore (7.82 per thousand). Epilepsy constitutes 70
per cent of all the cases detected during the survey at
Table IV. Prevalence of severe mental morbidity and mental health care by primary health care personnel
Bangalore
Population studied
Baroda
Calcutta
Total
Patiala
35,548
39.655
34.582
36.595
146.380
Total number of patients
(severe mental morbidity)
395
181
287
517
1,380
Rate per 1000 population
1 l.l
4.6
8.3
14.1
9.4
No. of patients identified and-managed
by the PHC team during the intervention
phase
72
36
58
66
232
Percentage of patients managed by the PHC
team
18.2
19.9
20.2
12.8
16.8
Table V. Prevalence of severe mental morbidity—diagnosed categorization (based on IPSS)
Baroda
Bangalore
SI.
No.
Diagnosis
No. of
patients
Rate/
1000
No. of
patients
Patiala
Calcutta
Rate/
1000
No. of
patients
Rate/
1000
No. of
patients
Rate/
1000
1.
Epilepsy
278
7.82
51
1.28
59
1.71
116
3.17
2.
Organic brain syndrome
4
0.11
24
0.61
22
0.64
88
2.40
3.
Schizophrenia
65
1.83
70
1.77
71
2.05
113
3.09
4.
Mania
20
0.56
14
0.35
8
0.23
50
1.37
5.
Depressive psychosis
28
0.79
22
0.55
127
3.67
150
4.10
II.1
181
4.6
287
8.3
517
Total
Population studied
395
35.548
Bangalore while similar percentages at Baroda, Cal
cutta and Patiala are 28, 20 and 22 respectively. Most
of these cases are in the younger age group of upto 14
years of age and most of the patients on management
at the PHC in Bangalore have epilepsy. Similarly, the
rates for depressive psychosis are higher in Calcutta
and Patiala (3.67 and 4.10) compared to Bangalore
and Baroda (0.79 and 0.55).
The health worker - doctor team of the PHC was
about 20 percent effective in identifying and managing
the epileptics and psychotics in the community, follow
ing a short term training in basic mental health care.
39,655
34.582
14.1
36.595
Improvement in social functioning
All the patients detected and managed by the
PHC team were also assessed by the research staff
using the IPSS during the intervention phase. The
same patients were reassessed by the research staff
during the final survey. Thus their improvement could
be evaluated by comparing the two IPSS. While the
changes in the social discrepancy score indicate
improvement in all the patients managed by the PHC
team, these changes have not been very marked. It
must indeed be remembered that the large majority of
these patients were chronically disabled with several
years history of illnesses. It is well known that chronic
133
psychosis and epilepsy need long-term and regular
medication to show satisfactory improvement in
symptomatology and social functioning.
Attitude survey
During the final survey, the attitude questionnaire
was again administered to those who had responded to
it earlier, during the beginning of the intervention
phase, with the aim of finding out if the attitudes
towards mental health had changed favourably as a
result of the intervention by the PHC personnel. The
results of the attitude survey, before and after the
intervention phase show that at all the 4 centres
there was an overall change in the attitudes in the
positive direction as measured by the simple 15 items
attitude questionnaire before and after the interven
tion. While the overall changes are satisfactory, item
wise analysis showed that, certain crucial items like
suitability of the local health centre for treatment of
most of the mental illnesses had not changed consider
ably. There appears to be doubt regarding the causa
tion of mental illness too as items on caution like
blackmagic, evil spirits, masturbation, excessive sex
and bad deeds of past and present life had not changed
satisfactorily. These items elicited very few correct
answers not only in the initial survey but during the
repeat survey also.
Cost of the programme
The simple and crude costing exercise carried out
(‘Pure cost analysis’) estimated the cost of training and
intervention ie case finding and case holding by PHC
personnel, cost of monitoring and cost of the final
survey to evaluate the performance of the PHC per
sonnel. The cost of records, drugs, training material
and other incidentals involved in the training, wages of
the research staff and the cost of travel were the main
costs taken into consideration. The wages of the PHC
personnel were not considered as they were already in
employment for carrying out various health care acti
vities. The total cost of the programme for training and
intervention, monitoring and final survey amounts to
about a lakh of rupees at each centre.
Consideration of costs will have to take into
account the fact that the study was carried out as a
research project with specific goals and with research
staff specifically appointed for the purpose. A major
portion of the total costs was constituted by the salar
ies, for the research staff. For larger scale replication of
the intervention programme, the costs are likely to be
less.
134
Comments
The design of the study aimed to integrate mental
health into primary health care by training the existing
primary care personnel and evaluate this integration in
a methodical way. It prioritized mental health prob
lems and attempted an intervention strategy keeping in
mind the limited resources. In other words the study
was in the nature of Health Services Research aimed to
systematically study the means by which relevant bio
medical knowledge is brought to bear on the health of
individuals and communities under a given set of con
ditions.
Training for PHC personnel
The quality of the training would have been
enhanced, by making it oriented towards more practi
cal and field work with the use of more audio visual
material. It is known that while conducting in-service
training programmes for persons whose motivation is
at best average, the use of certain principles of adult
interactive learning adds to the overall usefulness of
the programme (These include the use of techniques
like role play and simulation games and some activity
in which all the participants are involved in every
training session). Simulation exercises of identifying
cases in the community, referring them to a PHC.
convincing unwilling family members, health educa
tion of the community, follow up visits to patients etc.
could have made the training more interesting. They
would have contributed to the development of skills in
addition to gaining knowledge.
The training in mental health was offered only to
the medical officers and health workers, although
there are several other important functionaries who
contribute to the team at every PHC. Such as the
supervisors of health workers viz health inspectors
and lady health visitors, block health educators and
the pharmacist. Involvement of these personnel after
appropriate training would have contributed to the
performance of the personnel as a team. Lack of a
built-in mechanism in the study design for continuous,
on the job training probably contributed to the poor
performance of the personnel, during the intervention
phase. Continuous refresher inputs are known to con
tribute to the quality of work of health personnel.
Evaluation of the training
The training for PHC personnel evaluated by the
pre - and post- training assessments showed that the
knowledge gain of doctors and health workers at all 4
centres was satisfactory and there were changes in their
attitudes in the right direction. However, when they
were required to use this knowledge in their practical
work, their performance was not satisfactory. This
shows that knowledge gain alone does not always lead
to working differently. There are several other factors
in addition to new knowledge gained and skills deve
loped, which contribute to the effectiveness of a train
ing programme. It was found during the intervention
phase that the doctors’ ability to correctly diagnose
and manage the detected cases which came to them in
the PHC was reasonably adequate.
Intervention by the PHC personnel
It was found that the PHC personnel were able to
detect and manage less than 20 per cent of the actual
severe mental morbidity from their catchment areas,
during the intervention phase. Evaluation of any pro
gramme, should identify, in addition to successful
aspects of the programme, deficiencies that are amena
ble to corrective action.
There are several specific factors which may have
contributed to the poor performance of the PHC team.
Many of these factors came to light as the investigators
gained an understanding of the functioning of the
primary health care structure. It was assumed that if
health workers and doctors of PHCs were trained in
mental health care, this component would easily get
integrated with the PHC system. The various other
functionaries in the system like the supervisory staff of
the health workers, the block health educators and
most important the administrative supervisors of the
PHC doctors, (such as the District Health Officer,)
were not taken into consideration. The integration was
attempted only from the lower end of the health care
hierarchy, while experience has shown that integration
occurs only when it is attempted at all levels of the
hierarchy. In the present study, the intervention was
carried out only in a portion of the PHC with an
approximate population of 40,000, involving only
those health workers who worked in these areas. The
health workers from the non-study areas of the'PHC
did not have anything to do with the mental health care
programme. Review discussions, at monthly meetings
of the PHC with health workers did not involve the
whole group with the result that the discussion tended
to be less intensive. The operationalization could have
been better, if the total population of the PHC had
been covered by the intervention programme. Staff
vacancies were also an impediment in this programme.
It was clear that the records to be maintained by PHC
personnel should be very simple and easy to fill up and
maintain. The records for the health workers, as a rule,
should be in the local languages. In the present study,
even though the case history and follow up records
were simple, there was scope for further simplification
and improvement. Recording and reporting can
become an integral component of the activities of the
health workers, only if they are regularly scrutinized,
reviewed and feedback given to them by their own
superiors month to month. Thus, a hierarchial systems
of regular recording, reporting, review and feedback
has to be established for mental health care too. In the
present study, as the monitoring was carried out by the
research staff, the superior officers were not actively
involved, thus resulting in loss of seriousness and
intensity.
The attitudinal changes in the community were
expected to occur by the work of the PHC team (ie
detection, referral and management of cases and men
tal health education). The health personnel were not
particularly equipped in the task of mental health edu
cation. They were not given any health education aids
like posters, pamphlets, charts etc, for this activity.
However, additional inputs need to be provided if wide
ranging attitudinal changes are expected of the com
munity. It is generally agreed that if health care pro
grammes are to succeed, it is essential to ensure of the
involvement and participation of the community for
whom the programme is delivered. In the present
study, the intervention phase did not plan for any
organised programme or activity to seek the involve
ment of the community. Active community participa
tion would have enhanced the effectiveness of the
coverage of the programme. It was observed that a
‘team-approach’was lacking in the PHCs. The doctors
and health workers did not trust each other in general,
there seemed to be mutual distrust and disrespect
between them. In all the study areas, the performance
of the PHCs in various national programmes was far
below targets and expectations. The absence of a team
spirit and well coordinated work amongst the person
nel in the PHC, certainly contributed to the quality of
performance of the health personnel.
Prevalence of severe mental morbidity
This study estimated the prevalence rates of severe
mental illnesses and epilepsy at 4 different centres in
the country using an uniform method of case identifi
cation, assessment and diagnostic categorization. A
135
simple method of identifying the priority conditions of
psychoses and epilepsy was used. This method
designed for use by multipurpose health workers of
PHCs for identifying the severely mentally ill, had
been already cross validated with the ideal method of a
door-to-door survey using a standardised tool10.
The method employed in the present study may be
criticized as an oversimplification of psychiatric case
finding. It must be emphasized, however, that this
method is intended for identifying the most severe
forms of morbidity such as psychosis and epilepsy in
the community. A method like this may be useful only
in close-knit society of a small or medium sized village,
and it may not yield similar results in urban or semiurban communities.
Although the morbidity rates of mental disorders
obtained by various epidemiological studies are highly
variable, the range is very narrow when one considers
the rates of only psychosis or only schizophrenia. The
rates of all psychoses, schizophrenia and epilepsy esti
mated from this study are comparable to what is
reported by most other authors. The rates for all cases
are highly variable and they range from less than 10 per
thousand to over 300 per thousand. The rates for 'all
cases’ estimated by the present study are, as expected,
lower than most other reports as the present study
aimed to estimate only the severe mental morbidity.
There were certain interesting variations in the
prevalence at the 4 study areas (Table V). While the
prevalence of epilepsy was 7.82 per thousand at Banga
lore it was only 1.28 at Baroda and 1.71 at Calcutta.
The rate for all psychoses was higher in Patiala and
Calcutta, compared to Baroda and Bangalore and
mainly contributed by the larger numbers of depres
sive psychosis at both these centres. The rates ‘all cases’
ranged from 4.6 in Baroda to 14.1 in Patiala.
The ‘case definition and categorization’, and the
‘case finding’ methods employed in an epidemiological
exercise should be primarily chosen depending on the
purpose of the inquiry. An important use of any epide
miological data is ‘planning, organizing, delivering
and evaluating’ services. As early as in 1977, Sarto
rius"1 cautioned that exercises in epidemiology aimed
only at estimating the prevalence and speculating on
the etiology of mental illnesses needing considerable
time, money and trained personnel, are not any more
justified particularly in developing countries. How
ever, if their purpose is essentially operational—ie for
136
planning, organizing and evaluating services—they
may be considered worthwhile. In spite of several psy
chiatric epidemiological studies in our country, as
noted by Wig & Murthy19, “none of these have ulti
mately resulted in a well organized plan to demon
strate the usefulness of the available psychiatric skills
to help the identified patients”.
This ICMR/DST collaborative study on severe
mental morbidity represents an important milestone in
the development of the mental health policy in India.
The study has also played a pioneering role in launching
community-based mental health care programmes and
health services research in the field of mental health.
The primary aim of this multicentric study was to assist
in better planning, organization and evaluation of
mental health services in the country. These aims have
been fulfilled, to a large extent, by the study, which has
yielded certain interesting leads on the feasibility of the
improvement of the existing PHC personnel in mental
health care, with certain additional inputs (organiza
tional and managerial) and under proper supervision.
References
I.
Overbeck-Wright. A.W. Lunacy in India. Bailliere. Tindall
& Cox, London. 1921.
2.
Dube, K.C. A study of prevalence and biosocial variables in
mental illness in a rural and an urban community in Uttar
Pradesh. India. Acta Psychial Stand 46: 327, 1970.
3.
Surya. N.C.. Dutta, S.P.. Gopalakrishna. R„ Sundaram, S.
and Kutty. J. Mental morbidity in Pondicherry. Transaction
of AH India Institute of Mental Health, 50, 1964.
4
Verghese. A.. Beig. A., Senseman. L.A.. Sunder Rao, S.S.
and Benjamin, V. A social and psychiatric study of a repre
sentative group of families in Vellore town. Indian J Med
Res 61: 60S. 1973.
5.
Sethi, B.B.. Gupta. S.C. and Rajkumar. 300 urban families
(A psychiatric study). Indian J Psychial 9: 280, 1967.
6.
Sethi. B.B.. Gupta, S.C. and Rajkumar. Psychiatric sur
vey of 500 rural families. Indian J Psychial 14: 183, 1972.
7.
Elnager, M.M., Maitra, P. and Rao. M.N. Mental health in
an Indian rural community. Brit J Psychial 118: 499, 1971.
8.
Carstairs. G.M. and Kapur. R.L. The great universe of
Kota: Stress change and mental disorder in an Indian vil
lage. Hogarth Press. London. 1976.
9.
Nandi. D.N., Ajmany. S.. Ganguly. H„ Banerjee. G.. Boral,
G.C.. Ghosh, A. and Sarkar. S. Psychiatric disorders in a
rural community in West Bengal-An epidemiological
study. Indian J Psychial 17: SI. 1975.
10.
Isaac. M.K. and Kapur, R.L. A cost-effectiveness analysis
of three different methods of psychiatric case finding in the
general population. Bfit J Psychiat 137: 540. 1980.
16.
Kapur, R.L., Chandrashekar, C.R., Kapur, M. and Kaliaperumal. V.G. Social dysfunctioning as a measure of severity
of psychiatric illness. Indian Psydtiat 23: 27. 1981.
11.
Kapur, M., Kshama. R.and Kapur, R.L. A brief orientation
course for basic health workers on psychiatric problems in
rural areas. Indian J Psychol Med 2: 69. 1980.
17.
12.
Kalyanasundaram, S„ Isaac. M.K. and Kapur, R.L. Intro
ducing elements of psychiatry into primary health care in
South India. Indian J Psychol Med 2: 91. 1980.
Isaac, M.K.. Kapur. R.l... Chandrashekar. C.R.. Kapur. M.
and Parthasarathy. R. Mental health delivery through rural
primary care development and evaluation of a training pro
gramme. Indian J Psychiat 24: 131. 1982.
18.
13.
Organization of mental health services in developing coun
tries. 16th Report of the Expert Committee on Mental
Health. WHO Tech Rep Ser. 564.
Sartorius, Nl Priorities for research likely to contribute to
better provision of mental health care in developing coun
tries. Soc Psychiat 12: 171. 1977.
19.
14.
Kapur. R.L., Kapur, M. and Carstairs. G.M. Indian Psychi
atric Survey Schedule (IPSS). Soe Psychiat 9: 71. 1974.
Wig. N.N. and Murthy, R.S. Planning community mental
health services in India—Some observations. Indian J Psy
chol Med 2: 51. 1980.
15.
Katz. M.M. and Lyerly. S.B. Methods of measuring adjust
ment and social adjustment in a community: 1. Rationale
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Psychol Rep 13: 503. 1963.
This write-up by Dr. M.K. Isaac. NIM H ANS. Bangalore, is based
on the final report of the Collaborative Study on Severe Mental
Morbidity.
137
Z] • /•
COMMuW.i? ■■ AUTH GcLL
47/1,(i-irst Hoof )C.. Marks Aoad
BANGALOSE - 560 001
, $~
_N_ational Workshop on .Rehabilitation
t aT££/Disa/'l o'cf ~~ ~b~ "nIMHANS
Bangalore - J4£rch ij" -’ ~14,’ '1981 ~
Paper on
Social SecufTEy /Teasures for the
Welfare of tine Me nt a 1 ly Disabled
By
Smt. Sarala Gopalan
Executive Director, Central Social Welfare Board
It is a happy co-incidence that the NIMHANS are
celebrating their Silver Jubilee during the International
Year of the Disabled and in the month of March.which has
the World Disabled Day on the 22nd this year.
This
augurs well for greater care, concern and understanding
of the problems of the Mentally Disabled that can bring
about necessary changes in social attitudes that will
help integration of the Mentally Disabled with the main
stream of the society
and give them a quality of life
worth living.
The magnitude
of. disability
in India
The United Nation*s surveys have shown that 10 out
of every 100 persons have some kind of disability.
It
is also believed that 1.5% of the world population will
fall in the category of mentally or intellectually dis
abled persons.
While in itself this proportion of
disabled persons is large, the problem is aggravated
further in populous countries like India which account
for 14% of the world population making for one out of
every seven persons an Indian.
It has been found that
a baby is born every 1-J second, 55,000 babies everyday
and 21 million a year in the world, while India adds
13 million to her population every year !
The United
Nations survey also refers to 4 to 7% of the births
being of abnormals.
Even after birth, 3% of the
world’s population suffers from mal-nutrition.
2
The poorer the country, the greater the impact of
mal-nutrition and disabilities consequent on mal
nutrition,
The data mentioned above adds up to a
very very large number of persons that need special
care in an economically poor populous countries like
India and highlight the astounding proportion of the
problem looming before us and hence our great concern
for the care of this large number.
Social Securi'
and Social'
Welfare
I have been asked to discuss social security
measures for the welfare of the mentally disabled.
I was slightly intrigued as to how I should treat
the subject - whether limit it to ’social security’
or consider the garnet of social welfare measures for
the mentally disabled.
because, technically,
I make this distinction,
’social security’
in its widest
sense would cover only catering to 'economic risks’
of each category of people and the discussion would
limit (js to subjects like pensions, doles or
insurance.
It would certainly not cover even general
economic or infrastructural or developmental factors.
’Social Welfare' on the other hand would have a very
wide coverage of physical, economic, emotional,
attitudinal and organisational factors.
I have
chosen to adopt the latter concept for discussion in
this paper and not to restrict the discussion to only
'social security’ measures.
The Manta11^_
disabled definition
Mentally disabled again is a wide term
embracing persons who are mentally ill or intellectually
handicapped.
Intellectually handicapped could be
either slow learners due to some deficiency or
mentally retarded persons.
In this paper I do not
wish to discuss these different categories in detail
3
and bring out finer distinctions amongst them and
their problems in coping
with the demands of the
society but treat the mentally disabled as one group
while being very conscious of the fact that each
category requires specialised treatment.
The promise
The United Nations have made special emphasis
on the world’s least privileged and most vulnerable
"silent minorities" i.e. estimated at 40 million
mentally retarded men, women and children in 1971. .
The General Assembly of the United Nations endorsed
"A bill of Rights" specifying economic, community
and family safeguards for the intellectually handi
capped.
The basic
steps
The most important thing for us in India is
that the 1981 Census has included a detailed
counting of the disabled persons which is the
pre-requisite of basic planning.
Secondly, the
preparatory meetings at the United Nations experts
level has realised the importance of preventive
measures through a comprehensive medical check-up
for early diagnosis and treatment and nutrition
intervention to deserving persons to combat dis
abilities.
These basic steps are very essential
though these facilities do cost a great deal and
poor countries are not able to meet the demands
completely and cry a halt to deterioration and
disabilities.
While tackling the problems of the
mentally disabled from prevention to rehabilitation
would be an area of priority for attention and
expenditure, from the human angle,from the
developmental angle it gets relegated as
4
unproductive,
for the whole sector of social
service is of low priority, and within the sector,
may be the mentally disabled are lower priority,.
This is because we have all along focussed so
strongly on their disabilities, and considered
them as a burden on Society, and we have not been
able to see their abilities and channelise those
abilities into productive processes and treat them
as partners of progress in Society.
Problems and
Solutions
Having laid down the magnitude of the problem
and the para-meters of the discussions and the
realisation of the need to take concrete action
for the benefit of the mentally disabled persons^
I would identify the basic problems as social
attitudes and paucity of infrastructural facilities
for the prevention, diagnosis, care, and rehabilita
tion of this unfortunate group and the solution a
steady untiring effort at building up this
infrastructure mobilising material and manpower
resources for their benefit.
Social
attitude
The greatest problem, in my view, is the
social attitude towards disabledin general and the
mentally disabled in particular.
The family, the
community, and the society consider that the
mentally disabled person is rjust to be condemned
as a useless piece of furniture occupying space
or using resources without any benefits.
Either
such a parson is jeered at as a laughing stock or
pitied as a wet cat !
Unfortunately even our
legislations treat them as enemies of Society as
though the Society is to be protected against
them - they being condemned, if anything, as
harmful elements.
Rarely one thinks of concern or
leva for such parsons.
They are not to be blamed
for their condition and more than sympathy they
need love and the social attitude towards them-
and as to transform into one of love.
The mentally
disabled persons should feel that they are wanted.
Mind you, a majority of them are roally not useless
vegetative beings incapable of giving anything to the
family, corimunity and the society in return for care
and attention. In fact a large proportion of them
in the I Q range of 60 - 80 are capable of assuming
a dignified and productive role in society provided
they are given the facilities, education and oppor
tunities.
Such a social attitude towards them
would certainly change the world for them and make
it worth living.
I think it is the primary concern
of the International Year of the Disabled Persons
to create this awareness in the people to treat ', tihair
/fortunate
loss■/brethern with sympathy and love and create
opportunities for them to improve their quality of
life.
Mho is to
—
Families in general do not consider it their
responsibility, (though there may be exceptions to
this) to care for the mentally disabled persons
and just allow them to attain a vegetative growth,
or think it is the responsibility of the State or
the philanthrophists to look after these unwanted
persons.
It is very necessary that the families
have to be educated on the care of the mentally
disabled persons, as it is neither feasible nor
desirable to relegate this responsibility to the
State.
This is not to say that institutional
care is not essential at all
It is necessary
6 :■
and has to be developed for taking cars of very
bad cases while those that can be tackled outside
the institutions should be dealt with accordingly.
Infra sjjr u c tu r e
In the whole country, there are just less
than a couple of 100 institutions spread very
thinly over the different parts of the country that
have special facilities for educating, training and
rehabilitating the mentally disabled persons.
It
is very necessary that this infrastructure be built
up systematically in larger numbers to take in the
large numbers that are left outside.
Simultaneously,
as is the theme of the IYDP, it is necessary to
integrate the disabled persons with normal persons
wherever it is feasible to do so.
Building up of
this organisational net work calls for sensitisation
of the people to the needs of the disabled persons
and awakening social consciousness to this problem.
It does call for mobilisation of material and man
power resources.
Here we do face great scarcity
not only of funds for buildings, medicines, materials
nutrition etc. but also dearth of qualified techni
cians both to deal with the dishbility and training
and education of the disabled in various aspects.
It is very essential that a lot of attention is
paid to creating the technical man-power required
to handle this massive problem of the disabled
persons in every aspect.
The Government and the
Central Social Welfare Board have schemes of
grant-in-aid to build this most required infra
structure,
But the support may not have been
equal to the enormity of the need.
Since it is
Government's policy not to take up the task on
7
itself but to support voluntary agencies to take up
the task, more and more agencies have to come^'to
build
a strong infrastructure.
The mentally disabled in particular require
Rehabilitation
rehabilitation in the form of work experience, not
only for making a livelihood, but as a process of
treatment of their disability itself.
A great deal
of aptituds test, and vocational training is
necessary, and calls for a net work of'^sheltered
workshops, as a process of rehabilitation of the
mentally disabled persons.
A whole range of other
problems can be visualised in achieving this - like
hostels and accommodation for their staying, trans
portation, identification of jobs, products, markets
which alone can guarantee regular and sustained work
for them.
This becomes more serious in a general
situation of unemployment even for normal and able
bodied persons.
This again would become a great
social responsibility and not a mere Government
responsibility and needs an awakening of social
consciousness.
I think it would be healthy both
for them and for the society to take this positive
attitude towards the mentally disabled persons.
Diagnosis &
PrevontioiT'"
Many disabilities including mental retardation
can be arrested if diagnised in time and treated
adequately.
May be such timely treatment may even
prevent acceleration of the disability, provided
such preventive and diagnostic services are avail
able.
This calls for constant vigilance to trace
*A sheltered workshop is a work-oriented rehabilita
tion facility with controlled working environment and
individualized vocational goals, which utilizes work
experience and related services for assisting the
handicapped person to progress towards normal living
and a productive vocational status.
8
any signs of disability by health check-up and
health care not to mention Pre-natal, natal and
post-natal cars.
This also requires education and
guidance for the parents and others interested in
the handicapped children.
It also requires
coordination of health, education, training and
employment facilities.
Most of all, a net work
of counselling services have to be established
both to tackle the disabled persons and to educate
their relatives who have to help them get on in
life.
All these services are sadly absent today
on a country-wide basis, though there may be small
cases of excellent services in some Metropolitan
areas in the country.
Intensi v 3 car e
lack of '*
facilities
The problem of the ineducable who require
greater care and attention and may be institutional
care is really appalling.
These are more costly
services and therefore more difficult to create.
The services now available are very poor and need
more organisational efforts on the part of all
concerned - individuals, organisations and the
Government,
T.he__ Groug.
_Ins_urance for
11T£ _mo_n ta11£ ”
disa bled_
It would be interesting to understand the
efforts made by Government to create a group
insurance for the mentally disabled persons.
The Life Insurance Corporation of India announced
a group Insurance Annuity Scheme in 1978 for the
Mentally Disabled persons.
this sdtieme
The important aspect of
that it should be operated by
institutions dealing with Mentally Disabled persons
for groups of more than 25 parents of disabled.
The disabled persons will be entitled to get Rs.40/-
9 :-
to Rs.200/- pur month under the scheme after a
period of 5 years of contribution.
The experience
of the scheme was that the response was very poor,
as institutions reported that a very small per
centage of the parents were capable of paying any
kind of fees oven to the institutions and therefore
insurance would be beyond their reach.
Secondly,
the method of disbursement of these annuities to the
disabled persons was not satisfactorily worked out.
Unfortunately this Social Security Pleasures in the
real sense of 'social security* doesn’t seem to
have taken off the ground to replace parental care
on the death ofj^parent of the disabled.
This needs
to be further pursued to make the scheme more
viable and useful to those that can benefit out of
such a scheme.
C onelusion
While there is no neglect of the importance
of developing self-reliance on the part of the
mentally disabled persons through education,
training and sheltered employment, care and concern
either of the family or community is very important
for this category of persons and the society has
to understand and give them more’love* than to any
other group, as this seems to be one disability
which can be removed more by concern,care and
love than any other kind of disability.
«#«**#**»
TABLE NO. 10.21 : HUMBER OF PATIENTS OF MENTAL DISORDER TREATED IN SPECIALISED MENTAL
HOSPITALS ACCORDING TO VARIOUS CAUSES AS PER I.C.D.-IX DURING
1992
Si.
STATES/
NO.
UTs.
I.C.D
-
COOES NUMBER AND DISEASE
PSYCOSES
NEUROSES
MENTAL RETARTED
(290-299)
(300-316)
(317-319)
GRAND TOTAL
(290-319)
M
F
T
H
F
T
M
F
T
M
F
2
3
4
5
6
7
8
9
10
11
12
13
14
1.Andhra Pradesh
2.Assam
1743
. 660
2403
31
NR
146
22
NR
11
33
1880
NR
702
NR
2582
NR
982
5764
2468
1
166
NR
NR
NR
NR
3.Bihar
NR
4431
115
NR
952
5383
322
18
340
41
848
623
1471
670
310
980
29
12
12
4. Goa
5
17
4782
1530
938
5.Gujarat
383
106
489
13 ,
32 '
5
18
45
2
47
441
113
NR
T
554
6.Jammu & Kashmir
296
308
604
16
48
3
331
326
657
1860
1230
3090
786
248
1034
94
2
47
5
7.Karnataka
141
2740
1525
4265
8.Kerala
4746
1629
6375
256
123
379
40
18
58
5042
1770
6812
9.Madhya Pradesh
395
102
497
28
9
37
9
8
17
432
119
551
10.Maharashtra
25
3337
1551
4888
NR
NR
NR
2568
1500
4068
NR
NR
NR
709
NR
NR
734
NR
60
NR
26
NR
86
11.Nagaland
12.Orissa
499
296
795
151
101
252
33
10
43
683
407
1090
13.Punjab
129
45
174
8
0
8
2
0
139
45
184
216
164
154
370
55
12
14
176
142
67
6
7
31
2
62
14.Rajasthan
15.Tamil Nadu
556
436
992
3717
808
NR
1178
4895
16.Uttar Pradesh
17.West Bengal
290
128
NR
NR
NR
18.Delhi
372
NR
138
1098
NR
510
96
35
131
23351
9493
32844
3694
1101
4795
TOTAL
Note :
HR <= Not Received
SOURCEz SPECIALISED HEM TAL HOSPITALS.
NR
'
827
597
1424
98
8
3948
2
942
1221
306
5169
1248
NR
NR
NR
NR
7
26
NR
487
NR
19
180
667
496
188
684
27541
10782
38323
TABLE HO. 10.22 : REPORTED CASES AND DEATHS DUE TO COMMUNICABLE
DISEASES IN STATES/U.Ts IN INDIA DURING 1993
SI.
STATES/U.Ts.
DIPHTHERIA
POLIOMYELITIS
TETANUS-NEONATAL
NO.
2
1
1.
ANDHRA PRADESH
C
D
C
D
3
4
5
6
1026
28
1435
33
C
.
D
7
8
83
27’
2.
ARUNACHAL PRADESH
14
0
0
0
0
0
3.
ASSAM
75
11
18
0
90
12
4.
BIHAR
5.
GOA
0
2
0
6.
GUJARAT
HARYANA
218
34
34
443
61
48
1
0
278
0
0
0
0
6
94
0
167
0
7.
8.
9,
HIMACHAL PRADESH
JAMMU & KASHMIR
4
2227
10.
KARNATAKA
11.
KERALA
306
40
12.
13.
14.
MADHYA PRADESH
314
MAHARASHTRA
MANIPUR
163
15.
MEGHALAYA
16.
MIZORAM
17.
NAGALAND
18.
19.
1
178
3
673
0
147
31
2
0
^4
2
8
71
452
3
9
1
4
842
102
112
0
8
86
44
0
18
0
0
0
100
0
7
0
3
0
0
0
0
0
3
2
ORISSA
233
166
0
18
0
97
PUNJAB
22
20.
RAJASTHAN
21.
22.
SIKKIM
TAMIL NADU
245
0
14
0
21
8
10
0
1
197
44
4
622
0
89
19
1120
5
949
0
0
8
11
29
150
0
14
2316
165
58160
0
23.
TRIPURA
11
0
231
8
24.
UTTAR PRADESH
449
70
926
1268
112
1092
7
7
0
0
1
0
0
0
0
0
0
0
0
25.
WEST BENGAL
26.
A & N ISLANDS
27.
CHANDIGARH
28.
D & N HAVEL I
1
0
29.
30.
DAMAN & DIU
0
207
0
0
0
0
66
48
164
0
41
DELHI
31.
LAKSHADWEEP
0
0
1085
0
0
0
0
32.
PONDICHERRY
0
0
0
0
0
0
7131
397
7576
176
TOTAL
167
1384
6606
-CONTD.ON NE:KT PAGE).........
TABLE MO. 10.22 : REPORTED CASES AND DEATHS DUE TO COMMUNICABLE
DISEASES IN STATES/U.Ts IK INDIA DURING 1993
SI.
A.R.I
STATES/U.Ts.
ENTERIC FEVER
PNEUMONIA
NO.
2
1
C
D
C
D
C
D
15
16
17
18
19
20
330
35808
129
56506
ANDHRA PRADESH
ARUNACHAL PRADESH
1496165
2.
33865
5
1745
0
2569
42
0
3.
ASSAM
672743
47
17777
97
17667
17
4.
BIHAR
5.
GOA
2-
372
6
133
0
6.
GUJARAT
HARYANA
28093
403178
355
4553
87
8515
24
448738
64
46
4596
747878
208
8995
45540
109
0
105954
11977
19074
7
9
174943
1.
7.
9.
HIMACHAL PRADESH
JAMMU S KASHMIR
10.
KARNATAKA
896076
147
16574
1
68
11.
KERALA
2870610
113
16735
30
33451
11598
?2
2
12.
MADHYA PRADESH
649241
475
.44252
182
70026
84
13.
MAHARASHTRA
442971
203
.15543
557
14658
76
14.
MANIPUR
14964
1
5044
5
2821
4611
8
8.
15.
MEGHALAYA
132124
14
1669
16.
MIZORAM
24999
6296
10
3191
20
0
346
213
27564
249
17.
NAGALAND
18.
ORISSA
0
0
0
195
437
2
0
536
33054
46
19.
PUNJAB
1584229
288681
20.
RAJASTHAN
402634
21.
SIKKIM
31338
12
973
6
14
0
22.
TAM-IL NADU
141743
110
721
39
6313
31
23.
TRIPURA
UTTAR PRADESH
34902
1800
29027
11
201
1695
1
505781
28
349
24535
345
21913
86
1059
124
5688
58
73841
18
183
9
1211
2
.40500
3
264
6
40
24.
55
•
2758
27
2441
5
69910
309
13605
78
26.
WEST BENGAL
A & N ISLANDS
27.
CHANDIGARH
28.
D & N HAVELI
29.
DAMAN & D1U
7265
0
0
0
81
0
30.
143110
90
2
28654
31.
DELHI
LAKSHADWEEP
512
0
8711
306
29
0
32.
PONDICHERRY
25.
TOTAL
8660
48
0
46665
0
1335
0
924
0
12373146
3322
488261
3118
357452
888
NOTE: ARI - ACUTE RESPIRATORY INFECTION
................................................................................................. '........................... CONTD.ON NEXT PAGE-
169
TABLE HO. 10.22 : REPORTED CASES AND DEATHS DUE TO COMMUNICABLE
DISEASES IM STATES/U.Ts IN INDIA DURING 1993
SI.
GONOCOCCAL
STATES/U.Ts.
TUBERCULOSIS
INFECTION
NO.
2
1
,C
D
C
D
27
28
29
30
50137
0
186466
1010
ARUNACHAL PRADESH
49
ASSAM
887
0
0
8062
17726
26
81
ANDHRA PRADESH
BIHAR
5.
GOA
25
0
9152
63
6.
GUJARAT
221
2
39069
238
7.
HARYANA
62
0
27559
193
8.
9,
HIMACHAL PRADESH
39
0
17166
212
JAMMU & KASHMIR
2341
10.
6352
0
9
9672
KARNATAKA
43786
0
537
11.
KERALA
989
0
40406
12.
13.
MADHYA PRADESH
MAHARASHTRA
4051
1509
6
51612
334
0
87783
1250
14.
MANIPUR
14
0
1240
15.
16.
MEGHALAYA
80
0
MIZORAM
50
0
0
1361
1164
210
1
7
17.
NAGALAND
58
436
22
1
18.
ORISSA
2605
616
PUNJAB
98
0
0
46630
19.
19750
121
20.
RAJASTHAN
1529
0
82220
560
21.
SIKKIM
18
0
876
3
22.
121
TAMIL NADU
TRIPURA
819
30
4
32288
23.
24.
0
0
0
UTTAR PRADESH
1077
0
265889
278
25.
WEST BENGAL
0
0
10954
187
26.
A & N ISLANDS
9
0
1214
26
27.
28.
CHANDIGARH
D & N HAVELI
1
0
0
685
882
0
3
DAMAN & DIU
0
31.
DELHI
LAKSHADWEEP
496
0 '
0
85133
0
32.
PONDICHERRY
56
0
21919
0
26
73602
21
1111100
7952
29.
30.
TOTAL
4
1822
NOTE :C = CASES. 0 = DEATHS.
OATA IS PROVISIONAL AND NOT COMPARABLE DUE TO ILL-•DEFINED COVERAGE
SOURCE: MONTLY HEALTH CONDITIONS REPORTS-STATES/U.,T.S( D.H.S).
STATUS PALER ON
DELIVERY OF MENTAL HEALTH
SERVICES IN INDIA
-THE LAST AO YEARS
BY
DRi R.SRINIVASA MURTHY
MBBS, MD, MNAMS
ASSOCIATE PROFESSOR OF PSYCHIATRY
NATIONAL INSTITUTE OF MENTAL HEALTH
AND NEURO-SCIENCES,
P.O.BOX 2979,
bangalore-560029.
FOR:
INDIAN COUNCIL OF MEDICAL RESEARCH,,
NEW DELHI-110029,
APRIL, 1982.
DELIVERY OF MENTAL HEALTH SEKV
1.
Hi iIWLA-LA8T-4p YEARS
INTRODUCTION
Organisation of mental health services in developing count.
has been the subject matter of a number of national and international
meetings and conferences. The essential focus of the professions] r
has been the very important awareness of the available mental health •;
how that can alter the quality of life to the millions mentally li
the paucity of the services in the developing countries. Hie stag;-;;.
descrepancy in. the number of psychiatrists in different parts of 1-■
world are real. Most countries of Asia and Africa have less than <s
psychiatrist per million population, the U.K., the U.S.S.R. and Ire
each have more than 50 per million, while in the U.S.A, there are
probably by now over 120 psychiatrists per million. If we take the
widely accepted estimate of 1% as the prevalence of seriously dlsa'
mental disorder in all communities (WHO, 1975), we see that for c?.h
working psychiatrist there are about 80 such patients in U.S.A.,
Ireland, 170 in U.S.S.R. and 190 in England and Wales; there are no.;5000 in Senegal, 20,000 in Nigeria and 50,000 in Ethiopia (Harding.
These discrepancies have been very much in rhe minds of the mental
and health professionals in, our country . Efforts have been made re
to solve this problem by a number ox approaches, some ::f them very
specially suited to the National context. It is in this context
this review of the developments in die last 40 years has been chosen
for review to examine the trends -in care, the problems and possibilities
for future work. The time app‘- re oppurtune as’there f.s a tremendous
interest in PRIMARY HEALTH CARE and the inclusion of MENTAL HEALTH CARE
with primary health care can take the needed services to those who
need most.
The changing scene in the last 40 years is brought by the
following write about the Madras Mental Hospital very aptlys
’Psychiatric service till two decades before, was only
custodial in nature. The only mental hospital in the
state (TAMIL NADU), was established more than 100 years
ago in Madras and drugs like Serpas.il, paraldehyde and
■ barbiturates were mainly employed combined with mechanics.!.
restraint to keep the patient under control and around
1359 the use of chlorpromazine was introduced. As in oth«n
countries the social stigma of mental illness prevented
people seeking psychiatric help but during the last 20 yea--.
there aeems to be a change in their attitude towards mental
illness and more and more people seek early treatment. Be
it la not uncommon even during the present days., many pa>:
.
seek indigenous treatment before coming over for modern
treatment. In 1943, open hospital system was introduced ■
mental hospital and psychiatric out patient services wen
introduced for the first time in city medical colleges in
1953 and 1954... a centre was opened in Madurai in 1960
find we were able to utilise ths services of the clinical
psychologists and social workers to help us manage the
.
day hospital was' started for the first time in 1961. At
present there are 9 medical colleges... and in all these
medical colleges, the department of psychiatry was started
in course of time..A ae more and more psychiatrists became
available, the services were extended to almost all.district.
headquarters and taluk centres sc much so at present a
2
psychiatric centre is situated within 50 to 100 miles
of all potential patients living in the state'
(Vaidyelingam, 1382).
This transformation, at- least in one state in the country
over aueh a short time epan-from a single centre in the state to
niorc than 20 is remarkable indeed. The following reviews focusses
on the factors that made these changes possible and also highlight
the areas where further work needs to be carried out.
2.
DEVELOPMENT OF HEALTH SERVICES IN INDIA (1940-1981)
The historical development of health services Ln the country
provides an oppurtunity to understand the trends in general health
service and see the place of mental health service in the overall r
programmes. The topic of how the various committees have functioned and
what has happenned to the recommendations have been reviewed by Bose
(1980), Banerjee (1976) and Naik (1977). The following is a brief
account of the developments.
2:1
The historical record is traditionally started with the
Bhore Committee appointed in 1943. However, Bose (1980)- has rightly
pointed out that the health planning began much earlier. The National
Planning Committee (NPC) was appointed in 1933 under the Chairmanship
of. Jawaharlal Nehru and began its work in 1939, The NPC appointed
a number of sub-committee one of which was on the National Health
under the chairmanship of Col, S,S.Sokhey. The interim report of
the sub-committce was presented on 30 August, 1940. However the
report on national health was published in 1948. The National
Planning Committee passed several resolutions on national health,
items 6 and 7 read as follows:
'as a minimum step in order to meet the special conditions
prevailing in India, we recommend the training of a large
number of health workers. These health workers should
be given elementary training in practical community and
personal hygiene, first aid and simple medical treatment,
stress being laid on the social aspects and implications
of medical and public health, There should be one health
worker for every 1000 population and this probably should
be attained within five years. Selected health workers
should be given further training at suitable intervals
so that they might be better trained for this service.
There should be ultimately one qualified medical man or
woman for every 1000 of population and one bed for
every 600 population. Within the next 10 years, the
objectives aimed at should be one medical man or woman
for every 3000 of population and a bed for 1500 of
population'1.
It is rather tragic to note that in 1982, we are far' from
having reached the needs accepted in 1940, With this rather
discouraging observation the development of health services can be
surveyed.
3
2 :2
SHORE COMMITTEE REPORT:
The HEALTH SURVEY AND DEVELOPMENT COMMITTEE was set up by
Che. colonial Government in 1943 under the chairmanship of Sir Joseph
Shore. The report of this committee was published in four volumes in
1946. Tills committee recommendations provided an almost revolutionary
alternative to the existing health system in the country. The guiding
principles of the committee were;
(i)
No individual should fail to secure adequate medical care
because of inability to pay for it.
(ii)
Health programmes must, from the beginning lay special
emphasis on preventive work.
(iii)
The need is urgent for providing as much medical and
preventive care as possible to the vast rural population
of the country because they received medical attention of
most meagre description although they pay the heaviest toll
when the famine and pestilence sweeps through the land; and
(iv)
The doctor of the future should be a social physician
attracting the people and guiding them to healthier end
happier life.
The major recomi. mdation wss the setting up of infrastructure
in the rural areas with the primary health centre as the chief focus.
The committee l,.td down the .staffing criteria for these peripheral
centres for each unit population of 40,000 which has not been realised
even today in 1982.
2:3
The first Five Year Plan (1951-^1956) considered the.needs of
the country and largely influenced by the above recommendations< laid
down the following priorities in the Health Plan: (1) provision of
water supply and sanitation,(2) control of malaria;(3) preventive health
care of the rural population with health units and mobile units;
(4) health services for the mothers and children; (5) education and
training and health education; (6) self sufficiency in drugs and
equipment; and (7) family planning and population control. The plan
recognised that 'Malaria is the most important public health problem.
in India and its control should therefore be assigned tha top priori*.in national planning'. Tuberculosis was recognised as a major public
health problem next in importance only to malaria.
The important development in this plan period is the
expansion of the medical infrastructure in India. Tn this period the
National Malaria Control Programme was launched in 1953 to be converted
into the National Malaria Eradication Programme (NMEP) in 1953.
2:4
The Second Five Year Plan (1956—.1961) adopted the same
strategy as the first plan. There was greater emphasis on Institutional
facilities at the local level. The objectives were; (1) establishment
of institutional facilities to serve as basis from which services can be
rendered to people both locally and in surrounding territories;
(2)
development._of technic, manpower to appropriate training programmes;
(3)
institutional measures to,control communicable diseases which may
be widely prevalent in the community; (4) an active compaign for
environmental hygiene; and (5) family planning and other supportive
programmes for raising the standard of health of the people.
One of the most important action taken during the second
plan period is the establishment of primary health units in as many
developmental blocks as possible. Thus from 67 PHC's at the end
of First plan, there were 2565 PHC's at the end of the Second plan
period. This trend continued to the third plan when the number was
4631. (TABLE I).
2:5
Another important development in this period was the
appointment of the Health Survey and Planning Committee in August
1959 under the chairmanship of Dr. A.L, Mudaliar. The report of
this committee was published in two volumes in 1962. This committee
first discussed the. recommendations of the Chore Committee, the
present position (1960) and then made their own recommendations.
One of the important observations by the Mudaliar Committee
was ths recognition that 'it would be neither practical to provide
medical coverage in the near future on the scale visualised by the
Bhore Committee nor would it be feasible for the state to extend
such coverage on the basis of medical care services free for all.
We are of the view, that if the hospital beds could be provided in
the course of two or three plan periods at a scale of one bed per
thousand population, it should be considered fairly satisfactory’.
It was further said 'while t’.a idea of primary health centre is
an excellent one, it would not serve any useful purpose if centres
are established without adequate facilities, resources and personnel'.
They had one major suggestion in this regard, namely, ''w? think that
in the present state, with the increased facilities of road communica
tions, telephone and telegraph devices and in view of the proposed
establishment of modern hospitals at district headquarters and the
taluks, it may be preferable to provide medical coverage to the
rural population through mobile health vans, visiting them from the
district and taluk headquarters instead of multiplying PHC's in the
existing patterns'. However as noted the establishment of PHC want
ahead.
During this period, the National Smallpox Eradication
Programme was launched in 1962-63 and soon to be followed in 1966
a separate Department of Family Planning in the Ministry of Health.
2;6
THIRD FIVE YEAR PLAN (1961-66) reviewed the plans of the
earlier period in regard to the working of the PHC's. This pointed
out that the sources of problems arose from (i) shortage of health
personnel, (2) delays in construction of buildings, (3) inadequate
training facilities for different categories of staff required for
service in rural areas. The following measures were planned in the
Third Plan: (i) creation of a single cadre of personnel working in
the rural areas as well as urban areas, with insistence that each
person spend some period of work in the rural areas and service in
rural areas to be taken for promotions, advance increments or
selection to postgraduate training; (ii) residential accommocation
for medical personnel; (ill) scholarships to students in medical
colleges with the obligation ' serve in rural rreas after graduation
5
for a minimum period; (iv) services of medical practitioners
both in the rural and urban areas should be utilised on a part
time basis in the hospitals and dispensaries and for school
health services; and (v) the services of qualified and. properly
trained graduates in indegenous systems of medicine in PHC and
subcentres in addition to the medical officer should be utilized'.
2:7
The Fourth plan period (1969-1974) saw setbacks in the
malaria eradication programme. It was also noted that in spite of
all the. importance expressed, as many as 340 Community DevelopmentBlocks had no primary health centre. Only 50% of the PHC's had
hospital buildings and only 2.5% had residential quarters. During
this period, the increasing importance to family planning became
evident. A notable feature at this point in the health system
development is the number of VERTICAL PROGRAMMES aimed at problems
like tuberculosis,,leprosy, malaria, smallpox,.MCH Services etc.
etc. This often led to poor coordination of the day...to day work
at the field level and the lack of confidence of.the community
in the peripherally placed rural health personnel. This was
noted and the Kartar Singh Committee-aimed to solve this.
2:8
Tlie Kartar Singh Committee was mainly focussed on the
improper utilisation of the health personnel in the rural-areas.
The various categories of health auxiliaries not only were under
different administrative h ids, but also varrad in their duration
of training (ranging from a few weeks to few years) and the
emoluments. T' s heterogenecity was considered undesirable for
.operational effectiveness as each category was bothered about the
fulfilling their planned targets with no single person having
the confidence of the community,
The committee suggested the introduction of the
MULTIPURPOSE WORKER SCHEME all over.the country. The essential
feature of this is the reduction, in the area and population covered
by an individual worker, the increasing the skills of the workers
and integrating all health activities and streamlining the pay
structure. Ttiis is theoretically a very good approach. However,
in the first five years since its introduction only 10% of the
districts had adopted this scheme and a decade later in 1982 the
coverage is not more than 2G%, In addition,, even where it has
been in progress the change of name and working pattern has not
been followed by streamlining of the pay'structure and service.
conditions, Th’js, a good idea has led to discontent among the
health workers.
2:9
The Fifth Five Year Plan (1974-197*)) put forward a new
strategy, the MINIMUM NEEDS PROGRAMME. This programme- aimed at
'the primary objective during the Fifth Plan is to provide minimum
public health facilities integrated with family .planning and
nutrition for vulnerable groups namely children, pregnant women,
and lactating mothers'-, The specific approaches were as follows:
(1) inereasing the- accessibility of health, services* to rural areas ;
(ii) correcting the regional imbalance; (ill) further development
of referral services by r oving deficiencies in district and
subdivisions! hospitals; u.v) intensification u. control and
6
eradication of malaria and smallpox; (v) qualitative improvement
in the education and training of health personnel; and (vi)
development of reference services by providing specialists attention
to common diseases in rural areas*'. The following targets were set
out under the minimum needs programme - one. PHC for each community
development block; one sub-centre for a population unit of 10,000;
upgrading of one in 4 PHCs to a 30 bedded rural hospital.
2:10
The major review committee that came into being during.
this period is the GROUP ON MEDICAL EDUCATION AND SUPPORT MANPOWER
headed by Dr. J.B.Srivastava in 1974. They presented a document
titled 'Health Services and Medical Education: A programme for Imme
diate Action'. The committee noted that the importance of the
community in all health programmes has bean missing in the previous
planning. They suggested'IMMEDIATE ACTION on the following FOUR
Programmes, namely (i) organisation of basic health services
(including nutrition, health education and family planning) within
the community itself (emphasis added) and training the personnel
needed for the purpose; (li) organisation of an economic and
efficient programme of health services to bridge the community with
the first level referral centre, vis the PHC (including'the strength
ening of the PHC itself); (iii) the creation of a National Referral
Services Complex by the development of proper linkages between the
PHC and-higher level referral ind service centtc-a; and to create the
necessary administrative ui ;: . l.i.-ricial machinery fol' the organisation
of the entire programme of medical and health education from the point
of view of the objectives and needs of the. proposed programme of
national health services.
The committee noted that 'during the last 25 years, the
cadres of functionaries which provide health services to the community
have multiplied greatly because each programme was run virtually
independently of the others and with little health coordination,
both among the field workers and among those at the supervisory level.
Even the two doctors at the PHC had separate spheres of activity, one
being devoted to the family planning programme and the other to the
provision of general health services. It is now realised that in the
interest of economy as well as of efficiency, it is necessary to creat<
a single multipurpose cadre to provide all the different promotive,
preventive and curative services needed, (including- the control of
communicable diseases) and also to include, within the responsibilities
of this cadre, a medium of eurative services, an emphasis on material
and child welfare services and family planning'.
The committee recommended the creation of a new cadre of
personnel and functioning of the existing personnel as follows: 'there
is now a male health worker for every 6OUO-7OQO population and one
female health worker for every 10,000 population. The proposed target
for the Fifth plan is to provide one male and female worker each for a
population of 8,000., Wille we welcome this, we recommend‘that by the
end of the Sixth Plan we should strive to provide,one male and one
female worker, each for every.5000 population. We- also recommend that
every health worker should.be trained and equipped to-give simple
specified remedies (including •■'■oven indige:._-ue> replies as well)for
day to day illnesses. Apart from the fact that this will provide
7
an essential and needed curative service to the people it will also
increase the acceptability, utility and efficiency of the health
workers themselves’. This category of health workers were referred
as HEALTH WORKERS
The committee also called for setting up of a Medical and
Health Education Commission by an Act of Parliament for coordination
and maintenance of standards in health and medical education,’
The committee also emphasised the need for a new cadre of
workers close to the community, not full time employed in health care
activity and carrying cut simple activities of prevention and curative
nature.
2; 1.1
COMMUNITY HEALTH VOLUNTEER'SCHEME;
A major result of the shift in thinking in health planning
as expressed in the Srivastava committee report was the scheme to train
a large number of CHVs in the short period of five years. This scheme
was launched on the birth Anniversary of Mahatma Gandhi in 1977.
According to this scheme, CHV is selected in collaboration with the
village leaders one for 1000 population. He is given training for a
period of three months, He a taught the fundamentals of health
sciences, measures for maint-ining health, hygiene, treatment of
common infectious diseases, ailments, first aid etc. He is expected
to provide basic health care in these areas. He will also serve as
the first informant of the health status of the community to thfe
medical officer incharge of the PHC under the immediate guidance of
the MPW. The trained worker is provided with, a medical kit and an
honorarium for the service rendered to the community on a part time
basis.
This scheme was launched and was progressing as planned for
the first two years till the National Development Council of 1979
asked the states to meet 502 of the expenditure on this scheme from
the states, which has brought a big setback.
The TABLES 1 TO V in APPENDIX provide an idea of the
development of general health services in the country.
To summarise, the developments, in the health field the
efforts have been, directed to reach the iuost needy and to provide
basic health care, i,e. to those chosen priorities. The-two broad
approaches used has been the systematic and progressive DECENTRALISATION
and DEPROFESSIONALISATION. These trends have Important implications
for the planning of Mental health services.
3•
CENTAL health COMPONENT IN MAJOR HEALTH COMMITTEES;
3,1
Mental health needs of the population have figured in the
different health surveys and special’committees set: up in the last 4
decades. The offer an underr’anding of the hopes and failures regarding
mental health care in the la.*, c forty years. Foil, ing is the relevant
sections.
8
3.1.1
One of the earliest references at the turn of the period of
•this review is the report in the INDIAN MEDICAL REVIEW (1938). At that
time it was noted that 'there are 17 mental hospitals in British India
with an accommodation for 8425 patients, but the number of patients
actually confined in the hospitals in 1936 was 11,792.- There was
overcrowding in almost all the hospitals, but it was more acute in
Madras. Bombay and the United provinces...Psychiatric clinics attached
to large hospitals, medical schools and colleges do not exist in Madras
for the treatment of mental defective patients. In Bombay there is a
psychiatric clinic attached to the J.J.Hospital, Bombay, in charge of
an Honorary Medical Officer, who runs it for two days in week. Bengal
has a clinic attached to the Carmichael Medical College, Belgachia,
managed by a committee appointed for the purpose. There is a small
clinic attached to the K.G. Medical College Hospital, Lucknow, in the
United provinces,which is a sub-section of the medical out-patientdepartment of the College Hospital and in charge of the physician of
that department. No such clinics exist in the Punjab, Bihar,--Central
provinces and Berar, Assam, North West Frontier Province, Orissa,
Baluchistan and Coorg....No facilities for the training of the mentally
defective children exist in the United provinces, Punjab, Bihar,
Central Provinces and Berar, Assam, Sind, NWFP, Orissa, Baluchistan
and Coorg.
Major expression of concern for mental health was noted In
the Shore Committee report (19'6).
3.2
-
SHORE COMMIT!: i REPORT;
The: findings and recommendations are as follows: ‘...even if
the proportion of mental patients be taken as 2 per thousand population
in India, hospital accommodation should be available for atleast 8,00,000
mental patients as against the existing provision for a little over 10,000
beds for the country as a whole. In India the existing number of mental
hospital beds la in the ratio of one bed to about 40,000 of the population
while in England, the corresponding ratio is approximately one bed to
300 population.
The PROPOSALS WERE '...as against this background of mental
ill health the existing provision for the medical care of such patlc
is altogether inadequate and unsatisfactory. We therefore, make the
following recommendations for the short term programme;
(a)
The creation of mental health organisations as part of the
establishments under the Director General of Health Services at the
Centre and of the Provincial Directors of Health Services. The .
creation of mental health organisations as part of the DGHS at the
Centre and of the Provincial DHSs is /: in our view, of such great
importance that we have placed if among the our reconiman.dations < So
little information is available regarding the incidence of mental
ill health in the country and the developments in this field of
health administration, even in the wore progressive countries, are so
recent that we feel we shall not be justified in making detailed
recommendations regarding the mental health organisation which the
country requires. We must let 8 this task to .the hr-.-1th departments
9
with the guidance of the specialists, whose appointment we have
suggested.
(b)
The improvement of the existing 17 mental hospitals and
the establishment of two new institutions in the first five years
and of five more during the next five years, Radical improvements
should be made in the existing mental hospitals inc order to make them
conform to modern standards, Provision should also be made for all
the newer methods of diagnosis and treatment. Apart from such
remodelling of existing mental hospitals we recommend the creation
of 7 new institutions during the short term programme, of which
at least two should be established as early as possible during the
first five years period.
(c)
The prevision of facilities for training, in mental
health work for medical men iti India and abroad and foe ancillary
personnel in India.
Nowhere in this country are available all
the facilities necessary for starting a course for the Diploma in
Psychological Medicine. We recommend that, as early as possible,
courses of training for thia diploma should be developed in Bombay
and Calcutta in association with the universities concerned. We
also suggest that, as soon as possible, similar Liploma courses
should be developed in the un;/erslties of othei p,.>viocial capitals.
In the mean time a certain number of carefully selected medical
men, with some ex rience of work in meat 1 hospitals in India,
should be sent abroad for training, Provision should be made for
sending atleast 20 doctors during the first five years and 20 during
the second five years of our programme.
We have also made proposals for developing training
facilities for non-raedical personnel including such workers as
occupational therapists, psychiatric social workers, psychologists,
nursing staff and male and female ward attendants.
(d)
The establishment of Department of Mental Health in the
proposed All India Medical Institute. This Department is calculated
to promote (i) development of facilities for the undergraduate and
postgraduate training of doctors in all branches of psychological
medicine and the demonstration to the provincial authorities of the
standards to be aimed at when similar facilities are created by
these authorities in their own territories;(2) the promotion of
research In the field of mental health and (3). participation in
the organisation of the mental health programme for the area in
which the Institute is located.
3•3
MUDALIAR COMMITTEE (1962) :
Under the heading of MENTAL HEALTH, the committee reviewed °
the progress made subsequent to the Shore Cotn®ittee,i.e. in the period
of nearly two decades, as. follows: .reliable statistics regarding the
incidence of mental morbidity in India are not available. It is
believed that enormous number f patients require naychiatric assistance
and service...as against the total need of the number of beds available
in mental hospital in India is only 15>or>'''. There is hardly any
10
provision for the education of mental defectives. Provision for
the treatment of psychosomatic diseases in general hospitals is
inadequate.
On the positive side 'the ALL INDIA INSTITUTE OF MENTAL
HEALTH was established in July, 1954 as a result of the recommends
of the Bhore Committee and started functioning in 1955 in' association
with the mental hospital, Bangalore. This institute provides
facilities for postgraduate teaching and research...it conducts a
two year diploma course in mental psychology (D.M.P.). The Diploma
in psychiatric nursing is of one year duration.
The Mental Hospital Ranchi which was previously under a
Board of Trustees has now been taken over by the Central Government
with a view of reorganising it on sound lines and also making Lt a
model centre for treatment of mental disorders.
Under the second five year plan scheme for the establishment
of Child Guidance clinics and psychiatric departments in teaching
hospitals, 8 such units have coma up in Andhra, Madras (2), Punjab,
Uttar Pradesh, Old Bombay state, Madhya Pradesh and Bihar.
general,
The RECOMMENDATJ NS were made undev three heads, -triz;'
training, research.
a, General: In the preventive field there should be (i) provision of
mental health services at pre-primary, primary and secondary schools
by the employment of not only of psychiatrists and psychiatric social
workers but of school counsellors among the teachers who have
undergone intensive training and who should be able to deal with
children with emotional and other problems; (ii) marital and pre
marital guidance in the social field; (iii) child guidance and
psychiatric clinics in all teaching and other major and district
hospitals.
In the curative field (i) in patient and outpatient
departments at lay hospitals; (ii) independent psychiatric clinics
or mental health clinics and (iii) institution for mental defectives
were stressed,
b. Training; There is need for (i) training and mental health
personnel; (ii) orientation in mental hygiene of such professional
groups as pediatricians, school teachers, nurses and administrators:
(iii) orientation in mental health for all medical and health
personnel; (iv) meeting the acute shortage of psychiatrists,
clinical psychologists and psychiatric nurses by developing the
Ranchi Mental Hospital into a full fledged training institution
additional to All India Institute of Mental Health, Bangalore and
(v) arranging that ultimately each region, if not each stafe, become
self sufficient in the matter of training its total requirement of
mental health personnel,
11
c.
Research: This is need in such subjects as : (1) causes of mental
diseases and disorders; (ii) factors which promote mental health;
(iii). personal and educational problems of children; (iv) the genesis
of unhealthy parent child relationships; (v) in association with
the practitioners of indigenous medicine, research into the treatment
of mental illness by ancient methods; (vi) possibilities of integra
ting psychiatric teaching into medical curriculum; (vii) malnutrition:
and (vili) suicide and crime.
3•4
SRIVASTAVA COMMITTEE:
The background to the functioning of this committee in
1974 has been referred to earlier in..,.The document PLAN FOR IMMEDIATE
ACTION does not contain any specific proposals for .developing mental
health programmes, as the purpose of this committee was to suggest
policy approaches rather than specific programmes. (Ministry of Health,
1974).
One of the important outcomes of this committee's
recommendation was the CHV scheme. It is relevant to note that the
training of CHV contains an element of mental health. Out of the
total training of 200 hours, one hour was kept for mental health. One
of the 12 chapters in the CHV manual also devoted to recognition
and management of mental he,, th emergencies ana problems. The
objective and the content of training material included in CHV
training is give; as APPENDIX, This step is very significant as
MENTAL HEALTH has been considered relevant at the most peripheral
level in the primary health care system,
3,3 A^A ATA CONFERENCE; (1978) This international conference in which
India took an active"part has come to be recognised as the turning
point in the organisation of health services for all. The term
'HEALTH FOR ALL' has become the focus of muoh activity and reorientation
of health programmes around the globe. In view of this the inclusion
of MENTAL HEALTH as part of primary health care by this conference,
as one of the eight essential components of PHC as follows:
The Conference,
Stressing that primary health care should focus on the main
health problems in the community but recognising that these
problems and ways of solving them will vary from one
country to another.
Recommends that primary' health care should include atleast.:
education concerning prevailing health problems and the
methods of identifying, preventing and controlling them;
promotion of food supply and proper nutrition and adequate
supply of safe water and basic sanitation; maternal and
child health care, including family planning; immunisation
against major infectious diseases; prevention and control
of locally endemic diseases; appropriate treatment of
common diseases and injuries; promotion of mental health;
(emphasis added) and provision of essential drugs.
(WHO, 1978).
12
A committment to primary health care in this sense calls for adequate
programmes and methods of mental health care,
The above review clearly shows that the mental health needs
have been in the minthe minds of the leading health professionals
during the last 4 decades though their implementation has been to a
varying degree.
4.
MENTAL HEALTH COMPONENT IN MAJOR PROGRAMMES:
FIVE YEAR PLANS
The last five year plans provide a glimpse of the
importance attached to the mental health services in the overall
development of the country as well as the measures taken to organise
services. The impression one gets on reading the plan documents is
one of relative low importance to mental health services.
4.1
FIRST FIVE YEAR PLAN:
Under the title’Mental Diseases’ the following observations
and provisions were made.
’Although little information is available regarding the,
incidence of mentr•: ill health in the country, there is
no doubt that mental disorder and mental deficiency are
prevalent on a wide scale, The number of persons suffering
from varying degrees of mental disorder who may not require
hospitalisation but should recieve treatment and those
suffering from mental deficiency is likely to run into
several millions. The existing provision for the medical
care of such persons is altogether inadequate and
unsatisfactory. Each state health administration, through
its mental health organisation, should attempt collection
of information. It is estimated that hospital accommodation
should be available for 8,00,000 mental patients but the
existing provision is little over 10,000 beds for the country
as a whole. Radical improvements are required in the
existing mental hospitals in order to make them conform
to modern standards. Provision should also be made for ajl
the methods of diagnosis and treatment. Apart from such
remodelling of mental hospitals, the Central Government
are upgrading two mental institutions, namely one in
Bangalore and the other at Ranchi, The establishment of
an All India Institute-of Mental Health in association
with the Bangalore Mental Hospital will involve an
expenditure during the five year period of Rs. 9.7 lakhs
non-recurring and Rs, 3,4 lakhs recurring. This expenditure
is to be shared between the Central.Government and the
State Government in Mysore, There are hardly any psychiatric
clinics, A beginning should be made in special and teaching
hospitals and later extended to district hospitals.
There
are no facilities for training in psychological medicine in
the country. It •'necessary that a certain number of
13
selected medical men with some experience of work in mental
hospitals in India should he sent abroad for training.
The provision made by the various states and the Centre
for mental hospitals are indicated below:
4.2
STATE
SCHEMES
____
EXPENDITURE
(in lakhs) (1951-56)
MYSORE
Mental Hospital,
Bangalore
5.00
SAURASTRA
Training in psychiatry
0.Q4
RANCHI
Mental Hospita,
Bangalore,
4.00
TOTAL:
9,04
SECOND FIVE YEAR PLAN:
There is no specific section that considers the problems of
mental disorders in the second nlan document. However, the psychiatric •
departments are included as fo.': ows under ‘MEDICAL EDUCATION1:
'The plan provides about Rs. 20 < ores for the expansion of
medical colleges and attached hospitals, establishment of
preventive medicine and psychiatric departments in medical
colleges, completion of All India Institute of Medical
Sciences and Schemes for upgrading certain departments of
medical colleges for postgraduate training and research’.
4.3
THIRD FIVE YEAR PLAN:
There is no separate mention of mental disorders under the
health section of the plan document. However an allotment of Rs. 25
lakhs have been made under the category of MENTAL HEALTH which is
part of medical care.
4.4
FOURTH FIVE YEAR PLAN;
In the plan document there is no separate section under Health
to look at the needs of mental health but a provision of Rs. 2.0 crores
was made under the broad Leading of Medical Care and the subheading
mental health. This is to compare with the amounts made to voluntary
agencies (Rs. 5 crores), dental health services (3.50 crores).
4.5
FIFTH FIVE YEAR PLAN:
The plan considered the needs of mental health under Health.
under subsection ’Rehabilitation centres and Psychiatric Clinics' as
follows:
14
’Rehabilitation programmes for the physically handicapped
and establishment of psychiatric clinics for the -mentally
ill will continue to receive emphasis during the Fifth
Plan'.
This was reflected in grant of Rs.. 50 lakhs to All India Institute of
Mental Health, Bangalore under the head of postgraduate medical
education. This amount was comparable to that given to V.P. Chest
Institute, Delhi, Dr. Rajendra Prasad Opthalmic Centre, New Delhi.
Under Centrallysponsorred schemes, ESTABLISHMENT OF
PSYCHIATRIC CLINICS figured under the other programmes alongwith
school health and an allocation of Rs. 1.0 crore was made,
The allocation of specific grants under the FIVE PLANS is
given below:
OUTLAYS FOR 'MENTAL HEALTH' IN FIVE YEAR PLANS
First Five Year Plan
Second Five Year Plan
Third Five Year Plan
Fourth Five Year Plan
Mental health
Estb. of Psychiatric clinics
Fifth Five Year Plan
A.I.M.H, Bangalore
Estb. Psych. Clinics
4.6
Rs. 0.094 crores
’ NA
Rs. 0.25 crores
Rs. 2.00 crores
Rs. 0.50 crores
Rs. 0,50 crores
Rs. 1.00 crore
SIXTH FIVE YEAR PLAN;
The Sixth plan in its planned targets includes the targets
to be achieved in the next twenty years ’to identify and provide
urgent treatment, to those with mental disorders as follows:
'Under the heading of Mental Health, 20% population
coverage is expected by 1985, 50% by 1950 and 75% by
2000 AD. This refers to case detection and treatment.
In addition, the proposed plan includes 64.23 lakhs
for control of drug abuses in the category of new schemes
arid 8,30 lakhs for NIMHANS Bangalore. There is specifi
cally no details regarding any starring of new hospitals
and psychiatric units'.
5.
DEVELOPMENT GF MENTAL HEALTH SERVICES IN INDIA;
The following sections deals with the historical development
of various types of mental health services .with special focus on the
way mental hospitals, general hospital psychiatric units? and district
psychiatric units have been
ganised. In a wa till recently the
growth and development of met-.al hospitals was the process of providing
mental health service delivery.-
15
5.1
Historically, the ancient Hindu texts contain many profound
insights into human psychology and mental health. Modern commentators
(Rao.
. Varma...,,,.., Neki......) have indicated that the
relationship between Guru and Chela is not unlike that between a
psychotherapist and the patient. From time immemorial rural
populations have sought relief for their mental and physical ills
by consulting those claimed to be able to commune with unseen spirits
and to invoke supernatural aid for the sufferer. For many centuries
the public have been served by practitioners of traditional Ayurvedic
and Unani systems of medicine. It is also appropriate to note that
Ayurveda was in possession and using a potent tranquiliser- Reserpine
for the management of psychosis for centuries prior to its discovery
and wider application by modern medicine in the 1950s.
5.2
GROWTH OF MENTAL HOSPITALS;
The historical development of mental hospitals has been
reviewed in a series of writings by Varma (1953a, 1953b, 1965, 1978,
1982) from which the greater part of this section is taken.
Hospitals in India were popular since the time of Ashoka,
the Great (274-235 B.C.) who organised measures for the relief of
suffering men by provision of herbs, roots and fruits. Mental
patients were treated alongw'th physically ill ones. There is no
specific mention of mental h ratals in the ancient. Indian writings.
None is mentioned by Caraka,Jivak (500 B.C.) practiced neurosurgery
and performed se ■ .ral operations on the .rain. Every monarch of
•repute established hospitals in his kingdom. Businessmen, nobles,
landlords, vied with one another to open new institutions and
leaving sufficient endowments for their upkeep and maintainence.
Still there is no mention of mental hospital except one at Dhar near
Mandu in Madhya Pradesh. This was established by Mahmood Khilji
(1436-1469) and Maulana Fazulur-lah Hakim was the physician. Certain
temples in the country specialise in sleep treatment, for example in
Tamil Nadu there are temples at Gunaseslum, Thirumuruganpondi,
Anumanthaparam, ThiruvidiamarutHur and Shlingur (Somasundaram, 1973).
Some Nazars have also this reputation.
Attempts were made to segregate the mentally ill towards
the middle and latter part of the 19th Century. Forsaken stables,
barracks and prisons were freely used and whenever necessary, high
walls were used to house the patients. They were left to the care
of the keepers and rods, confined by straight jackets, locked up in
cells and treated with rnorhia, opium, hot baths, and leeches.
Until 1905 all the asylums were under the charge of a civil surgeon;
in that year ’alienists5' were appointed to lookafter the insane.
This provision was the result of the efforts of Lord Morley, the
then Secretary of State of India. Although in general the conditions
of the mental hospitals were very unsatisfactory and the ’achievements
of the psychiatrists, barring a few notable exceptions, have been
practically nil' (Varma 1953).
16
The history of psychiatry in India is the, history of
establishment of mental hospitals arid then increasing their
accommodations from time to time as the exigencies o^ .time, demanded.
The first attempt to build a lunatic asylum was made, at
Bombay.in 1745 When orders were given, to construct at the cost of
Rs. 125 at the back of the hospital, No tra.ce.of,: this hospital is
: found'at a later date,' Trie second asylum was seen in falc.utta sin •
1787 which was meant for irisane Europeans. This asylum was,in a
poor state so the Assistant Surgeon, William. Pick, offeredrfo build
one at his own cost, He was permitted to do,.so, and the, .East India . '
Company agreed to pay him a rent of Rs, .400 pgr. ajonth. Some time.
later another was'rented for female'patients, This institution
served till 1817 when the surgeon Beardsmpre succeeded in getting
a new lunatic asylum built in the outskirts of Calcutta immediately
behind the Presidency General Hospital, It appears to.he a
beautiful hospital and the patients were' properly.looked after.
Every good thing has an end and a.o had t.h.io institution. It was
purely a private effort and Govt, took'ft'over and called it
Bhawanipur European Lunatic Asylum. In. ,1874, people, in Calcutta
could.see 'ten.or more horrible looking ipen pulling along the
streets a big scavenging cart', They were patients■from the lunatic'
asylum. This created to muc coinmotion in the press and parliament
in England that Government was forced to build a new hospital,
European Mental ” spital at Ranchi in 1913. The third lunatic
asylum was openea in Madras in 1793 whicu is.still in existence,.
The forth was started at Monghyr iii 1795 for.ithe Indian sepoys. '
This was closed in 1821 when the Patna Lunatic asylum was founded.,
Patna was closed in 1952. A number of institutions sprans up later
on and are still in existence. They were .situated at Varanasi which
was opened in 1809, Waitair in 1863, Nagpur in 1864, Agra in 1869.,
Trivandrum in 1870, Calicut in 1872, Tezpur in 1876, Ratnagiri■in 1866.
and Baroda in 1898,
During the later period of eighteenth century, lunatics were
considered horrible and were treated no better than wild animals who
howled at night and disturbed the peace and tranquility of the officials
and Government. As they were the most troublesome persons, everyone
was anxious to get rid' of them inside high enclosures round and<
dilapidated buildings that could be easily made available.In. the
absence of any better site, forsaken stables and barracks were turned
into lunatic asylums. If the superintendent was a humanitarian, he
rached his brain and made the best use of what he had. The/patients
were then comfortable. On the other hand, if he was only a civil
surgeon and an administrator with no interest in mental disease, the
treatment of patients was left to the keepers. These keepers were
lazy, illiterate and sadistic', ’ They, had no sympathy for poor patients
and employed all methods to torture their wards.
All lunatic asylum." were placed under the charge of a
civil surgi’on till 1905, when a special provision was made-which
created some special asylums. They wo.ro placed under the care o'
an alienist as the psychiatrists, were then.called. This was
definitely a major step forward as for the first time psychiatry
was. recognised as a speciality. Other institutions for the
mentally ill thus came into existence. They were Thana (1902)
Yervada (19’3), Trichur (1914), European Mental Hospital (19’8),
Mental observation ward, Bhawanlpur, Calcutta (1922), Indian
Mental Hospital, Ranchi (1925), Indore (1927). Gwalior (1935),
Bagla Unmad Ashram (.1935), Bangalore (1937), Jodhpur (1940),
Lumblr.i Park, Calcutta (1940), Bhavanagar (1942), Jaipur (1944)
and Amritsar (1947). The following nsmsr- stand out for their
contributions to the development and improvement of mental
hospitals in India. Berkeley Hill, Lodge patch, Honigfeerger,
Valentine Conolly and Dhujibhoy,
A complete list of the mental hospitals. in India at
this time as.well as the dates of their institution and the
current bed strength are given la APPENDIX AS TA.BLE VI.
5.3
GROWTH OF GENERAL HOSPITAL PSYCHIATRIC WITS:
The growth 'nd d -ci'-pr. :nt cf
j
psychiatr:
units in India has been considered ’an important change in the fie.
of psychiatry’ .Wig, 1978). Wig refen. to it as a alow add silent
changu but in many ways a iu.i.;6r revolution in the whole approach t>
psychiatric treatment in our lifetime (Wig, 1978). He has also
reviewed the historical development of this important development
alongwith raising questions that need to be answered in the. future
The Indian Medical Review (1938) referred to these early
units as follows; ’In Bombay there is a psychiatric clinic attache
to the J.J, Hospital, Bombay in the charge of an Honarary Medical
Officer, who runs it two days in a week. Bengal has a clinic
attached to the Carmichael Medical College, Belgachia managed by a
committee attached for this purpose. There is a small clinic
attached to K.G. Medical College, Lucknow, in the United Provinces
which is a sub-section of the medical outpatient department of the
college hospital and is in charge of the physician of that
department. No such clinics exist in the Punjab, Bihar, Central
provinces, and Herat, Assam, NWFP, Orissa, Baluchistan and Coorg*
(IMR, 1938).
Wig (1973) credits the starting of the first general
hospital psychiatric unit (GHPU) to Dr. Cirendra Sekhar Bose at.
R.G, Kar Medical College in J933, The second unit was opened in
J.J. Hospital in 1938 at BoigbtCy by Dr. IC.K.Masani., The other unit
of K.E.M. Hospital was begun by D :. Yt-hia, N.5. in the early
forties. Further centres were, opened by
at Lucknow in 1958 an
by Dr. J,S. Neki at Amritsar in 1958, Subsequently a large number
of rnneral hospital peychlr’Tie unit.;; cane -o ba established. It
IS
was estimated that there are 90 such’ units in the early 1970's.
A list of the known units of this type is given as Appendix.
(Sharma, 1976).
The introduction of these units as a method of mental
health delivery system has very important implications for the
development of mental health service in the-country. They have
given a big push to not only for the greater acceptance of
psychiatric services by general public but also changed the mental
health scene in terms of training of mental 'health professionals
and research work.
Most of these centres, in the initial phases started in
collaboration with neurology and were named as 'neuropsychiatric
clinics' and many psychiatrists had their training in neurology.
The existence of GHPU in the general hospitals, though resented.
initially as 'mental hospitals coming to general hospitals but
very soon was accepted as valuable partners in the total health
care system. The GHPU have a number of advantages over traditional
mental hospitals. Some of them are (i) they are situated right in
the community and they are more accessible and easily approachable,
(ii) families can easily visit, and relatives can stay with disturbed
patients, (ill) there is no ■
of mentet hospl,"'i_ (tv) there
are no legal restrictions on admission or treatment, (v) proximity
of other medical icilitieu ensure chore ;h physical investigations
and early detection of associated physical problems, All this has
brought new hope to patients.
The other most Important spin off has been the starting
of the postgraduate training centres. Notable among these are the
ones at Delhi, Lucknow, Chandigarh, Madurai and Bombay. As a matter.
of fact at this point the jadjor contribution of trained mental
health professionals has been from these centres more than the
two mental hospital based centres at Ranchi and Bangalore. It can
also be said that there is a qualitative change in the type of
medical personnel seeking to specialise in mental health profession.
The still more significant contribution of the GHPU has
been the research contributions. Wig (1978) estimated that nearly
75% of research publications in psychiatry in India in the last W
years have come from the departments based in these units, Perhaps
the general atmosphere of a university department in a general
hospital stimulates research activity. Notable also have been the
number of efforts made to understand the problems of treatment
utilisation (Srinivasa Murthy et al. 1974. 1977) and the involvement
of non-medical personnel for care of the mentally ill in the
community (Suman et al, 1980). Because of the limited in patient
facilities in these units, ambulatory care has become the norm laud
has further decreased the myth of mental illness being only
possible to be treated in closed mental hospitals,
There are a number ' research and sei vice is«ues that
have not been satisfactorily answered regarding the OHP units.
These are, the strfing pattern, bed strength. the management of
1'9
chronic patients, and the scope for outreach programmes.
Wig (1978) has rightly.summarised the current importance
of GHI’Us and the scope for .future development as follows; ’with the
coming of general hospital psychiatric .units, psychiatry has come.
of age in India. It has broken,the walls of mental hospitals but
it has yet to break the mental walls of'hospital based psychiatry.
to become larger community based mental health movement. As today’s
general hospital psychiatrist is a far cry from mental hospital
alienist of hundred years ago. similarly tomorrow’s mental health
professional will be considerably different than today's psychiatrist.
Perhaps a part of old psychiatry must, die if new mental health
movement has lo succeed. '.The 'old leaves must fall off if new
flowers, have to bloom.. Time appears ripe for evolution ..and change
to meet the future needs’,
A number of publications refer, to the development of the
GHPUs in. the country (Hrabhakaranj 1968, Parekh et al, 1968, Sethi
and Gupta. 1972, Khanna et al. 1974, Vahia et al, 1974, Wig and Shah,
1973, Wig, 1978, Sharma & Hussain, .1977. Malhotra et al, 1982).
5.4
DISTRICT PSYCHIATRIC V ITS:
the'de’’ lopment "sf district ps'chiatric units,.recommended by
a number of health committees notably tne Mudaliar Committee has been
very slow and uneven, at present every district in Kerala and Tamil
Nadu have a district psychiatric! units. Some of the districts of
Karnataka have, similar units. However the situation in other states ■
of India are very unsatisfactory. In Haryana only 2 of the 12
districts have psychiatric units, Himachal Pradesh has.it in only
one and situation is not any better in Punjab, Thus.it'is estimated
that of the nearly 400 district hospitals there are not likely to
be more than 40 such unite, i.e, in not more than 16% of the
district hospitals,
6.
MRRTAL HEALTH STATISTICS';
■
The availability of data relating of the magnitude of the
mental health problems as well as the current patterns of utilisation
of existing psychiatric services forms an essential base for all
future planning of .services. We have information on both these areas.
It was rightly pointed out both by the Bhcre Committee (1946)
and the Mudaliar Committee (1962) that nd correct estimates of mental?’.
Ill in the country are available^ In fact,' they used an estimate of
2 per thousand which is very much below the reposted figure's from
epidemiological studies done io the 1960s and 1970s, Prof. K.C.Dube’s
major epidemiological study paved the way to'systematic'study of the
prevalence of mental disorders in the country. Following this more
than a dozen studies Lave been carried from different parts of the
country. These have been e ellently reviewed by Prabhu (1981). The
overall impression, giving 'lewancc to t..e methodological problems,
20
is that mental disorders are not any way less in India as compared
to the West. The conservative figures for severe mental disorders
is around 2% (prevalence).
The information in regard to the adequacy or inadequacy of
the existing mental health facilities to meet the estimated numbers
requiring urgent help is not so satisfactory. As referred to in an
earlier section, in 1961, a statistical survey estimated that not
more than 2.5% of those requiring help are receiving the same from
mental hospital?. The currently existing agency to collect and
collate the information is the CENTRAL HEALTH INTELLIGENCE BUREAU
attached to the DGHS, New Delhi. This agency collects information
annually from the Mental Hospitals and publishes them annually
since 1970. The data from these publications have been put together
in the APPENDIX TABLE VI to provide an idea of the information
regarding mental hospital utilisation. Some coftiments regarding the
TABLE referred to above are called for. Firstly, it is tb be noted
that the collection of information is*not complete each year, for
example for the state of Maharashtra the data was incomplete every
year reported (something that should have been corrected by feed*back); Secondly the data collected only include the Mental Hospitals
and not the other mental health facilities like General Hospital
psychiatric units(more than 10'* in number), priv’.e nursing homes,
district hospitals etc. etc,
r. appears If
that these centres
are providing the care to the same extent or to a greater extent
than the mental ho , ifcals; Thirdly, the ar. lysis had been confined
to admission, discharge and deaths till 1977. It is essential that
broad diagnostic groups are used for presentation of data as has been
done in the 1977 report. However this important activity carried
out by CHIB is important to continue and the effort is commendable.
With the above elaborations and increasing efforts the available data
should help in further planning and evaluation of mental health
services.
In this connection, the ICMR supported workshop relating to
a standard approach to collecting minimum data from the different
psychiatric centres in a standardised manner, held at Chandigarh in
March, 1981 is of importance. The planned collaborative work should
take the available data base further and open new possibilities for
evaluation of services in the different centres (ICMR, 1981).
7.
MENTAL HEALTH MANPOWER AND TRAINING FACILITIES:
At the time of independence, there were only a handful of
psychiatrists and no organised facility for training of psychiatrists
in the country. The recommendations of the Bhore Committee led to the
establishments of ALL INDIA INSTITUTE OF MENTAL HEALTH at Bangalore in
collaboration with the existing Mental Hospital, Bangalore, in 1954.
From January 1955 the first postgraduate diploma in psychological
medicine was initiated. Since then a large number of training centres
have come up and the following is a brief account as to their development
as well as the current manpower position.
21
7.1
MANPOWER:
About 900 qualified psychiatrists are working both in the
Government and private practice settings. At this time there are
both D.P.M. and M.D. qualified persons functioning as psychiatrists.
400-500 clinical psychologists are working both in collaboration
and indpendently at different centres in the country. The number of
psychiatric social workers is estimated to be around 300. The
number of trained psychiatric nurses is about 600.
7.2
TRAINING OF UNDERGRADUATES:
Of the 108 medical colleges in the country, about half the
colleges have an Academic department of psychiatry. In another
quarter a psychiatrist functions as part of the general medicine
department with no additional staff. However, it is estimated that
nearly a quarter of the colleges do not still have psychiatrists.
The actual amount of training is grossly inadequate, as the minimum
amount of training required as per the Medicdl council of India
rules is only 2 weeks of training, Often this occurs in a distant
mental hospital. This lacunae in giving adequate exposure and
competence needs urgent attention. If: is noteworthy that this need
has been repeatedly expressed in a number of expert committees and
other iorums as reviewed in a earlier section.
7.3
TRAINING OF PT'CHIATRISTS:
In contrast to the undergraduate training, the postgraduate
training can be considered to be in a better footing. At present
about two dozen centres offer oppurtunities for training in psychiatry.
Both Diploma and M.D. programmes are available. The location of the
training centres as of 1981 is given as a map in APPENDIX
The first training course to be started was the DPM course at
Bangalore in 1955. Twelve students were taken for this course. The
All India Institute of Mental Health (AIIMH) was initially affiliated
to the Mysore University and subsequently in 1966 got affiliated
to Bangalore University. The seats for D.P.M, were increased to 15 in
1961-62, In 1966-67 M.D. course in psychological medicine was started
with four candidates. The number of M.D, seats were increased to 8 in
1978-79, The other major centre where postgraduate training is going
on are at Delhi, Chandigarh, Lucknow, Madurai, Bombay, Madras, Vellore.
Varanasi, Calcutta, Ranchi, Goa and Trivandrum (APPENDIX......... for
complete list and distribution). It is estimated that about 100
psychiatrists are trained from different centres annually.
7.4
TRAINING OF CLINICAL PSYCHOLOGISTS:
The first programme of training for diploma in Medical (Clinical)
Psychology was stated in January 1955, at the AIIMH, Bangalore. Currently
it has a 2 year programme. The training programme was changed to Diploma
in Medical and Social Psychology (DMSP) in the year I960 and since 1978
it is referred to as M.Phil in medical and social psychology.
Twelve tra|nees are taken every year. Over the last 25 years hbout
300 candidates have qualified as clinical psychologists. This
"ivititute referred to as NXMHANS since 1974 has a three year Doctoral
course in clinical psychology since 1967 and takes two candidates for
this training. In addition, post-diploma doctoral programme is also
available. The only other centre Offering training in clinical
psychology is at the Central Institute of Psychiatry, Ranchi;
7 •5
training OF SOCIAL WORKERS (PSYCHIATRY).:
Training in psychiatric social work'-is available both at
the NIMHANS, Bangalore and CIP, Ranchi. The diploma course was
started at Bangalore in" 19.67, . which is of two years duration.. In
1970 CIP, Ranchi -instituted a similar programme, Currently-'.it
is known as the M.Phil programme. Every year a group of 8 students
are taken in NIMHANS, Bangalore. So far about 50 have been trained
at Bangalore.
In addition to 'this a number of schools of social wo'rk ’
provide training, in Masters in Social wbrh with a special paperon psychiatric social work.
l,f>
TRAINING TN PSYCHIATRIC
RSING:
The first .liploma in Psychiatric! Nursing course was started
at AIIMH, Bangalore in 1956. This was a one year course and offered
as a postbasic diploma in psychiatric nursing (DPN), The first batch
consisted of 15 nurses from different parts of the country. The DPI'
programme is available only at Bangalore. So far. 6Q0 persons have
received training. The Institute NIMHANS also carried out a 9 month
course, Certificate Course, in psychiatric nursing for men nurses from
1962 onwards (Reddentma, 1982).
There is provision for a two year postgraduate course (M.Sc.)
in psychiatric-nursing at'Delhi and Chandigarh, At present the
number of psychiatric nurses with postgraduate qualification are only
a handful. There are plans -to start the M.Sc. course at NIMHANS,.
’Bangalore from 198.3.
7.7
Till 1981 there was no opportunity for any advanced .training in
the area of community psychiatry in the country.. However, in‘JulyAugust, a six week course was offered for mental health professionals
for EXTENSION OF MENTAL HEALTH SERVICES IN THE COMMUNITY. A group of.
7 mental health professionals took part in this training programme.
This training was supported by the Indian Council of Medical Research,
New Delhi.
This planned annual training programme hopes to .provide
opportunities for advanced.training to-mental health professionals
and increases the know, how in the area of- ccmAitui.it:v psychiatry
(ICMR. ,1981).
■ Similarly'training courses in. child psychiatry, psycho
pharmacology, forensic, psychiatry, psychotherapy have been
considered to bo required bur.ut present those interested, have
to seek training outside the country -
The situation in'regard to manpower development and
training has.been reviewed by Neki (1973). It has also been one
of the repeated recommendations of the expert committees. The
postgraduate training-facilities' can be considered to be in better
position than the undergraduate, training in psychiatry. However,
the hope that all mental health.training could occur at least
within the regions of the country expressed by the Mudaliar
Committee remains a far dream.
8•
1:01,5 0F IMDIAK PSYCHIATRIC SOCIETY:
The Indian Psychiatric society as.the official organisation
brining together the mental health professionals together has been
actively considering the needs in the area of delivery of mental
health services. These have been reflected in the various resolutions,
workshops held and the Presidential addresses. The following is a
summary of the major actions and'activities cf rhe society, in this ■
ares.
8.1 Historicallv. the Indian Psychiatric Society can Ke traced to
1936 when sanction was obtained for the formation of the INDIAN
DIVISION of the. Royal Medico-psychological Association in 1936.
However there was some delay in actually getting the Division
started and the first meeting was held on 23,2.1939, The scientific
session included three papers namely (i) a century of psychiatry in
the Punjab by Lt. Col. Lodge Patch; (ii) a bird's eye view of
Australian Psychiatry by Dr. Banaraei Dot and (iii) a plea for neuro ;
psychiatric clinics by Dr. K.N.H, Rlzvi. The concern for the care of
the mentally ill and improving treatment facilities is clear from
this scientific Session (TPS, 2978).
8.2
The growth and development of the Indian Psychiatric Socie'v
has been the subject matter of a number of papers and it will not beconsidered in detail here, (IPS, 1972, IPS, 1978), It is important
to note that from a handful in the late 1340s currently the membershir.
has crossed 600. In 1893 India had only one psychiatrist, it took a
quarter century to raise this number to 5, but the growth from.then
on has been rapid, though far from adequate even now.'
8.3
One of the first activities to be. taken up by the TPS was
the revision of the Indian Lunacy Act 1912, In addition, the need to
have a Central Health representative was felt strongly, as is
reflected by the Presidential address c.C Col. Kirpal Singh*.,it
appears necessary that a Directorate. of Mental Health should be
created at the Centre tinder the Director General of Health Services.
This Directorate should be responsible for raying down standards for
the various mental health ir titutions in the • nuatry and for
24
enforcing the same. Besides, this, Directorates of Mental Health
are necessary in the states so as to enable the planning, organi
sation and direction of preventive mental health and psychiatric
clinics and institutions for a large category of patients who do
not suffer from insanity, and therefore, do not need to be
admitted to a mental hospital (1959).
8•First Conference of Superintendents of Mental Hospitals in INDIA;
This conference was held at AGRA on the 25th and 26th Nov.,
I960. The conference specifically examined the draft Mental Health
Bill and recommended for its adoption. In addition the following
resolutions were passed, which have relevance to the area of delivery
of mental health services (Min. of Health, 1960).
Resolution 3: This conference emphasises that it is necessary for
selected medical auxiliaries working in the medical and health
institutions to be given a short period of training in psychiatry
after their normal training, Short training courses of 3 months
may be arranged at training centres which already exist and or
which may be set up in future.
Resolution 5: The attentfo given to peychclogy uad psychiatry
in the present medical courses considered to be insufficient. The
casual visits L. a mental hospital are tot obviously likely to give
the undergraduate sufficient knowledge of the subject. Without
increasing the duration of the medical course, the curriculum may
be reviewed and improved and strengthened.
Resolution 7: This conference viewing with concern the poor standards
obtaining in moat mental hospitals in the country considers (i) that
the improvement of the existing mental hospitals e.g. remodelling
and modernising the buildings, provision of improved treatment
facilities and amenities, provision of adequate staff etc. is the
most important need of today and should be given the highest
priority in the National Planning during the Third Five Year Plan;
(ii) that hospitals for chronic patients with wings for mentally
defectives, senile and epileptic patients should immediately be
set up; (iii) that psychiatric clinics and psychiatric wards be
added to general hospitals and hospitals attached to medical
colleges, There should be atleast one clinic for each district.
Such clinics and wards should be in charge of qualified psychiatrist.
Resolution 10: This conference recommends that an Adviser in Mental
Health be appointed by the Government of India in the-Ministry of
Health to advise the Government on mental health and similar Advisers
be appointed in the states also.
Resolution 13: This conference recommends training of Child
Psychiatrists from among qualified psychiatrists and the establi
shment of mental health services for children and adolescents such
as child guidance clinics, Mental Health Services in schools and
Colleges; youth counselling., premarital councelling, and Marriage
Guidance Clinics.
Resolution 15; This Conference recommends that Government sponsor
health education in the field of mental health.
8.5
Standing Committee on Public Education in Mental Health;
This is a committee of TPS which submitted its report to.
the Executive Council on.10.11.1964. The Committee noted that
there are 15,000 mental hospital beds and the total number of
patients treated annually in these hospitals doen not exceed
30,000. If to thia is added the figure of 90,000 individuals
treated as outpatients, even then th?, total strength of individuals
receiving expert help for mental disorders does not come, to more
than 2.5% of those who need it (St'ii’istical .Abstract, 1961). The
Committee went on to make the-fol.lowing observation:
’Even if almost all the five y-aar plan effort in the fields
of health were gen; 1 to lucres«»•**><> ti.e •-■whcr of psychiatric
doctors, it would be impossible co provide an adequate
number
hospital beds and mar al specialists in the next
50-10Q years ...... even if the training facilities in the
country are doubled and tripled, which is not easy, it
could still require 100 years to provide an adequate number
of psychiatrists for working in the curative field’
(National Committee for World Mental Health Year i960).
The cumittac noted that 'it looks we are confronted with
an impasse; and adequate arrangements fot locking after the mentally
sick will always remain beyond our right. Should we not then, gear
our resources to preventing mental disorders, if we see little
possibility of being able to cater for adequate treatment facilities:
and preventive mental health programme seen to be the answer to.
present impasse in Che field of psychiatry'-.
The Committee surveyed the situation as it existed and
recommended the following activities FOR EXTENSION OF THE PRESENT
ACTIVITIES : (i) raising the standards, of care in the mental
hospitals, (ii) opening the hospitals for preventive usefulness,
(iii) group discussions with,convalescent patients and their
guardians; (iv) improving the involving-ofathe general public'in
the work- of mental..hospitals, (v) educational activities directed
to undergraduates, general practitioners and other personnel and
(vi)
use of public press, platform, radio and cinema for public,
education.
26
The Committee outlined the following activities as FURTHER
AVENUES; (i) Incorporation of mental health with public health,
namely the task nof public health workers should include not only
the spotting out of actual cases of mental illness but also to get
some idea of the conditions which still act as protective and
preventive surroundings and of the weaknesses that are concealed
by them; further although the services of specialists will be
required where any manifest mental trouble has broken out, a public.
health worker should be prepared to administer ^psychiatric first
aid in cases that need it; he can moreover function as a useful
link between the psychiatric service and the community; (ii) mental
health services in district hospitals; (ill) involvement of
psychiatric hospital staff in community welfare activities like
parent teacher activities, social welfare activities.
The task of IPS was considered to lie in providing
leadership, creating llason and coordinating activity, assisting ,
in organising orientation courses, and stimulating public awareness
by measures like’Mental health week' , arranging mental health
exhibition (IPS, 1964) ,
The above recommendations of IPS was very comprehensive
indeed and alongwlth the recr mendations of 'Mud;-Liar Committee could
have acted as a blue print ft organising L.-ntal bt-alth service.
However this did not occur in the next few years is reflected in
the Presidential .-dresses of Dube (1966) and Bhaskaran (1970),
Dube (1966) noted:
’..Since the recommendations of the Bhore Committee very
little has been done in the first Three Five Year Plans for development
of mental health activities, and mental hospitals have not yet caught
the eye of the planners. It is a dismal picture. Inspite of all the
g.dds and little help from the state, the enthusiastic administrators
of mental hospitals have helped to improve the atmosphere in the
hospitals within their limited resources,..there is a very urgent
need to improve those institutions at once. With all the force at
my command I plead for placing this development on the highest
priority. I believe for a long time to come, mental hospitals will
remain the nucleus of mental health services *,
Bhaskaran (1970) had the following specific suggestions with
a wider coverage;
'...from the.point of view of concrete action in the field of
rehabilitation of the unwanted chronic, mentally ill with particular
reference to our country, the following steps are suggested
immediate measures; (1) scrapping the Indian Lunacy Act of 1912 and
replacing it with a more humane and progressive legal code; (ii)
launching pilot projects in the. home care of schizophrenic patients;
(ill) establishment of sheltered workshops in association with mental
hospitals and independently in the community; (iv) establishing
hostels for ex-patients; (v) training a cadre of social workers and
public health nurses for the b.ter care of chronic df.-xh5.rged patients;
27
(vi) developing broad based psychiatric facilities for both
outpatient treatment and inpatient treatment on a short stay
basis in close association with a view to preventing chronicity;
converting
(vii)
the custodial type mental hospitals into dynamic
therapeutic communities and using them as only waystations in
a comprehensive community mental health service net-work; and
(viii)
a great degree of committment on the part of psychiatrists
in the matter of rehabilitation measures for the chronic patients
and providing bold imaginative leadership in launching new
projects’.
8.6
At the turn of the 1970s a number of Presidential
addresses were addressed to this important area of delivery of
mental health services. Before looking at these, it is relevant
to take note of the recommendations of an important INTERNATIONAL
WORKSHOP ON PRIORITIES IN MENTAL HEALTH CARE held at Madurai from
21 to 22 January,1971 by ths joint collaboration of IPS and WFMH.
The recommendations of this workshop are as follows (IPS, 197-1):
'(i) Cases of mental and emotional disorder are very
numerous, and trained professionals in this field are
very few; hence, mental health care must be given by
many other types of workers, including (a) general
practitioners and -idical officers; n) nurses, health
visitors and midwives; (c) social workers, including
volunt y social workers and g im sevaks and (d)
government and voluntary agencies. ALL OF THESE WORKERS
WILL REQUIRE INSTRUCTION IK MENTAL HEALTH AND MENTAL
ILLNESS, SUITED TO THEIR LEVEL OF PROFESSIONAL TRAINING
(emphasis added); (ii) members of the familities of
the affected patients should also be instructed so that
they can help in the management and after-care of
patients; fill) the recognition and treatment of mental
disorders should be part of the work of the curative
health service in primary health centre,in district
hospitals and in general and teaching hospitals; (iv)
there is still a place for mental hospitals, but they
should be centres of active treatment of severe and
chronic cases, In order to improve the standards of care,
they should have more trained staff, When new mental .
hospitals are built, they should be kept small in size and
their work should include outpatient clinics and after
care; (v) there is a need for early recognition and
treatment of emotional disturbance and retardation in
school children; (vl) the present Lunacy Act (1912) hinders
humane and effective care of the psychotic patient, and
should be amended in accordance with suggestions of IPS;
and (vii) there should be a full time adviser on Mental
Health at the Central Govt, level and/or at the Directorate
of mental Health Services, to coordinate plans and
implement them. In the same year Bagadia (1971) in his
presidential address noted that the mental health services
available at prese
in the community do not even touch
the fringe of the ^zouxem. He called wr setting of general
hoapitr' psychiatric units apa^t from teaching hospitals.
.
;
28
every hospital in‘the city an'4‘ every district hospital should have
a psychiatric department! The' following'year, Dr. S.S.Jayaram (197’:)
put forward his- ideas 'The following methods .can be put into effect
here and now in our country to integrate psychiatry, and general
practice'. " He focussed, ph the; role of the general practitioner in
the total mental health care system. , The following Presidential
address by Dr. Vidya Sagar (1973) expressed the opinion that 'there
should be qualified psychiatrists at the District Hesdquart<zrs..,. .
hospital and later st the sub-divisional hospital5. He also felt
that 'the basic doctor working at the PHCs and in1general practice
have to be sufficiently informed in psychiatry, as they.Are in the
diseases of the eye, ear, nose and throat, so as to be able to
diagnostpsychiatric illnesses and treat most of them and refer othe-'s
to the psychiatrists at the referral and Headquarters Hospital’,
8.7
The Indian Psychiatric Society organised two workshops in
1975 and 1976. The Trivandrum workshop was devoted to the subject
of paraprofessionals in mental health care arid the Nagpur workshop
was focussed on Rural Psychiatry'
.
8.8
Review of the concern expressed and the avenues suggested
by the members of the Indian Psychiatric Sc;J.cty speak a uniform
language for the extension of mental health services to most of the
people as soon as possible. Further, the various suggestions have
called for varying degrees o' decentralisation .rid deprofessionalisatiot),
9.
ICMR RESEARCH RELATED TO DELIVERY OF HEALTH SERVICES:
The Indian Council of Medical Research, New Delhi has been
actively supporting research related to the prevalence of mental
disorders as well as organisation of.mental health services in the
country.
9.1
One of the first major epidemiological study in India was
carried out by Prof. K.C. Dub.ri with the support of the ICMR, New
Delhi. This study initiated in 1964 and published in 1970 (Dube, 1970)
was a major one in that for the' first time the estimates regarding the
prevalence of severe mental disorders was made Available. As it
happens the prevalence turned out to be nearly 10 times, that assumed
by the Bhore Committee and the Mudaliar Committees for making their
■recommendations. Similar has been the result of the.epidemiological
study carried out by Prof. A, Varghese,in the Vellore town. This'
study was of equal significance as greater effort was directed to
find the exact amount of neurotic disorders. Thus, we,have a much
higher figure for the prevalence of neurosis from this study. This
study also made the- unique contribution by carrying out a survey of
■children for the first time.
9.2
In the Mid 1970s ICMR brought out a book on Drug Abuse in
India compiling all the data relating to the work on drug abuse in
jfldia. ■ This also outlined the needed action to meet the problem.
29
9.3
The next major Initiative from JCMR was the formation of
an Advisory Group on Mental Health. This group of senior
psychiatrists met. for the first time in July, 1979. This group
reviewed the current status qf research in mental health and
identified the broad areas that need to be taken up for further
research work. One of the mechanisms suggested by the Advisory'
Group is the formation of TASK FORCES and Working Groups on 7
areas. The purpose of these were to bring together a group of
interested professionals working in that area to formulate
detailed proposals for support by the Council. One of the
working groups was devoted to the ’DELIVERY OF MENTAL HEALTH
SERVICES’.
9.4
The working Group on Delivery of Mental Health Services
tact on two occasions and outlined the heeds in this area;, Besides
focussing on the needs, two specific proposals to train mental
health professionals and general practitioners were recommended
for support, These proposals alongwith others from the other
Groups was considered by the Advisory Body in October, 1980 and
s final list of specific project proposals were selected'for ~
immediate support, .Of those selected both the proposals from
the Delivery of Mental Health Services group were chosen.
9.5
The ICMR training course on EXTENSION OF MENTAL HEALTH
SERVICES IN THE COMMON IT' vas carried out 1 . the month of JulyAugust (6 weeks) at Bangexore, Chandigarh and Delni* Seven
persons from ’ ffererit parts of the. country took part in this
training course. This training provided the trainees an
oppurtunity to become personally acquainted with the ongoing
community psychiatry projects at Chandigarh and Delhi, meet
the investigators and research staff in these areas, and examine
the areas for future work, as well as an oppurtunity for the
Centres to view the ongoing work from unbiased professionals
point of view. The training course has been valuable and one
of the reflections of this is the specific proposals developed
and sent by the trainees to the ICMR for support soon after the
completion of the training (ICMR-, 1981).
Further work initiated from the trainees in their own .
centres will be of Interest.
9.6
The training of the General practitioners project based
at Bangalore, Vellore and Hyderabad i.s in progress.
9.7
The other major projects initiated by the Council in
collaboration with, department of Science and Technology la the
mulricentered study on 'SEVERE MENTAL MORBIDITY*. This is located
at Bangalore, Calcutta, Baroda andfi»/W<L•, It has reached the stage
of intervention and the results are awaited.• The focue. of work
in this project is the evaluation of effectiveness of basic health
workers and PHC doctors to carry our. mental health tasks alongwith
the general health care. A number o” research .tools for studying
public attitude, measuring social functioning and identification
rr mentally ill in the c auairy have beer, leveloped/
30
Thus the contributidh of the Council has been Bignifics.nl ,
especially welcome is tfye renewed Interest in operational research
and training.
10.
WORLD KEALiJ! ORGANISATION MEETINGS AND RECOMMENDATIONS :
10.1
During the last 10 years the Regional Office of the WHO,
has conducted a number of workshops to examine the needs of the
region and possible approaches to the organisation of. mental iieau.:i
services. The first of these is a series of Seminars on’place of
psychiatry in Medical Education1' held in 1969, 1971, and 197?..
These seminars recommended that (i) psychiatry must be given a
legitimate place in the medical curriculum as an independent
discipline; (ii) in the clinical years there should be at least
60 hours of clinical instruction; (iii) practical clinical
experience is an essential feature of psychiatric instruction and
the teaching specified should be followed by clinical clerkships
of a month’s duration and (iv) psychiatry should be taught
properly, with appropriate facilities in the medical college
itself.
10.2
The Seminar on the ORGANISATION AND FUTURE NEEDS OF
MENTAL HEALTH SERVICES CV1) reviewed the existing services
and recommendations for . .'ture organic-tior, In yiew of the
limited specialist help, in planning future mental health services
particular attention should be paid i.o the needs of the most
gravely disordered, the psychotic and severally mentally deficient
persons. Ideally, if those in need of the services.were to
receive proper cere the services should be developed on a massive
scale. However it was felt that the planning should be realistic.
and economical, initiating low cost developments and in this
connection due emphasis should be placed on the expansion of
community services as a means of reserving the more costly hospital
services for the care of those requiring specialist treatment.
It was also noted that there was no current uniform pattern- of.
mental health care which would be acceptable for general
application to the widely varying geographical, social, cultural
and economic conditions encountered in different parts of India.
Thus there was clearly a need to experiment with different ways of
delivering mental health care to the rural areas. The participants
noted that one of the most important elements in the supply of
health care in India is the Primary Health Centre (PHC). Upto
now PHCs have not been developed to their full potential, but
as trained staff and supplies become available they will become
increasingly important elements in the delivery of health care,
and as soon as possible, the opportunity should be taken to provide
mental health care at and from these centres, through the multi
disciplinary mental health team and by the_use of other available
staff such as government medical Officers, nurses, family planning
workers and basic health workers who hove undergone suitable trainin;
In regard to th' role of mental hr.pitals, it was felt
although changing patter -s of hospital care in cartain parts of
the world may indicate that the role of mental hospital in the
31
overall service may diminish, it was considered that in India,, the
mental hospital would continue to form an important part of the
service, for sometime to come. Certain mental hospitals are grossly
overcrowded and in some areas no mental hospitals exist. The aim
should be to improve the conditions of those mental hospitals which
are overcrowded and in addition provide new mental hospitals of
limited size, say of: TOO to 200 beds, in areas which are demonstrably
deficient in beds for long term cate,
The needs of the mentally retarded was viewed as follows;
'for the mentally retarded, as in the case of the mental illness,
greater emphasis should be placed on developing services within the
community rather than in a hospital setting. The problem of caring
for the retarded is not primarily a medical, one but must involve
education and social work, as-well as the health services, Th'e aim
should be to improve existing homes and develop further residential
or day care facilities in association with the departments of
education and social welfare,
10,3
The Seminar on 'CCMMUNITT ACTION. FQR MENTAL HEALTH CARE* held
at Bangalore from October 26 to November 2? 1973 .(WHO 1974) reviewed
the situation especially the innovative approaches and the needs for
training of medical and paramedical personnel, The seminar urged for
the organisation of pilot pro acts at the different levels of care
in order to evolve efficient yatem of integrated services. It also
called for the identification of different categories of personnel
other than physicians and development of .'suitable training programmes.
It was also felt that the role of traditional healers in augmenting
the community mental health-services should be evaluated,
!
I
10.4
An important document relating to the delivery of mental health
services titled 'ORGANISATION OF MENTAL HEALTH SERVICES' IN DEVELOPING
COUNTRIES' was produced as a Technical Report (No, 564, WHO) in 1975.
This was the result of the deliberations of a group of eminent
psychiatrists as part of the Sixteenth Expert Committee on Mental
Health. The document lays down many important guidelines. Some of
the most important are:
Resolution No., 4; The Committee recommends that mental healthobjective;
should be defined in early country taking into account the natureextent
and consequences of mental disorders and the resources available, The
objectives should be realistic and should be formulated in terms of
health effect or service delivery to be achieved for a stated proportion
of the population in a defined area within a stated time.
Resolution 5i To achieve these objectives, the Committee recommends
decentralisation of mental health services, integration of mental
health services with agencies, Decentralisation of mental health
services implies that mental health care should be made available at
the community, district and regional levels through psychiatric inpatient
and outpatient units linked to the general medical facilities. The
creation of large mental hospitals should be discouraged and where Jjhey'
already exist the prime consideration should bo. to ensure that the staff/
patient ratio -allows .adequate-treatment, care and rehabilitation'.
They- should be supported by. a. network of- other services/as described
in this report. Integration of mental health care into the general
health service •“r£EJ.2_5?’a£health component should be
incorporated into the rwork , o-f the primary health worker,, the communit_y
health centre, district and regional health centres and hospitals.
Collaboration with r.onmedical community agencies means that.the
contribution of community agents such as religious leaders, teachers,
development workers, the police and the various associations should
be sought and that mental health professionals should devote part t-f
their time to the mental health education of such workers in.the
community in order to make such a broad approach possible.
The committee further spells out the needed changes to
implement the above:
Resolution No, 3: The committee recommends that governments make
adequate financial provision for the following programme: (a)
recruitment, training, and employment of personnel^ (b) adequate
provision of drugs; (c) a, network of facilities, Including transport;
•and (d> data collection and research. In the developing countries ’
trained mental health professionals are very scare indeed - often
they number less than one per million of the population, Clearly,
if basic mental health care, is to be done hy non-specialibed health
workers .at all levels, fror the nrimarv health worker to the,nurse
.or doctor working in-collaboration with and supported by more
specialised pei onnei. This will requ -e. changes in the roles snd
training.of both general health workers and mental health professional;
The implications for the training and. functioning of
professionals is .outlined as follows;
Resolution-No, 10: The.committee recommends that specialised mental
health workers should ..devote, only a part of their;working,hours to
•the clinical care of the patients; the., great er par.t of their time
should be spent in.training and .supervising non-speefalised health
workers, who will provide basic health.care in the community. This
will entail significant-changes-in■the role arid training of the
mettal; health professionals.
•Resolution No. 11: The Committee therefore, recommends that the
training of mental health professionals should include instruction
and supervised experience in this new task of training and
supporting non-specialised health workers. There will also, be need.,
to provide training in mental health service administration' for
personnel down from the various disciplines involved in these
services. In the view of the.Committee, there is still and will
■remain for some years, a pressing need for the recruitment and
training of additional mental health professionals' to carry- out
these new roles.
33
Resolution No. 13; The Committee recommends that steps should ba taken
to reduce the cost of drugs, to make them more readily available, and
to ensure that they are correctly- used.
In addition the other.recommendations refer to the need to
alter legislation, collect relevant data and carry out appropriate
research.
The above summarised recommendations are very relevant and
important. In this document we have a commitment to basic mental health
care outlined as well as the necessary steps to be taken. Thus the
committee has clearly pointed out the importance of PRIORITIES, the
need for DECENTRALISATION of the services and the involvement of all
categories of health and welfare personnel (DEPROFESSIONALISATION).
Further it has outlined the needed ROLE CHANGE and FUNCTIONING of
the specialist mental health professionals. The other requirements
like the drug availability, the legal changes and the research
commitments have all been given due recognition. Thue, this forms
a very important document as a guiding Instrument for planning
mental health services.
10.5
Further commitment to mental health was reflected in the
International Conference on PRIMARY HEALTH CAR" at Alina Ata in 1978.
The-document of this confers <:e titled HEALTH 1*OR ALL outlines a '
number of recommendations. As pointed out in greater detail in an
earlier section •... ). the elements of p- imary health care include
PROMOTION OF MENTAL HEALTH. Thus the -commitment to mental health
care at the primary health care is very strong indeed. Indeed, as
agreed to in the Alma Ata declaration, the member signatories are
bound to take steps to fulfil the goal of Health for All by 2000,
India is one of the signatories to the above goal.
1
10.6
A number of other WHO meetings have further supported the
above approaches in their deliberations. Notable among these are
the following documents from these meetings: Consultation on drug
treatment of neuropsychiatric disorders in developing countries
(1976); Child mental health and psychosocial development (1977);
The application of advances in neurosciences for the control of
neurological disorders (1978); the promotion and development of
traditional medicine (1978); and Training and utilisation of
•
auxiliary personnel for rural -health teams in developing countries
(1979). in addition to these the WHO convened a STUDY GROUP ON
MENTAL HEALTH CARE IN DEVELOPING COUNTRIES in 1981. This meeting
reviewed the work done in the proceeding years from the time of
the 1975 document ("organisation of mental health services in
developing countries) was prepared. The report of the study group
should be very beneficial for future planning of services.
11■
INNOVATIVE APPROACHES TO MENTAL HEALTH CARE:
11.1
During the last 40 years, specifically in the last two decades
efforts have been directed to meet the shortage of facilities of trained
personnel in a number of inn native methods. ..ome of the important
34 .
..
ones are (i) involvement of family members in the care at
Amritsar, (ii) use of traditional methods of therapy like Yoga
at Bombay and (iii) alternative approaches developed for the
care of university students and school children. In addition
the two major systematic efforts.to integrate mental health
with general health care at Bangalore and Chandigarh have broken
new ground. These innovations simple in themselves, by their
novelty and appropriateness to the National context make it
possible to reach a larger section of those requiring urgent
psychiatric help. A brief account of these efforts and their
current status is given below:
11.2
INVOLVEMENT OF FAMILY IN PSYCHIATRIC CARE;
The major credit for considering this step to open the
gates of mental hospitals to the family members goes to Prof.
Vidya Sagar. He undertook this work at Amritsar Mental Hospital.
It arose as a result of his deep commitment to keep the status of
the mentally ill person intact through the illness as well as to
meet the shortages in facilities. This experiment and innovation
is best read in.the words of Prof. Vidya Sagar (APPENDIX...,).
The following is summarisation by Prof, G.M. Carstairs who has
been very familiar with the above work (Carstairs,, 19.74) .■
’..'.in the mid-x 1 — co Dr.' Vidya Sagar kjuK steps to
change the public image in that institution (Amritsar Hospital),
He had observer that patients were brought for admission only when
their mental illness was already long standing and when their
relatives had despaired of their ever recovering. Indeed,
relatives often made a long journey to bring a patient to the
hospital and were prepared to abandon him (or her) there- forever.
Dr. Vidya Sagar encouraged the relatives to stay, and pitched tents
within the hospital grounds for their accommodation. He also
encouraged them to participate in the daily nursing care, of the
patients, and by so doing to learn about their medication and find
out how to manage them. In the evenings, Dr. Vidya Sagar addressed
large meetings of patients and their relatives, in talks which'
outlined the principles of sound mental health and gave simple
descriptions of mental illnesses and how they could be treated,
His addresses were couched in the style of sermons of religious
teachers, with whom these country, people were familiar.
Eventually, his tents were replaced by simple stone houses, with
sanitary and kitchen facilities. The rumour began to spread round
the country Side that patients could be greatly helped, if not
cured, and that in many cases they could return to live in their
own villages. With this hope, families began to bring patients
at a much earlier stage of their illness and the frequency of
early discharge became correspondingly greater. Instead of being
a place of dread, associated with life long incarvation, the
hospital had become a renowned centre for active treatment and
for public Mental Health Education. *•
Similar attempts wore initiated at Vllore in the early19bds where family treatmer.' has be®-! a .'.cditi-- _11 along in the
last two decades. Specific research efforts to examine this approach
of care was undertaken by Narayanan et al (1972). At present
most general hospital psychiatric settings utilise this potential
of the families in the treatment of the mentally ill (Kohlmeyer,
1963; Chacko, 1967; Varghese, 1971; Narayanan, 1977; Geetha et
al, 1980; Bhatti et al, 1980, 1981).
11.3
TRADITIONAL METHODS OF THERAPY:
Significant effort to evaluate the utility of utilising
the long-known Patanjali system of Yoga for the treatment of
psychiatric problems has been undertaken by Vahia and his
colleagues (Vahia et al,1973, 1973b, 1977). Earlier attempts
were made to examine the utility of Ayurvedic and other drugs
by Hakimet at al (l<?5’3) but this work was not brought to a stage
to gain popular acceptance by the professionals. Currently,
efforts are underway at NIMHANS, Bangalore to evaluate the
Ayurvedic methods of treatment in the treatment of mental
disorders. Initial results are interesting (Mahal et al, 1976,
1974). The following section deals with the work of Vahia and
his colleagues. ( yfefow al, W?h MW /
Vahia and his colleagues carried out a series of studies
to evaluate the effectiv ess of patanjali system of Yoga. The
first experimental design included 102 patience in whom 50%
improvement v- a noted in 70% of the patients. In the next design
of double blind controlled trial 15 patients were studied. The
third stage of investigation was a double blind trial with a
drug with 33 patients. The results are promising, However there
has been limited extension of this very important revival of an
ancient method of therapy with relevancefo India (Balakrishna
et al, 1977),
11.4
SERVICES FOR STUDENTS AND SCHOOL CHILDREN;
The problems of University students and their mental health
needs have been the subject matter of a number of investigations.
This has been reviewed recently by Prabhu (1981). Using different
diagnostic criteria Thacore and Gupta (1972) and Aggarwal (1973)
found widely varying prevalence-rates among medical students ranging
from 1% to 31,3%, The nature of problems were personality
disorders, adjustment problems and anxiety related problems.
Wig et al (1969) found that academic problems were viewed by
Heads of Department as psychological problems while students
themselves stressed problems that created personal stress-."' in
their other studies Wig et al (1971) and Wig and Nugpal (1972,
1975) found that success at University-is"a' product of complex
interaction of various personal'ancTeuvlronjnental factors. In a
more recent study Chandrasekhar et al (1980) found a prevalence
rate of 16%, . •They'also found a number of characteristics relating
•to the prevalence of mental health problems like the family
income and life in. the family.
36
The studies done in University students point out sn
important area for urgent intervention because of the vary important
age characteristics of the student group. However, todate no
systematic efforts have been .made to handle the problems, though
the matter of student counsellors or teaching teachers to counsel
students on the campus has been suggested.
The work with school children initiated at NIMHANS
reached a more satisfactory stage of development. In a series of
attempts, efforts have been directed to develop a general training
programme of child mental health for all categories of teachers
and a more intensive programme for the interested teachers. A
Manual providing guidelines and a series of instruments for evaluation
of the training programme and the individual weekly seminars has
_b£en~!deveio.pgd._by the tream (Kapur, Cariappa, 1978a. 1978b, Kapur
i-.t al, 1980).
This wdftc needs' 'to k enlarged and "raplica.t.e<i,_..The^
. programme if it finds a wi.de acceptance can lead to a feasible
approach to meeting the mental health needs of the school children.
11,5
GENERAL PRACTITIONERS TRAINING;
Dr. Shamsunder and colleagues at UIJMHANS,’ Bangalore have
been involved in the system.- ~lc attempts, to de elop approaches to
provide training to the general practitioners', inxa method is
specially suited o the needs of the urban populations (Shamsunder
et al, 1978). The initial experiences have been very encouraging.
This training of G.Ps from a project supported by ICMR>. New Delhi
and being carried out at Vellore and Hyderabad at present. This
replication effort should have the way. for this type of programmes
to be launched tn other urban areas. The possibility to link it
with the activities of Indian Medical Association is- an attractive
and practical possibility. (Gautam et al, 1980, Krishna Murthy
et al, 1981).
11.6
BANGALORE EXPERIENCE IN COMMUNITY PSYCHIATRY;
The programme of community Psychiatry was launched in 1976
under the leadership of Prof. R.L. Kapur at the NIMHANS, Bangalore.
During the last 6 years,? number of approaches relevant to the
rural areas have been developed. The overall effort has been to
integrate mental health with general health services.
The aim of the rural project" was to develop suitable
training programmes for ..the doctors and the multipurpose workers
from the various primary health centres in the state of Karnataka,
sc that after their training for PHC personnel could provide Basic.
mental health care in their respective catclniient areas. By basic
mental health care ft d.s meant detection and management of
epilepsy- and psychosis. The above objectives have been presented
diagrammatic-ally- in the following figure.
37
SCHEME FOR MENTAL HEALTH. CARE
Functions
Mental Hospital
Long term custodial care
Medical College Unit
jk
Diagnosis and management of
difficult areas
District Hospital Specialist
|P
Management of cases who require
admission.
P.H.C,. Doctor
Jik
Diagnosis, prescription
Direction of MPW's.
Multipurpos;e Workers
t
1/
Detection, follow up,
community education,
psychiatric emergencies
&
Traditional
Healers
\ i
Psycllotics and epileptics in community
The first task t t-.’cHs rlv fu” * m'- ' .he final
objectives was to start a service programme in n rural area
with a popula: ..on of 1,03,000. The s "vice programme was carried
out by a team of one psychiatrist, one psychiatric social worker
and one psychiatric nurse. Since the Inception of the service
programme the team has visited 122 villages o<id covered a
population of 76,000. 442 patients of epilepsy and psychosis
are on follow up. The regular attendance at the clinic which
is run three times a week ranges between 7Q--80 and all types of
medical problems are attended to. In case s patient does
not turn up on the day he is asked to,the treats makes a home
visit, In case p. patient■cannot come to the clinic the medicines
are given to a relative or a neighbour. Sometimes one single
individual takes medicines for all the patients in the
village. During the. last 4 years (1977^8(1) 61 with schizophrenia,
37 with acute psychotic episodes, 32 MDP. 335 epileptics, 37 n?r.?-o>';
depressives and 38 other psychiatric cases were seen and treated
(Chandrasekhar et al, 1^81; Kapur, 1981; Kapur et al, 1980;
Farthasarathy et al, 1981).
A manual for the basic health workers to identify and
refer cases to the PHC has been developed and tried out.
Similarly a Manual for doctor's training has also been developed.
The team has undertaken the training of basic health workers in
different PHC blocks and reported the experience as being positive.
Following this experience, a multicerstred project on SEVERE MENTAL
MORBIDITY in 4 centres is in progress with the support of the
ICMR, New Delhi. The centres involved arc; Patiala, Bangalore,
Baroda, Calcutta. The results of thia collaborative study should
provide further guideline to the methods to be used for the extension
of mental health services into the rural areas through the existing
general health services. Plan to train the doctors of Karnataka in
groups is due to start in 1982 .
11-. 7
CHANDIGARH EXPERIENCE TN GOMMPNITY PSYCHIATRY:
The Chandigarh experience to develop a model for rural
psychiatric service has been under the leadership of Prof.N.N.Wig
and Dr. R.Srinivasa Murthy. This work has been part of a WHO
Project titled 'STRATEGIES FOR EXTENDING MENTAL HEALTH CARE'. This
is a multicentred project carried out in 7 geographically defined
areas in Brazil, Colombia, Egypt, India, Philiplnes, Senegal and
Sudan and designed to develop and evaluate alternative and low cost
methods of mental health care (including training methods) in
developing countries (WHO, 1976).
The basic approach adopted in this model is to integrate
mental health with general health services and provide basic
mental health care as part of primary health care. This is
presented diagrammatically in Figures 1, 2 and 3.
The specific aims were to: (i) develop methods of priority
selection for intervention
the field of men "al health, care;
(ii) develop, and cvalr...ir ■■
is .3 taol; w Rented training iii
mental health care for.health workers and those in other systems'
of health care; (iii) evaluate effectiveness of alternative and low
cost 'methods of mental health care introduced into basic health
services; and (iv) develop and evaluate ways of stimulating the
community's understanding of and response to the problems related
to mental disorders.
The study was initiated in June 1975 in the Raipur Rani
Block of Ambala District of Haryana State, North India. A study
area population of about 60,000 was chosen based on the already
existing administrative structure, A series of BASELINE OBSERVATIONS
were carried out to (i) study the health staff perceptions,
attitude to mental disorders, willingness to take on mental health
care; (ii) screening of the general health clinic populations for
psychiatric problems and (iii) interview with community leaders.
These were carried out to be used as measures of evaluation of
effectiveness of Intervention as well as- to decide on priorities
to be chosen for basic mental health care work. Detailed reports
have been made elsewhere (Wig et al ; 1980, Harding et al, 1980,
Climent et al, 1980).
Baaed on the findings of the baseline observations, the
following were selected aa priorities for intervention, namely,
acute.psychosis, epilepsy, chronic psychosis, psychotic depression
and mental retardation, The task distribution is shown in Figure :
A Manual for the use by the Primary Health Care Personnel both in
English and Hindi was prepared and finalised for use (Wig and
Srinivasa Murthy, 1979, 1981). The main approach was to teach and
ALTERNATIVES
PSGVIQWG BASIC hf.HTAL HEALTH SERVICES TO All
* :m6RAT!0hl KITH qCNgWAL KKAl?H SERVICT?'
INCREASE IN TRAIHEO
PSYCHIATRIC I RQFESS1OKAL&
INCLUSION W PSYCHIATRIC TRAININ'’
•N MEWCAL f.llUCATlOH
PSYCHIATRIC DRAINING FUR GENERAL
PSYCHIATRIC TRAINING FOR CQCTDR3
IN RURAL PRIMARY HCALTH CiNTREG
Tr.AIMJMG’.OF BASIC HEALTH WORKERS
FOR SPKCIHED PSYCHIATRIC CONDITIONS
(McMCAtt AWAREHESS OF PUBLIC TO
utilise PRESENTLY AVAILABLE skrvices
PlMUH-E 1
39
provide skills to suspect, identify and diagnose, refer the problem
cases and initiate treatment for suitable cases. Three (limited
range) drugs namely Chlorpromazine, Phenobarbitone and Imipramine were
chosen for use. Following class room training on the job inservice
training was continued. Gradually mental health clinics were
started at the subcentres so that patients could get the needed
drugs and help close to their homes. The initial period of work
of the health workers was supervised and supported by the research
staff. Simple records for follow up and drug supply were maintained
(Wig, Srinivasa Murthy and Harding, 1581),
The results of this project completed in 19.81 show that it
is possible to integrate mental health with' general health services
by choosing priorities and developing proper training programmes for
-Xhe-health-personnel..,_ .Hpwjvet,. thls..reguirea.. (i)..tbe-comltffien£.~of. —. .
the health authorities to include mental health as part of PH care,
'(ii) provision of adequate drugs, (ill) the availability of support
and supervision from the PHC doctors and (iv) further crystallisation
of knowledge regarding the treatment schedules to be used in the
community without daily and continuous supervision of specialised
staff. Other research issues that need to he taken note of for
further work ia given in a later section.
11.8
In addition to the—' major offer' ..c at Br.:.balore and
Chandigarh, a number of other centres are attempting similar thrusts
into the commun..y. Notable among this is the work by Varghese
and colleagues at Vellore. The other experiment is at Ahmedabad under
the leadership of Shah and Buch where an effort was made to train
MENTAL HEALTH WORKERS to function in the District Hospitals. The
detailed reports of their functioning subsequent to their training
is not available for comments at this stage. However, the fact
that it has been not continued after the first batch indicates to
problems regarding a separate cadre for mental health care.
11.9
Traditional healers have been the subject of study by
Kapur (1975, 1977); Sethi and colleagues from Lucknow (1978).
At present this is an area with great degree of interest and thought
to have a potential for providing mental health care. However,
systematic efforts to involve them are awaited. Till such efforts
are carried out any opinion for or against would be uncalled for
and premature. Thia is an area for systematic study and not for
political or emotional rhetoric (Neki, 1973; Sethi and Trlvedi,
1979; Sethi et al, 1977; Sethi et al, 1979a, 1979b, 1980). The
approach cannot be one of total acceptance as advocated by some
politicians or rejection aa quackery 9 for example the reaction of .
Indian Medical Association, One have to keep in mind that they
are playing a part and will continue to play a part till modern
services reach, the remotest village and basic mental health care
becomes a reality.
40
12.
SERVICES FOR THE MENTALLY RETARDED-:
12.1
The needs of the mentally retarded in the country has been
the subject matter of a large number of meetings- and workshops.
Notable among them are the meeting of the Expert group on National
Planning for the mentally handicapped .in India (Nov. 12-19, 1979)
at New Delhi (Sinclair, 1979), and the Hird Asian Conference on
.Mental Retardation (Nov. 7r-ll, 1977) st Bangalore (FWMR, 1977).
The above two documents provide comprehensive accounts of the
magnitude of the problem (estimated to Be about 2v3% of the
population) and ths service lacunae. At present there are about
150 day care centres, schools- and institutions-, catering to a
maximum of 10,000. children i.e. approximately 0.04% of the number
of the mentally retarded in India, estimating the prevalence at
only 4 per thousand figure given for severe mental handicap.
(Sinclair, 1979). Even these centres have been concentrated in
"a few towns, for example, of the 150 centres-, Delhi, Bangalore,
Bombay, and Madras account for more than 50% of them.
12.2
'Thus, large parts of the country are to be left of any
meaningful services. Recent reports.'from the rural areas, ,to
study the needs of those living in the rural areas, point to the
needs being significant, contrary to the popular belief that
rural life protects retarded "rom problems (Sri’ ivasa Murthy et
al., 1981). Similarly the-c'
In t
.1
,i.rentable
causes of mental ’-e.tardation are also largely unmet (Srinivasa
Murthy, 1978).
12.3
The facilities for training teachers for the care of the
mentally retarded is still limited. At- present there is no provision
for.full professional (degree) course. Most tratni-ngs are of about
one year’s duration, The varying types of training do not-share a
common, curriculum. Organisation and bringing some uniformity in
training teachers is an urgent need. The creation of cadre of
personnel with special interest, skills and commitment to mental
handicap can go a long way to fulfil the needs of organising adequate
services.
12.4
It is salient to note that in the whole broad area.of mental
health, it ia with regard to mental retardation that voluntary
agencies and parent groups have played a significant role. The
active role by the. Federation .for the Welfare pf the Mentally
Retarded (India) New Delhi, to bring together parents, teachers and
professionals, and to stimulate them to plan services- has been
Very commendacle. Much future work needs to be done before we can
assure 'a meaningful life for the mentally retarded*.
13.
' VOLUNTARY ACTION FOR MENTAL WLTth
13.1
The report of the Indian Psychiatric Society's standing.
Committee on public education in mental health refers to the Indian
Council for mental Hygiene, located at Bombay and its affiliated
societies in other parts of f ,,e country. The./' we report,.(IPS, 196';'
41
also outlines a number of approaches to public action and education
as outlined in 8.5. However, tha active work in this area appears
very limited.
13.2
Notable among the voluntary agencies that have been active
in organising services has been in the area of mental retardation.
This has been considered in an earlier section (12.4).
13.3
The significant success reported by SANJIVINI, a voluntary
non-profit organisation located at Delhi has been an encouraging
experiment. This movement started in 1®76, as an effort to prevent
suicides and later on enlarged to act as a crisis intervention
centre. Sanjivini has been training lay persons for volunteer work
of the agency with the help of a panel of experts and active
collaboration of the various social and welfare agencies. The
present reports indicate that Sanjivini'' is fulfiling an important
need in the community. However, it is- too early to evaluate this
programme as it has to yet develop into full fledged organisation
beyond the initial effort, with its own philosophy. Similar
reports have been reported from Bangalore, Bombay and Vellore, though
details are not available. These activities- have an important
role to play not so much as service providers but more as
stimulators of services and public educators', as- well as liasion
between the.professionals a: i the public. They are also having
the potential of introducing innovative approaches to mental
health care. Tb.;- successes achieved by the Mental Hygiene movement
in U.S.A, and MIND in U.K. call for further efforts to encourage
these activities.
14.
MENTAL HEALTH LEGISLATION;
14.1
The need for revising the legislation regarding mentally
ill persons has been preoccupying the. mental health professionals
in the last 30 years. It is said that one of the first tasks
considered by the Indian Psychiatric Society in 1948, was to
redraft a new law to replace the Indian Lunacy- Act of 1912. This
need was emphasised by the Conference of Superintendents of Mental
Hospitals (Ministry of Health,- 1960) which concluded as follows;
’This conference after considering in detail the draft
mental health Bill recommends for adoption the Bill with
changes proposed by them1' (Resolution No. 1).
14.2
The Mental Health Advisory Committee constituted on the
29th September, 1962, had its first meeting on the 11th April.' 1963
and four sub-committees were constituted. One of them related to
the draft Mental Health Bill. The.second meeting of the Advisory
Committee was held on 8th November, 1965 at Ranchi and the
recixamendations of the sub-committees were, considered. In this
meeting,
vtha committen also endorsed the proposal to introduce
legislation for revising the existing Lunacy Act and
approved the draft Sill prepared by the Ministry of
Health:' (.Ministry of Health:, 1964^6),
14.3
However, the need continued to be on papers and the
urgency for changing it repeated by the IPS, the Presidents of
IPS in their Presidential address (Vtdye Sagar, 1972) with no
positive effect. It was only in April, 1978, a draft Bill was
introduced in the Parliament. The bill was referred to a select
ccrarsittee for revision. However, the Bill lapsed due to the
dissolution of the Parliament in 1979,.
..Recently, in December, 1981,' a”riew fevisecTdfaft Bill .
has been placed before the Parliament,. The DRAFT K5NTAL HEALTH
BILL (19.81) provides new provisions for (i) informal admissions,
(ii) certification of centres fur psychiatric care and (Iii)
the need for minimum criteria for .w.vfce centres. It can be hoped
that when the. BILL become ;.n Zv"->' the hope cf removing the social
stigma of psychiatric treatment will become less.
15.
NATIONAL MENTAL HEALTH PLAN}
15.1
The mental
i^e.ry Goi.vaAti.te ..uuaticuted in 1962
met in 1963, 19f.” and 1966 to consider the. various aspects of mental
health needs in che country. The areas that received consideration
were (i; the mental health bill
(ii) ambulatory treatment,
(iii) training-of mental health personnel, (19) starting of
epilepsy.clinics, (v) improvement of mental hospitals, (vi)
standardisation of forms and records for mental health services
and (vii) need for drugs (Ministry of Health, 1964-66), ,
15.2
The need for a comprehensive plan to organise nationwide
services has been often expressed (IPS, 1971). Many cf the
recommendations have been considered in detail in earlier sections
in 3.1 to 3.5, 4,1 to 4.5, 8.1 to 8.9. The need for e clear plan
led to the.formation of e group of 3 psychiatrists to assist the
President of IPS to prepare a blue print for national level of
planning of Mental Health (WHO Collaborating Centre, PCI, Chandigarh,
April, 1977).
15.3
However, it was only during 1981, the Directorate General
of Health Services organised a National level workshop to consider
a draft mental health plan. Thia was* held at AIT.MS, New Delhi
under the active, ccnvenership of Prof, N.H. Wig, in July 1981 (20-21)
The essential aspects of the suggested plan following the workshop
is to stimulate services both In the periphery and the Centre.
This is planned to be achieved by suitably integrating mental health
care at ail levels of health services. The plan outlines the
needs in terms of (i) appointment of a Mental Health Advisor at
the Centre for coordination, (ii) appropriate state level Mental
Health Advisors, (iii) ider: iffcatlnn of prio' .ties to be included
at different levels of health care from the VHW to the district
hospitals and referral centres, (ly) the tasks and training
programmes tc be developed for different levels of health
personnel, (v) strengthening of.mental hospitals, (vi) enhancing
undergraduate medical training in terras of mental health
components, and (yii) training in community psychiatry for
different categories of mental health personnel,
A positive decision to implement tha above,well
thoughtout programme and plan should go a long way in.
resulting meaningful basic mental services in the near future.
44
THE
FUTURE
................
The preceeding review of developments in the last
40 years has been viewed from different vantage- points. However
weighty the sentiments or forceful the. arguments, the most
important matter, is the quality and coverage of the services.
It is estimated that the currently available services do not
cover even 10Z of those requiring urgent psychiatric needs.
The positive and negative aspects or the agony and .
ecstacy of mental health care was brought out in a recent series
of articles that appeared in a 'widely circulated fortnightly,
INDIA TODAY,. In the matter of few months,.3 full page reports
appeared relating to mental health. The first appeared in June
and referred to the innovative approaches to mental health
care though health workers titled ‘the saaa approach1. The
second referred to as 1 playing,, on. the gullible(September,1981)
highlighted the force of superstitions in the form of witchcraft
which led the public in North. Karnataka look for solutions for
clearly medical problems from ao^rcers and magicians. The
third report referred to & "apB report in a mental hospital in
Kerala state, under the tit) 'moment <~r ’ti-v’nnr’ '
The above three aspects of In’ian psychiatry reflects
the real situation of mental health care in India »• the gullibility
~£ tuU-pt£b.l-is^..Xhe.di!.huinari_ conditions of mental hospitals and
the way out of the situatiotT By inKegratTng inentul-h®alth.. care--with general health services.
CAN HE EXPECT MEANINGFUL RESULTS IN THE NEAR ^FUTURE .?
There is no single answer to this vital question inspite
of the much avowed goal of HEALTH FOR ALL hy 2Q00 A.D. The
factors, that will decide the emergence of meaningful services
will depend on three factors;
i)
ii)
lit)
i)
General development of the community,
growth of general health services in the country,
the organisation of mental health services on sound
Principles.
General Development of the CotiHiunity;
What are the relevant aspects of general development that
are directly relevant to the organisation of mental health services?
Leaving aside the much talked of measures like the GNP, per capita
income, the -more directly relevant factors are the distribution of
the population, their accessibility and the general standard of
living.
45
India ia truly a nation of villages. We have 5,75,9.36
villages of various sizes. It is appropriate to note that about
80% of the population live in ths. rural areas. It is these
persons who have the least access to services. People in villages
live in.small groups. Nearly 60% live in villages of less than
500 population. If we consider those living in units of less
than 1000, it is 75%, Only 10% of population live in villages
of populations bigger than 5000 population. These thinly spread
population calls for a very- DECENTRALISED service. This its true
of all states of India and more so in some states like Himachal
Pradesh where more than 90% live: in units' of less than 500.
population (GOT, 1980).
In a recent report titled’'how-well connected’are our
villages’' Sangal (1981) points out that of the 4,51,632 villages
with?less than 1000 population, only 24% have all weather roads,
15% fair weather roads and 61% of villages still remain to be
connected with any road’. The figure for all weather roads that
needs to be connected with in future,.,for all villages is 4,07297
(71%). This data refers to March 31, 1978.
The situation in regard to the provision of drinking
water to our villages is e .ally dismal (pratid and Manohar,
1981). According to a sv.r y carried ou_ in 1972-/3, of the. 5,76,0.00
villages, 1,13,000 (20%) have no water supply safe for drinking
purposes withii a mile distance,!,85,LJQ (32%) have unprotected
water, supply open to the risk, of pollution and another 2,14,000
(37%) are dependent on wells-, tanks, ponds and streams <-• sources
which are also unsafe. The villages that have protected water
supply from only 10% of the total rural population.
The accepted official figures of more than half of the
population, living under poverty line crystallises the long
distance that needs to be covered in the process of social
justice for all and minimum needs, of all population.
.... .^
(ii) General Health Services in the Country;
The actual situation in regard to the manpower, facilities
and various National programmes have been presented in TABLES 1 to
V. However Impressive are the pronouncements* and multitudinous
the schemes, the health statistics like the infant mortality* rate
indicate the long road ahead to reach the minimum standards of
health care, Only two examples will suffice to illustrate the
point, namely the problems of MALNUTRITION AND TUBERCULOSIS.
One of the major areas, of success in our national life
has been conversion of the country* from ’'begging bowl to bread
basket’. The total .foodgrains production at the beginning of the
First Five Year Plan in 1950 was 55 million tonnes. During the
year 1977-78 the production reached over 125 -million tonnes. Thus,
the capacity for producing the foodgrains exce.ds the capacity
developed during the preceew.'ng 7000 year... However, it has been
reported that 30% of school children are malnourished. Out of
the 100 million pre-school children, 3- million suffer from
severe degree of malnutrition. Further several surveys haye
show that the severer forms of malnutrition among children
between six months to two years is common and almost'10^15%
babies suffer from third degree malnutrition. The nutritional
status of pregnant women is equally grim. In one study 57.5%
were anemic, symptoms of vitamin deficiency were present in
11-42%. In an another study, 90% of pregnant women and 80%
of nursing mothers had a calorie requirement Below the minimum
requirements and further 29% and 34% of the above two groups
received'less than 50% of the daily requirement (reviewed in
detail elsewhere Srinivasa Murthy, 1979),
It is exactly a Century since Robert Koch demonstrated
that ^consumption’' was caused by germs. It was tn the 1940 a and
1950a that specific drugs became available'for effective treatment^
In the later part of 1950s the excellent studies of 'Madras
Tuberculosis centre (TCC, 1959, 1960) made domiciliary treatment
of tuberculosis a practicality.
However, even today a large
part of the open infective cases are not recHiying treatment.
As recent as last year, professionals noted that the IE. programme
in villages are ’Woefully deficient^ CTOI, 1981) and called for
a ’new strategy' (IE, 1981),
Further examples ata general, hearth, area also point
similar limitati' s in implementation of health programmes.
The development of mental health services, generally
considered a luxury,cannot occur when more clearly 'FELT NEEDS'
outlined above are not tackled effectively. The development
or inclusion of mental health care ns part of basic health care
can occur only as part of growing strength and effgctivsaess or
the primary health care, systci^i.-* -
(iii) Approaches to Future organisation of Mental Health 'Services;
The foregoing review of the road taken by the mental
health services and the current position points to twr isp--;
pointers for future. Firstly, mental health care cannot develop
and outpace the overall development’or organisation of health
and welfare services. The second point'is that, the approaches
suggested since 1950s whether in the Presidential addresses of IPS,
or the conferences or scientific papers or thevresults of the
pilot studies, all show that if realistic coverage (in terms of
those who urgently used) have tc be obtained, DECENTRALISATION
and DEFROFESSIONALISATiON are mandatory. This approach is not
only the right way but also it will allow the country to a'.-.id
the errors of the West at the initial phases of the organisation
of mental health services. T?e problem? of ■llsen't'anglfng' the
differing interests of different profess fen-* •„ .'that often limit
the innovative approaches to Be implemented is not a problem in
our country where there are so few professionals and where the
roler have not yet goet crys J.lieed, Thia p.vt
has Been very
well made by German (19",5);
'the major advantage for the psychiatrist in a developing
(African) country is the very paucity of previous provision
for the mentally sick. Thus he does- not have to expend
hla energies in frustrating attempts to dismantle an
inert and cumerscme administrative structure; nor does he
have to concern himself with finding a method of absorbing
large numbers' of solidly built mental Hospitals into a
more efficient and humane psychiatric programme; there is
little need for him to struggle with large armies of
personnel in various categories, each preoccupied with and
defensing about its own status, and sancrosanct tradition
and in varying degrees unwilling to change from the
security of well defined roles to meet the challenges of
the present and future,...they have at least a fairly.
clean canvas on which to develop their themes'.
How can pilot ideas whether the starting of district
hospitals (a measure recommended to be completed in the 1960s
by the Mudaliar report but still unimplemented) or the deprofessior
nallsatfon shown to he relevant at Chandigarh and Sangalore,
become a reality beyond the confines of the pilot studies. It
is rightly said th§t the. pile studies enjoy the benefit of
committed staff. 4-nitisl
of others and do net have
managerial problem'. However, when it is extended at a bigger
scale, problems c„me, One need not look oo far for such
experiences. The example of pulmonary tuberculosis is there to
warn us to not look for quick results. It was in 1959 and
1961 (TRC, 1959, 1960) that the dramatic approach to DOMICILIARY
CARE was hailed as a new way to reach all the tuberculous
patients, The conclusions of this dramatic study is worth
recalling;
'The findings of the present study, based on a comparison
of the two types of treatment over a period of 12 months,
show that despite the manifest advantages of sanatorium
cave r rest, adequate diet, nursing and supervised medicine
taking - the merits of domiciliary chemotherapy are
comparable to those of the sanatorium treatment, and that
it would therefore be appropriate to treat the majority of
patients at. home, provided an adequate service was established'
(emphasis added).
Inspite of this dramatic result and bold conclusion, wc
still, in 1981 and 1982 hear that there is need for a new strategy
(IE, 1981) and the TB programmes is woefully deficient in villages
(TOI, 1981), The failures have been ’in not providing an adequate
service to be established *'. In other words, Sanjlvi ’. has this to
say? (The Hindu, 24.3.82).
48
'Therefore what we. need to eradicate tuberculosis and this.
will apply to leprosy also is. not more research,, more
knowledge but more cccrmitment on the part of everyone,
governments and citizens alike to create the organisational
and managerial minutia needed'1.
The Mental Health Plans for future, FOUR ’aspects ne»d
to be given importance. These are!
i.
££.
iii.
iv.
The political committment,
the professional committment,
the crystallisation .of knowledge in mental health care,
public education and involvement.
POLITICAL COMMITTMENT:
It may sound rather odd to start with political committment.
What is mean by politiaal committment? It is a committment for
cars, in terms of funds, recognition of importance and emphasis
in deciding priorities. The importance of this aspect is emphasised
by Benerji (.1976) as follows:
'political forces
a dcuinant role in tuti shaping of the
health, services of a community,' through decisions on research
allocation, manpower policy’, choice of technology and the
degree bd which the liauitH ser/ices are to be available and
accessible to the population, for instance/.
Other professionals working in the organisational aspects of health
care and other services in the country have been led to the
realisation of what can be referred to as 'the political will’',
Swaminathan of the planning commission had this to say in a recent
TV interview 'any amount of professional skill cannot replace the
political will1.
The political will or the social committment will influence
in terms of money allotted, the duality of care, the importance
given to the work by tha public and professionals tn a myriad ways
to make the programmes popular and acceptable. The record of .the
'political will' in the. mental health area, taking the amount of
money committed to mental health in the health plans and five year
plans speak of low priority. Thin has to change.
May be that the
professionals have been too preoccupied with clinical questions to
speak the language of care in terms of lost productivity and
social burden, which, appeal to the planners. It is time this
matter received adequate attention. The repeated failures and long
delays to get the legislative changes’ also speak of how the people
who matter look at urgent, mental health needs. Whether we call it
Political will which is influenced by lobbying or education, we
need to urgently give due importance to it.
49
THE PROFESSIONAL COMMITTMENT;
The review of the work of the professionals provide an
idea of the professional committment. The necessity of the
roles of professionals to be different is clear when we consider
decentralisation and deprofessionalisation, The whole new approach
can fail and no positive results teacher, if the professionals
(i) set up 'artificial'' rigid boundaries between different mental
health personnel, Cii) do not devote enough of its efforts to
this area of work in terms of sheer -manpower, time and research
efforts, (iii) do not break the barriers about drug utilisation
by the health personnel of different categories.
Each of these and other resistances of professionals,
till now.considered a super speciality to become a basic health
service, similar to Malaria or family planning will be real.
These heart burns, doubts failures end frustrations have been
faced boldly and squarely, A change in the outlook to accept
this as the REAL ALTERNATIVE rather than a second rate method
is vital, How can this occur? This can results by professional
efforts to crystallise mental health skills and tasks and in
the long run by a new generation of professionals growing up
with these ideas. All th..c calls for wide oiscussion, sharing
of ideas, critical appraisal of pilot schemes and inclusion
of community - ntal health skills in he training phase of the
professionals.
ADVANCES IN MENTAL HEALTH KNOW HOW;
The third and very vital development is the crystallisation
of the knowledge of mental health care. It is to be recalled that
the domiciliary care of tuberculosis was demonstrated scientifically
before the care moved out of the walls of. sanatorium. Similarly
for mental health care we have to devote research efforts to define
the essentials of care of clinical problems in terms of recognition,
referral, treatment schedules and intervention strategies. This
is a big lacunae at present in all deprofessionalisation program....:..
The needs are protein and they have to be given the most stringent.
consideration so that tasks are not defined in an adhoc manner but
based on sound scientific facts. They should not be based on
isolated experiments but based on sound research efforts in setting
as similar to the field setting as possible. Some of the areas
for such consideration are outlined below:
’Clinical research as to the needed range of drugs, dosage
and duration, role of ECT have to be defined in clear
terms, if mental health care has to become part of general .
health services, At present, the clinical issues of what
psychotropic drug to use, how much dosage and for how
long varies among professionals, Cften these are not
based on any concrete clinical evidence of factors like
early response ; decreased relapse rate or lower side
effects, inougn tnese issues are not vital when
50
specialists are dealing with limited clientele in
specialised institutions, they can decide the success
or failure of the national level programmes involving
nonspecialists. Specific issues likes (!) the relative
effectiveness and safety of phanothiazines end ECT for
acute psychoses and depression, (ii) the differences in
the rate of relapse when the initial treatment for
psychoses or depression is 3 months as compared to 6
months to one year, (til) the relapse rates for
epilepsy when the treatment is stopped after one, two,
three, four or five years after the last fit, (tv) the
methods of public education and (v) cost effectiveness
of rehabilitative efforts with chronic patients.
The number of areas that can be taken up similarly
are many' (Srinivasa Murthy, 1981).
It is gratifying to note that the ICMR, New Delhi has decided to
set up an Advanced Centre for Community Mental Health Research.
This Centre should give the above issues top priority sb that
standard and generally acceptable methods of care become
available,
It can be said that these i.e, knowledge alone will
not be enough, But no one can doubt the need for a sound knowledge
based for future and large scale planning,
PUBLIC EDUCATION AND INVOLVEMENT:
The general public form the next vital link in the
organisation of mental health services. This recognition has
been the reason for the high priority given in health programmes
for health education. Public awareness needs to be mobilised at
many levels; (i), correcting the erroneous beleifs and exploitation
by opportunists to be stopped; (ii) to act as a pressure group to
bring about the political committment and (iii) to act ae watch
bodies on professionals, leet the professionals pursue their
isolated needs and concerns rather than matters of greater
importance to the public. .
The involvement of the general public will have to be’
by (i) public education by traditional methods like meetings,
pamphlets, use of mass media etc,, (ii) organisation of mental
health associations and (iii) ex^patiante; clubs etc. so that
they continuously support and supervise the growth and direction
of mental health services.
53
TO CONCLUDE. THE REVIEW OF THE .EFFORTS AT ORGANISATION
OF MENTAL HEALTH SERVICES IN THE LAST 40 YEARS GIVES US?THE LONG
DISTANCE THE PROFESSION HAS TRAVELLED AND THE APPROACHES ADOPTED.
IT ALSO OUTLINES THE TASKS AHEAD AND THE SCOPE FOR IMMEDIATE
ACTION,
THE CURRENT SITUATION RAISES HOPES OF POSITIVE RESULTS
IN THE NEAR FUTURE,
THE TIME SEiMS RIPE FOR CHANGES AND WITH
TBp INVOLVEMENT OF PUBLIC PROFESSIONALS AND PLANNERS AND EY
•■
WORKING OUT A LONG TERM PLAN ..MEANINGFUL RESULTS CAN BE SEEN'IN
NEAR FUTURE,
THUS, IT MAY BE APPROPRIATE FOR US TO CONSIDER
THIS AS BEING ON THE THRESHOLD OF ORGANISING BASIC MENTAL
HEALTH SERVICES WITHIN THE NEXT TWO DECADES WITH MINIMUM OF
INPUTS ». HERE POSSIBLY LIES THE ROAD. bTO REACH THE UNERASED’
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APPENDIX
TABLE I
Establishment of Primary Health Centres and subcentres
in India
TABLE II Health Infrastructure in Tilda,a
TABLE III Investment on Health and Family Welfare in Five Year Plan
TABLE IV
MEDICAL MANPOWERS IN INDIA 1978
TABLE V
Health care Services in India-Plans and Priorities
TABLE VI
Mental Health Statistics
TABLE VII Market Share of various drugs(l$73)
57
TABLE I
establishment ok primary health CENTRES AND SUBCENTRES IN INDIA
PHCs
First plan
Second Plan
Thxrd Plan
INTER-PLAN PERIOD
67
2565
4631
3 Years
Subceinters
As on 31.3.1967
.As on 31.3.1968
As on 31.3.1969
4793
494.6
4919
17 521
21 539
22 826
IV th Five Year Plan
As on 31.3.1970
As on 31.3.1971
As on 31.311972
As on 31.3.1973
As on 3I.3.I974,
5015
5112
5183
5248
5283
23 527
28 489
28 167
31 034
33 509
As on 31.3.1975
As on 31.3.1976
As on 31.5.1977
As on 31.3.1978
5293
5328
5380
5400
33 616
34 088
38 110
38 115
VIth Five Year Plan
As on 31.3.1979
5423
40 124
Vth Five Year Plan
TABLE II
HEALTH INFRASTRUCTURE IN INDIA
"Position on
1 .4.1978
Name of Programme
1 . Minimum Needs Programme
(i)
PHCs
(ii)
Sub-Centres
(iii)
Hural Hospitals
■ (iv) Subsidiary Health Units
(v) Mobile Units
I..
Communicable
(a)
Filaria
(i)
(ii)
(iii)
(iv)
(b)
(c)
(d)
5 430
.‘38 594
126
258
124
Diseases. Control programmes
Control Programmes
Control Units
.
Survey Units
Filaria Clinics
Rural Filaria-Control
148
17
23
3 Districts
National Smallpox Eradication Programme
(i)
Primary Vaccination(in million)
318.46
(ii)
. Re-Vaccination (in million)
1163.33
(iii)
Leprosy Control Programme
(i)
Control Units
371
(ii)
Upgraded Units
147
(iii)
S.E.T. Centres
5 770
(iv)
Urban Leprosy--Centres
405
(v)
Reconstructive Survey Units
64
(vi)
Training Centres for
Paramedical' staff
40
(v)
Temporary Hospitalisation Wards
165
Tuberculosis’ Control Programme
(i)
District T.B. Centres
(ii)
T.B. Isolation beds
(iii)
Demonstration Training Centres
(e)
Cholera Control Programme
Cholera Conbat Teams
(f)
Trachome Control Programme
Blccks/PHCs
(g)
Prevention of Blindness Programme
(i)
Mobile Units
(ii)
PHCs
(iii)
District Hospitals
(iv)
Medical colleges
'(v) Regional Colleges/Institutes
(iv)
National Institutes
311
42 500
17
41
4 591
15
700
100
8
4
1
TABLE III
A
INVESTMENT IN HEALTH AND FAMILY WELFARE IN FIVE YEAR PLANS
PLAN
Investment
on Health
(crore rupees)
t
Percentage of
Investment
Percentahe
total investme- on FP
of total
nt in Plan
Investment
(crore rurppees)
First (1951-56)
64-6
Second(1956-61)
135.8
Third (1961-1966) 223.9
Annual Plans
(1966-1909) 140.2
Fourth Plan(19^9y
335.5
Fl fth( 1974.-1979) 528.4
Draft 1968 Sixth
Plan
1263.4
0.65
4.97
26.97
0.03
0.11
0.31
2.1
82.93
1.25
2.1
1.7
285.76
285.65
1.81
0.96
1.8
765.00
1.08
3.3
2.9
2.6
TABLE IV
MEDICAL MANPOWER IN INDIA, 1978
Number of doctors registered with medical councils(1978)
Registered dentiats( 1978)
235 631
74419
Registered Homeopathic practitioners(78)
151 137
Registered Practitioners of Indian Syst. of Medicine (78) 273 641
Registered Pharm.acists(?8)
107 452
Registered Nurses(77)
Registered ANMs (77)
Registered Health visitors (77)
**•, ***♦ ******** ****** *
120 412
55 656
76618
bL
—■
(in millions)
Allocation
Plan priority programmes
I
1 Water supply and sanitation
2 Primary "Health Centres, Hospitals & Dispensaries
3 Control of Communicable Diseases
4
5
5
7
11
III
IP
V
49O.C .•
250*0
2J1.8
216.0
4.«
7.»
202.0
Education and Training
Family Plannin g
Indigenous system of Medicine
Other Schemes
o
1:9 Water supply and Sanitation
2 Control of Communicable diseases
3 Primary Health Centres,Hospitals & Dispensaries
760.0
640.0
360.0 '
4 Education and Training
5 Indigenous system of Medicine
6. Family Planning
7
7 Other schemes
8
360.0 '
40.0 .
30.0
60.0
9
Water supply and Sanitation
Control of Communicable diseases
Primary Health centres, Hospitals & Dispensaries
720.0
690.0
370.
5
6
7
Education and Training
Family planning
■Indigenous system of Medicine
Other schemes
350.0
269.7
40.0
50.0
1
2
3
4
Water supply and sanitation
Family planning
Control of communicable diseases
Education and training
5
6
7
8
Primary Health centres, Hospitals & Dispensaries
Minimum Needs Programmes
Indigenous system of Medicine
Other schemes
1
2
5
4
1 'Water supply and Sanitation
2 Minimum Needs Programmes
3 Control of Communicable Diseases
4 Primary Health Centres, Hospitals & Dispensaries
5
6
7
8
SOURCES:
Medical Education and training
Indigenous system of Medicine & Homes
Training programmes
Other Schemes
•
4,970.0'
3,009.3
1,270.0
982 .•
882 ,.9 t.764.9
158.3
276.9
10,220.0
2,914.7
1,686.1
1 ,552.8
945.6
280.7
172.0
408.7
1. Central Bureau of Health Intelligence, Directorate General of
Health services, Government of India, Pocket Book of Health
Statistics of India, 1’976.
2.
Government of India Planning commission, Draft Fifth Five year
Plan, Excluding Union Territories.
TABLE VI
MENTAL
HOSPITAL STATISTICS(1971-1978)**
A D M I S S I 0 N S
BEDS
HOSP.
A.P.
900
Assam
1000
STATE
.
1971
1972
1975
2
1463
1437 .
1793
***
1828
1
1 65»
*
1975
** 1976,
1977
2159
*
959
2481
.1715
1601
1407
1287
*
7277
1978
*
1293
■
.
2117
5
4677
4269
4499
4216
5558
*
*
6112
Gujarat”
558
4
*
305
*
577
456
472
486
*
515
1
*
3
J & K
..
175
2
975
891
10055.
*
604
*
1141
1111
1094
Kerala ■
1298
*
4752
7750
674&
7420
9489
■ 8540
507
5
2
*
7»96
M.P.
554
675
570
677
• 805
750
889
Maharashtra
5675
5
*
4421
*
5771
*
4805
5524
*
6542
5264
*
*
5368
*
5877
9455
Bihar
Karnataka
1260
2
5806
*
552
5107
7195
8395
*
Orissa'
.
60
1
797
1045
1080
1177
811
1
*
418
971
***
976
Punjab'
927
***
542
572
519'
1195
Rajaftthan
565
2
1995
1965
2579
2431
*
*
2296
1800
1
1480
1554
402
*
***
*
546
T. Nadu'
U.P. ' . '
1382
1459
1615
1794
1495
4
805
818
882
*
224
*
1197
*
440
*
474
W. Bengal
900
6
328
*
*
472
1326
*
1704
*
1989
1595
*
Goa
550
1
1087
*
286
*
*«'
1052
1278
1555
974
1268
Delhi 0,
285
1
572
*■**
***
*
68
***
754
-X-X--^
Total®- ,
'19326
41
32064
44546
51429
54457
39848
45108
■ 45606
52
27
29
55
55
52
No. Reporting
data
*
**
;
3Q
DATA INCOMPLETE
*** NO INFORMATION
FROM POCKET BOOK OF HEALTH STATISTICS IN INDIA - 1975, 1976,1978.1979.
MENTAL HOSPITAL INDIA (Year of starting in the brackets)
Bombay'(’1745); Calcutta (1787); Bhownipur. (1817); Rancji (1918); Madras (1795);
Icnayr (1795); Patna (1821); Ranchi (1925); Varanasi (1809); Waitair (1865);
•.gpur( 1864 );
Agra(l869); Trivandrum (1871) ; Calicut (1872);Tezpur (1876);
iV:tnagiri (1886); Baroda (1898); Thana (1902); Yervada(l91 3); Trichur (1914);
Calcutta(1922); Indoro(1927);■Gwalior(1955); Bangya Unmad(Calcutta)(1955);
Bangalore (1957) ; Jodhpur(1940); Lumbini Park-, Calcutta(l94O), Bha-rnagar(l942);
Jaipur (1944);Amritsar(1947); Hyderabad (1955); Srinager ,(1958); Jamnagar (i960);
-'hihadra (1966).
NO MENTAL HOSPITALS IN HARYANA
■
H. PRADESH
MANIPUR
MEGHALAYA
PRADESH,CHANDIGARE, MIZORAM, PONDICHERRY, and LAKSHEWEEP.
A&N island,
MARKET SHARE OF VARIOUS DRUGS ( Hathi Committee Report)
CATEGORY OF PRODUCTS
1973
%
TRADE SALES;
Antibiotics
19.9
Vitamins
11.7
Cough and Cold Preparations
5.5
Raematinics
5.3
Tonics and Health restorers
5.2
Harmones
4.8
Dermatological Preparations
4.1
Analgesics
3.8
Anti-diarrheals
3,1
Anti—rheumatics
3,1
Dietitics
2.6
Enzymes and digestants
2.5
Cardio-Vascular drugs
1.8
Anti-Spasmadics
1 .8
Psychotherapeutics
1 .7 •
Opthalmo.loqicals
1.7
Antiasthmatic's
1.6
Amoebic ides
1.5
Anti TB Preparations
1 .4
Antacids
1 .4
Anti-histaminics
1.4
Sulphonamides
Sales to Govt.Hosp, and Doctors
1.3
15.9
1 00.0
It is to be noted that the currently produced drugs
in the area of psychotheraputics is very limited.
Any plan
to extend services will call for enhancing the production
•and distribution system.
4
GMental Health Issues in Women
Dr. Vibhuti Patel
( Academic Advisor, SCWSD)
Presented on 20-6-2003 at the Certificate Course on Counselling for Care
Givers offered by Sophia Centre for Women’s Studies and Development,
Sophia College (SCWSD), Bhulabhai Desai Road, Mumbai-400026. Phone23635280, fax-23611183
E-mail-Sophia wornencentre@hotmail.com)
Member Secretary, Women Development Cell, University of Mumbai
INTRODUCTION
Proper understanding on mental health issues in women is very important for an
effective counselling. Women psychologists are providing new analytical tools and
insights to gain analytical vision to understand mental health issues of women.
Women’s Movement has provided fresh inputs in terms of individual and group
counselling, popularly known as “Consciousness raising” exercise, a form of
mutual counselling that enables women as a group to share experiences, problems,
feelings, dreams, utopia and action plan for rebuilding shattered lives. This process
of attaining feminist consciousness allows women to recognise that what they
perceive as personal problems are shared with others in a non- threatening and non
power oriented atmosphere. It also enables women to realise what they think of as
resulting of living in patriarchal society. “Consciousness raising can be seen as
enabling women to overcome false consciousness.”1 It empowers women to come
to a realisation of their own potential, makes them autonomous, self-dependent in
their decision-making power and emotionally self-reliant. It is an ongoing process
that brings about personal and collaborative change as opposed to structural change.
The need for small groups/ informal group discussion is emphasised in this method.
Manifestations of Depression:
Depression in women manifests in headaches, sleepless nights, constant tension,
detachment, irritability, loss of appetite, dryness of mouth, fear, self-blame, lack of
concentration, lack of interest in any kind of activity. Although chronic headaches
may not be psychosomatic, they can be caused by depression or anxiety. Thus,
counselling can help you identify and address emotional concerns and should be
considered as part of your treatment.”2 There are two types of stressors leading to
mental disorder. Biochemical stressors are hormonal fluctuations at the onset of
puberty, pre-menstrual phase, post partum phase and menopause. According to Dr.
K Ravishankar, “Estrogens have an effect on brain chemicals like serotonin and nor
epinephrine that are involved in headaches. An imbalance in serotonin levels has, in
feet, been implicated in disorders like migraine and depression.”3
Psychosocial stressors originate from the external social environment such as
women’s inferior social position, lack of power, homelessness, economic hardships,
man-made or natural disasters. They create learned helplessness (women’s
seeming passivity in the midst of crisis such as domestic violence, accidents, etc)
ahd reduce motivation to lead an active life. Stress related menial health issues are
illness in the family, death of one’s spouse, divorce, accident that might reduce or
destroy women’s ability to shoulder responsibility. After marriage, women get
displaced which brings about cultural loss and bereavement, loss of social networks
and supports, loss of traditional healing sites. Psychological stages through which
women pass are -enduring, suffering, reckoning, reconciling and normalising. The
successful completion of therapeutic cycle depends on how conducive the physical
and emotional systems are. Sometimes hysteria can also open up more
opportunities and increased freedom/space with added costs. Women cope with
tension by crying, talking it over, praying and engaging in creative work-music, artcraft-reading-studies-community work, team building.
Approaches to Mental Illnesses:
Universalist ETIC approach uses diagnostic categories of mental illnesses such as
neurosis, schizophrenia, psychosis, mania, phobia, paranoia so on and so forth.
Psychiatric labelling does not take cognisance of material reality faced by women
on a day-to-day experiential levels. It obscures social reality such as riots, natural
disasters, fire and accident while dealing with phobia among women. While
working with women victims of riots, we should know that their phobia about men
has a basis in the fact that they have witnessed killings and rape. Hence,
medicalisation of mental health in the Draft National Health Policy 2001 has been
criticized by women’s groups providing support to women in mental distress.4
EMIC approach emphasises cross-cultural psychiatry and evaluates phenomena of
mental illness from within a culture. Traditional treatment of the mental illness used
to be meditation, yoga, group-singing and listening to a discourser. A Culturally
sensitive counselling on mental health consequences of trauma take into
consideration women’s socio-cultural environment.
ETIC-EMIC debate gave way to new cross-cultural psychiatry where the emphasis
lay on the different contexts of mental illnesses in different cultures, not on bio
medical categories. Now, there are no two opinions about the statement that
psychotherapy should keep into consideration multicultural aspects of women’s
existential reality.5
Psychiatrists use chemotherapy i.e. administration of anti-depressants and
sedatives, shock therapy which induces shock, with or without convulsions, in a
patient by means of insulin or electric current through brain. Individual
psychotherapy includes hypnosis, suggestions, supportive therapy, re-education,
desensitisation and other forms of consultation, group psychotherapy, family
therapy and psychoanalysis.6
Four phases of Healing Cycles7 are:
1.Enduring- anxiety, grieving and loss of past
2.Acceptance- reality testing, preparedness and reckoning of the future reconciling,
evaluation of self and resources, recuperating
3.Recovery-rebuilding life, maximising options, setting new goals, healing
Normalising-stabiIity and routines, building relationships and community
4.
Unequal relationship between professional counsellor, who is UP THERE and the
seeker, who is DOWN BELOW creates a communication gap. In case of women,
this inequality is compounded by subjugation of women by the patriarchally
structured psychiatric system. Focus on ‘feminine qualities’ pathologises all
physiological changes of a woman, in childhood, adolescence, reproductive age and
menopause.
Philosophical basis of psychiatry as a bio-medical discipline prevents the mental
health professionals to take into consideration larger reality and macro issues
resulting from socio-economic and political factors. Psychiatry focuses on treating
the individual symptom while ignoring the disease. ‘Diagnosis’ frequently arouses
protests of indignation about labelling people as ill and treating them as impersonal
objects.8 Limitations of bio-medical perspectives lie in their narrow focus on
somatic and psychological factors in their diagnostic efforts, ignoring the impact of
socio-cultural and socio-demographic factors. In India, the focus is more on the
treatment of the illness, not on preventive and promotive efforts. Marginalisation of
mental health concerns results from the understanding that mental distress is a
manifestation of an individual problem, not directly related to social oppression and
not common to all women.9
Worsening Socio-economic and Political Situation and Mental Health of
Women:
Experiences from both industrialised and developing countries have revealed that
the prevalence of common mental disorders or minor psychiatric morbidity is high
among the urban low income and marginalized population. Women among them
are even more vulnerable. Globalisation, structural Adjustment Programmes,
increasing conflict with neighbouring countries and ongoing sectarian violence on
caste, ethnicity and communal lines within the country10 have put the population of
our country at high risk of mental illnesses.11 Alert India is a large NGO with 550
community workers working among the marginalized sections of Mumbai
metropolis. Their women health workers found that women who have to deal with
financial hardship, experience tremendous stress. Moreover, women within
community are affected differentially depending on their own place in the Indian
socio-economic hierarchy. In this regards, female-headed households are most
vulnerable to mental distress. The mental health professionals are only geared for
the episodic disasters and not the enduring disasters. Hence, there is a need for
interdisciplinary mental health interventions.
Professional counsellors act as facilitators in Self Help Groups (SHGs). They use
the technique of mutual counselling to identify areas of strategic interventions.
Need for Culture Specific Approach in Counselling:
Respect for basic human rights demands that the counsellor addresses the issues
concerning cultural mindsets and behavioural variety that determine women’s
mental responses to tragedies. If this variety is not appreciated, counselling will end
up being reductionist and homogenising. Here the soft wear is not formal education,
but life. Mental health of women victims and survivors of tragedy demands
multifaceted approach. Individual counselling by the professional counsellor can be
helpful in breaking ice. At the same time, women with similar experiences can
empower each other by narrating their problem areas and finding solutions.
Patriarchal biases of the Mental Health Establishments:
The mainstream mental health professionals are unable to impart the required
counselling to women due to misogyny. Stereotypical understanding about
women’s role in the family and society governs their psyche and if the so-called
“mentally ill” woman does not fit in that mould, she is declared ‘socially
incompetent’ woman. Witch hunting of lesbians by the mainstream psychiatrist is
so strong that even All India Institute of Medical Science has a special package for
counselling, “to correct deviant behaviour” of the lesbians. Subordination
domination relations between men and women are re-emphasised in the mainstream
counselling.
Sexual Violence and Mental Health:
’
Sexual assault, molestation, rape, sexual harassment at workplace, child sexual
abuse, nuisance calls cause psychological disturbances among girls and women.
The trauma of sexual violence sparks off tension and anxiety at a dangerous level.
Their mental health problems are manifested in anxiety, fear, avoidance, guilt, loss
of efficiency, lack of coordination, depression, sexual dysfunction, substance abuse,
relieving the traumatic incidents through memory, suicidal attempts, eating
disorders, disturbed sleep patterns, fear of encountering such situation once again. It
is found that “ women who undergo extreme sexual violence experience a loss of
self and self-esteem following the shock inflicted on them. When there is a
continuous period of traumatic stress, it becomes chronic, lessening the individual’s
ability to do any kind of constructive work.” 12 Hence, this forms of male violence
towards women is an important issue that demands public attention. Women’s
organisations have taken up this issue at a local, national and global level.
Domestic Violence and Mental Health of Women:
Discourse on mental health of women in the family situation gained serious
consideration in the context of campaign against violence against women.13 In
domestic violence situations, predicament of women is determined by their position
in power-relations vis-d-vis the rest of the family members. Many social work
researches which attribute deviant behaviour of adolescent girls to their working
mothers guilt trip women by narrowly focussing on single parameter14 and ignoring
factors such as peer -pressure, media, overall standards of morality in our society
and power relations in the nuclear/ joint family. Such researches are used by some
counsellors to cage women into domesticity and divert the attention from
generation of genuine support system for developmental needs of the daughters of
working mothers. Women’s rights organisations which are doing support work for
women in distress have started giving due importance to counselling.15
Adolescent Girls and Counselling:
The most mind-boggling problems faced by adolescent girls are decision-making in
the day-to-day life, self- dependence and career. Rapid changes in the socio
economic and cultural reality, parental expectations, values and norms, rising levels
of competition and pressure during examination time and a break down of
traditional family structures are factors that accelerate this alarming trend.16
Examination related anxiety results into sharp rise in girls hurting themselves
deliberately, leaving homes or killing themselves. Fear of failure is a root cause of
all qualms. Large number of students and their parents are seeking professional
help. Consulting a psychiatrist is no longer a taboo as the psychiatrist responds to
cries for help from a crippling academic burden. According to them, we have more
problem parents than problem children. Providing good and healthy role models is
very important. Parents who want their children to develop high self-esteem should
make it a point of treating them with respect and dignity. Concept of fiscal hygiene
is important for girls to understand the value of clean money earned through hard
work. Today’s adolescent girls are at the crossroads. But every crossroad leads to
new roads. Information revolution has made adolescent girls more aware and
precocious. They have to enhance their knowledge base. Broadening one’s personal
horizons is a sure way of tackling the crisis within oneself. Today’s girls find the
values instilled in them since their childhood, hollow in real life. Romance is found
utilitarian and consumerist. The economic security is bleak, emotional security is
becoming a victim of uncertain times. Globalisation has led to the emergence of
apparently homogeneous life-styles, necessities and comforts through media
images, whereas the reality of life is pathetically at variance with resources required
to maintain such a life. This has further deepened the crisis of the youth. Dictatorial
atmosphere in the family, educational institutions and in the community life, make
adolescents feel left out of the decision-making processes affecting their lives.
Hence it is very important to understand that,
“ Inclusion is trend,
Such as democracy,
Freedom and justice for all.
All means all,
No buts about it.
Inclusion is opposite of exclusion.
Inclusion is no to boycott.
Inclusion is a battle cry.
Challenge to the parents,
Child’s cry for his/her existence...
For welcome, for embrace,
To be remembered fondly...for award
For gift of love... like surprise,
Like treasure.
Inclusion means clean game,
General knowledge, courtesy, hard work.
Inclusion is great in its simplicity,
And surprising in its complexity.
Instead of investing in jails, mental asylums, hospitals, refugee camps,
To canalise resources for creating true homes,
True life, true human beings...
For humanising life.
Marsha Forest
Both in private and in the public spheres, we need to give more space for
development to the adolescent girls.
Counselling for Substance Abusers:
Support resources for substance abusers are counsellor, family members, significant
peers and school or treatment staff. Group therapy is an effective intervention
method with abusers. It facilitates the process of recovery of addicts.17 Sharing of
experiences by the abusers shows them ways to empower each other. Self-help
groups of abusers are more effective as they avoid problems generated due to
different wavelengths.
Counselling for HIV-AIDS Patients: This is very important issue faced the 21st
century. Counselling for dealing with social stigma and creating an alternate
support network are the most important aspects of providing emotional support to
the HIV-AIDs patients. The Lawyers Collective HIV/AIDS Unit holds monthly
drop-in meetings, with an objective of sharing information, experiences and resolve
mind boggling issues affecting the lives of HIV/AIDS patients. It also provides
legal aid and allied services to the needy. “ The main objective of the Unit is to
protect and promote the fundamental rights of persons living with HIV/AIDS
have been denied their rights in areas such as healthcare, employment, terminal
dues like gratuity, pension, marital rights relating to maintenance, custody of
children and housing.”18
Electronic Media and Mental Health:
People are inside the T.V. because there is vacuum outside the T.V. Different
standards of morality for men and women; are created by the film, television serials
and advertisement industry. Boys and men who watch pornography are always on
the look out for innocent adolescent girls. These girls are the victims of
pornography, blackmail and physical/psychological coercion. Adolescent girls
working, as domestic workers don’t have any emotional support, as there are hardly
any television and radio programmes for non-student urban youth. Dehumanisaton
of women can be prevented by promotion of women’s agency in the media so that
women can lead intellectually, psychologically and emotionally self-sufficient life.
Counselling in the Shelter Homes for Women:
The most promising solution to confusion and disorientation among the women
inmates of shelter-homes is a democratic space for brainstorming as autism is one
of the main problems faced them. Informal set up is more congenial to their
personal and career counselling. Workers at the shelter homes for women and girls
need to be made to understand that behind every behaviour, there is a story. It is
important for them to know the story. Panel of psychotherapists and
psychoanalysts in the shelter homes should also conduct the staff development
programme so that the staff can handle post trauma stress disorder among the
inmates with empathy rather than resorting to victim blaming.
Mental Health and Reproductive Rights of Women:
Societal attitude towards Indian women as son-producing machines creates painful
mental problems for women. Woman’s body is de-linked from her subjectivity. Pre
menstrual syndrome (PMS) and Post Partum depression (PPD) are regarded as
general complaints concerning women’s reproductive abilities. Weapon of Pre
menstrual syndrome as a debilitating factor has been used to run down women in
the family and at the workplace. PMS is a political category, which conveys that
biology is destiny for women. Instead of focusing on the genuine issues concerning
premenstrual discomfort in terms of fatigue, headache, cramps, headaches resulting
in to depression and crying spells, PMS provides reductionist and reactionary
'explanation for women’s discontent. Women don’t have right to decide, how many
children should they have and at what interval. New reproductive technologies
(NRTs) have robbed women of their individuality and reduced them into spare parts
for either scientific experimentation and/or sale. NRT values women only for their
ovaries, uterus, foetus, that too for production of male progeny. NRTs have caused
tremendous psychological burden on women in the arena of sexual activity for
procreation or only for recreation without procreation with the help of
contraception or abortion. Researches over last 3 decades have highlighted mental
problems associated with repeated induced abortions, long acting hormone based
contraceptives or conception inducing drugs.
Instead of using humane healing techniques of music, fragrance, get to gathersHo
deal with discomfort during pregnancy and post-partum depression, bio-medical
intervention of giving tranquillisers and electro-convulsive therapy are promoted
by the psychiatrists. This is the most vulgar example of the medicalisation of the
natural processes of women’s bodies. Gender sensitive training programmes should
be organised for medical officers of primary health centres and women health
workers adopting perspective promoted by the UNFPA.19
Menopause and Mental Health of Women:
Many psychologists have attributed harassment of daughter in law by her mother in
law to menopause. But it is not true for all women. Many women find staying with
their in-laws a liberating experience. It all depends on how society and family treat
an aging woman. Pathologisation of menopause and negative attributes given to
“old hag” (sadeli buddhi) experienced by women are responsible for identity crisis
and depression among women during this period. Here, the role of counsellor is to
recommend activities for self-actualisation and a healthy diet and vitamin
supplements to menopausal woman. Exercise is very important to increase
conversion of androgens to estrogens.
Women and Epilepsy: Disability and impaired quality of life caused by epilepsy
can be reduced by “psychiatric and psychosocial referral counselling on how to live
with refractory seizures and advise on vocational rehabilitation.”20 Persecution and
discrimination against epileptic women should be prevented, by giving
scientifically accurate public education through mass media. For the curriculum of
community workers training programme, module on epilepsy, seizure and
convulsion should be incorporated.
Mental Health of Women Senior Citizens: Geriatric care is an important area in
counselling. The most talked about problem concerning mental health of elderly
women is dementia i.e. “loss of cognitive functioning, memory, language abilities,
abstract thinking and planning”.21 Dementia is often reversible. Irreversible
dementia can arise due to amnesia, Hutington disease and Alzimer’s disease(AD).
Modem medicine treats this problem with estrogen replacement therapy, non
steroidal anti-inflammatory drugs and vitamins. Feminist senior citizens deal with
mental problems of elderly women by providing spiritually rich and emotionally
and intellectually stimulating group life to them. Discourses, singing, outing, social
service, meditation and mutuality and reciprocity in human relations make great
contribution towards their mental health. Vardhana, a group of feminists has
defined women above 60 years of age as “Women of Age” and has provided a
democratic and development oriented platform to Women of Age. As the age
structure of society is changing due to small family norm and increase in life
expectancy of women, the state and civil society institutions will have to pay
serious attention to geriatric care and come up with constructive schemes and
programmes. There should be increase in the budgetary provision for senior
citizens.
Mental Health of Women in the Mental Hospital:
A fire in Moideen Badusha Mental Home in Erwadi, Tamilnadu, on August, 6,
2001 which killed 28 inmates who were chained to their position, hence could not
run away, has once again invited attention of all concerned citizens to the condition
of women in the mental homes. Surviving women patients of the tragedy wer^
transferred to the Institute of Mental Health in Chennai. Now, they are no longer in
chains but their condition is not different from their earlier home.23
Pathologisation of women by using diagnostic labels is a major cause of
stigmatisation and ostracism of women. Women’s groups are demanding that
pegion-holing of people into set slots must stop. Interaction with the mental health
professionals is used by the family members and the community; to declare the
concerned woman “an unfit” to live in the family or to be a parent or to function as
an autonomous individual or to take up a job. Husband’s family uses the episode of
“mental disorder” to dispose her of or debar her from property right or right to live
in a matrimonial or parental home. “Madness certificate” of the mental health
professionals are used by husbands/ inlaws to divorce, desert or throw out wives
from their matrimonial homes. Women are admitted in the mental asylum as per the
directives of the Mental Health Act, I987and Lunacy Act, 1912.
Saarthak, a voluntary organisation has filed a petition in The Supreme Court (WP
© 334/2001 with WP © 562/2001) requesting the apex court to issue directives
banning direct Electro-convulsive Therapy (ECT), popularly known as SHOCK
therapy in the mental hospitals, psychiatric nursing homes and
govemment/municipal hospitals with psychiatric wards. 24 Several groups have
started signature campaign in support of the petition.
Once dumped in a mental asylum, it is impossible for her to get out of it even after
complete recovery. “ Women in the mental hospitals have fewer visitors, are
abandoned or tend to stay on longer than men within the institution. There are
fewer voluntary patients among women than among men. Even in adjudication for
a woman’s institutionalisation, the official discourses are often coloured by the sex
role stereotypes that the judges, police officials and the staff in mental hospitals
uphold.”25 Remarks of a social worker after the visit to the mental hospital are apt,
“ The interaction with female patients made me sadder. Almost all of them were
abandoned/ dumped by families or the police and court got them admitted after they
hit the rock bottom. Most of them were forced to face violent situations in their
lives and had painful and atrocious account to tell. In many cases, one could see
(although without an in-depth study, one can not claim and prove) that the mental
distress, ill health had its roots not in a person’s biology or psychology, but in
society, in our social environment”. 26
Iron wall of secrecy about the administration of drugs, surgery and ECT and their
side effects needs to be condemned by the citizen’s initiatives and ethical medical
practitioners. The long lasting side effects of biomedical approach need to be
highlighted. Our mental hospitals need to focus on psychotherapy and counselling
vfhich involve therapies that produce positive results and no negative side effects.
Long term stay in mental hospital leads to chronicity. Hence there is a need to
promote “half- way homes, hostels and most importantly, the treatment of women
patients in their family settings through follow up visits by nurses and social
workers.”27
8
Psychological Problems of Women in the Police Custody and Prison:
Activists working on prison reforms have demanded humane code-of-conduct for
governance of police custody and prisons, so that the inmates are not afflicted with
permanent psychological scars. Solitary confinement of women prisoners takes
away verbal articulation from them. Inter personal violence among prison inmales
can be reduced by counselling, group discussions and creative expressions. Women
political prisoners should not be forced to stay with hard-core criminals in the
custody or jail
Role of Support and Self-help Groups (SHGs): SHGs provide democratic space
for rebuilding broken lives. Non-power oriented special interest groups provide
stimulus for canalisation of creative energy. Mutual counselling focussing on
experience sharing without preaching or giving sermons can help psychologically
distressed women reorganise their life and enhance their potential Speak Out
Centres can provide platform for Community mental health intervention. Here
comes the endorsement from an expert, “At the height of feminist activism in the
1970s and 1980s, there was excitement in the air as women shared experiences
about themselves, their families, their lives and encounters. The growth of women’s
confidence and self esteem knew no bounds as they challenged established theories
about law, work, justice, equality and medicine. They talked late into the night,
wrote pamphlets, stuck wall posters, spoke at public meetings, filed writ petitions.
They felt reassured that theirs was not an isolated or individual problem. The
group’s endorsement and sharing of painful experiences perhaps did much more for
mental health than all medicines in the expert’s books. The women’s movement
helped avert many breakdowns.”28 Enduring therapeutic engagement at community
level can be group singing, festival celebrations, discourses on women’s issues and
public meetings.
Developmental Input: Cosmetic counselling offered by agony aunts is of no use.
Breakthrough counselling is need of an hour. To make women’s material reality
more secure, liberating and healthy is the only alternative to get out of repeated
attacks of mental illnesses. Developmental counselling aims at removal of chronic
conflict situation in women’s lives that is associated with high mental health
morbidity. It is more than a remedial service. It believes that involvement, readiness
and commitment on the part of the counsellor are necessary and basic conditions
for counselling success.”29 It is concerned with the development and facilitation of
human effectiveness. It increases self-direction and evolves better problem solving
and decision-making abilities. This is the central axis around which feminist
therapy or counselling revolves. It emerged in the wake of the women’s movement
as an alternative to hegemonic patriarchal mental health establishments that
depended on bio-medical approach to deal with the innate feeling of unhappiness in
women. At the same time to evolve safety nets in the community and criminal
justice system for protection from physical abuse. Budgetary allocation for medical
aid to treat mental illnesses of women should be enhanced. Mentally ill women
need legal protection in terms of property rights and right to dwelling place. We
need to create protective environment in personal and public life to prevent mental
illnesses among women. E.g. efforts to prevent man-made disasters such as riots,
loot, rampage. Mental illnesses result into deskilling of the individuals concerned.
Hence, there is a need to evolve a plan of action for the re-skilling based on their
preferences and abilities. Half way homes should be created where the mentally ill
women can do productive work during the day and go home in the evening. After
the recovery from the mental illnesses, they should be employed.30 Financial
security helps in rebuilding their sense of self-esteem. The most successful healer is
one who avoids victim blaming and provides patient listening.31 After talking /
catharsis, the seeker feels better. Girls and Women with communication disability
need special help.32 At the same time, “Reversing the process of alienation bj^
consciously building community networks is a must. Mental health professionals,
should be seen in the community rather than in the secure institute or clinics.” avers
a well known psychiatrist, Dr. Harish Shetty.33
Training Programmes on Counselling: Sensitization and training of general
practitioners and other health personnel to mental health, particularly, minor
psychiatric morbidity (anxiety-depression) is a must. There is a need for social
counsellors at health posts and public hospitals who are in touch with NGOs
providing institutional support to women in social distress. Sensitization of
teachers, community workers, youth groups, women’s organisations is extremely
important. Training sessions for professional and para-professional volunteers
should focus on supportive networks, group cohesion and solidarity. Training
should include modules on interviewing skills, history taking, mental status
examination. Electronic and print media should be trained in sensitising the general
public about psychological response to violence and providing information about
referral services as women and children affected by domestic violence, man-made
or social disasters have special psychological needs.
Counselling ought to make women more aware about their problems and the
oppression they face. Therapy can provide alternatives to deal with their problems.
Counselling can be used to bring to the fore the cognitive facility required to
recognise danger and threat to life, to assess the options and to leave if necessary,
among women victims of violence. Counsellor’s have become astrologers.
Counsellor should be proud with the arrogant and humble with the courteous. Don’t
do only supportive counselling. At times, you need to provoke. Role- playing is an
excellent procedure for learning about counselling. Role- playing situations can be
easily developed from the experience of people.34 The ethics of valuing and
respecting others must be observed by the counsellor.35 Common characteristics
required from the counsellor are concern, emotional investment, cognitive
detachment, sensitivity and introspection.36 The counsellor should know that
healing is a part of empowerment.
The World Health Report, 2001- Mental Health
The report advocates for the public health Approach to mental health. It avers
“Advances in neuroscience and behavioural medicine have shown that, like many
physical illnesses, mental and behavioral disorders are the result of a complex
interaction between biological, psychological and social factors. The report gives
special emphasis to the needs of women with mental disorder. They are
summarised as:
Medical-Early recognition, Information about illness & treatment, Medical care,
Support, hospitalisation
Community-No stigma, No discrimination, Social participation, Human rights
Family-Skills for care, family cohesion, networking, crisis support, financial
support, respite care
Rehabilitation- Social support, Education, Vocational support, day care, long-term
care, spiritual needs.
WHO approach to deal with biological, psychological & Social factors has
components of Prevention-Treatment-Rehabilitation. WHO recommends
■Pharmacotherapy
■Psychotherapy
■Psychosocial rehabilitation
H Vocational rehabilitation
■Housing-process of de-institutionalisation & psychiatric reform
Needs of women with Mental Disorder- Women with mental disorders need
support from the medical practitioners, community, family and institutions
providing support to women in distress.
■Medical-Early recognition, Information about illness & treatment, Medical care,
Support, hospitalisation
■Community-No stigma, No discrimination, Social participation, Human rights
■Family-Skills for care, family cohesion, networking, crisis support, financial
support, respite care
E Rehabilitation-Social support, Education, Vocational support, day care, long term
care, spiritual needs
WHO recommendations for Mental Healthcare include the following aspects:
■Provide treatment in primary care
■Make psychotropic drugs available
■Give care in community
■Educate the public
■Involve communities, families & consumers
■Establish National policies, programmes & legislations
■Develop human resource
■Link with other sectors
■Monitor community mental health
■Support more research
Conclusion
Subordinate status of women is the major cause of mental illnesses among women.
“For too many women, experience of self-worth, competence, autonomy, economic
independence, and physical, sexual, and emotional safety and security, so essential
to good mental health, are systematically denied because they are women.”37
Civil society and the state should provide more and more opportunities to women
of all age groups for self-actualisation so that women can achieve high level of
mental health. Respect for diversity, plurality and multicultural outlook ensure
democratic and tolerant milieu that is conducive for mental health of women. As
compared to institutionalisation based mainly on bio-medical intervention,
community or family-based rehabilitation of mentally ill women based on human
touch is far more effective.
Endnotes:
II
' Kramarae, Cheris and Dale Spender (Ed.s) Routledge International Encyclopedia of WomenGlobal Women’s Issue and Knowledge, Vol.I, Routledge, New York & London, 2000, p. 221.
2
Goel, Deepak “History of Headache”, Health Action, Special number- Managing Neurofcjgical
Disorders, Vol. 15, no. 6, June 2002, pp 13-17.
3
Times of India, 21-3-2002.
4
Davar, Bhargavi “Draft National Health Policy 2001-III, Mental Health : Serious
Misconceptions”, Economic and Political Weekly, Vol. XXXVII, No. 1, Jan 5-11,2002, pp.20-22.
5
Amico, Eleanor Reader’s Guide to Women’s Studies, Fitzroy Dearborn Publishers, Chicago and
London, 1998.
6
Shertzer, Bruce and Shelley Fundamentals of Counselling, Houghton Miffin Co, Boston, 1968,
p. 14.
7
Kearney, M.H Understanding Women’s Recovery From Illness and Trauma, New Delhi, Sage
Publications, 1999.
8
Noonan, Ellen Counselling Young People, Methuen, London and New York, 1983, p.48.
’ Vindhya, (J, A. Kiranmayi and V. Vijayalaxmi “Women in Psychological Distress-Evidence From
a Hospital Based Study”, Economic and Politcal Weekly, Oct. 27,2001, Vol.xxxvi, No. 43,
pp.4081-4087.
“Medico Friend Circle “Camage in Gujarat- A Public Health Crisis”, Mumbai, 13-5-2002.
11
Ali, Nasir and Surinder Jaswal “Political Unrest and Mental Health in Srinagar”, The Indian
Journal of Social Work, Special Issue- Mental Health Consequences of Disasters, Vol. 61, Issue 4,
October 2000, pp.598-618.
12
Nair, Jayasree Ramakrishnan and Hema Nair R “ (En) Gendering Health: A Brief History of
Women’s Involvement in Health Issues”, SAMYUKTA- A Journal of Women’s Studies, Vol. Il,
No. 1, January, 2002, pp.44.
13
Patel, Vibhuti “Domestic Violence, Mental Health of women and Medical Ethics”, Issues in
Medical ethics, Vol. XI, No.l, January-March, 2003, pp.13-14.
14
Philip , Tomy “Impact of Employment of Mothers on Mental Health of Adolescent Children”,
Perspectives in Social Work, Vol. XVII, No. 1, Jan.- April, 2002, pp. 30-38.
15
A. Tellis, Julian “Zero Tolerance, Humanscape, April, 2002, pp.10-11.
B. MASUM, Mahila Sarvangeen Utkarsh Mandal, Annual Report, Pune, 2000-2001.
46 Kumar, Laxmi “Adult And Adolescence- Lives of Compromise”, Generation Next- The
Complete Youth Magazine, Vol. 2, No. 2 &3, Feb.-March, 2001, pp. 23-24.
17 Gonet, Marlene Miziker Counselling the Adolescent Substance Abuser- School Based
Intervention and Prevention, Sage Publications, London- New Delhi, 1994, p.160.
18 .POSITIVE Dialogue, Lawyers Collective HIV/AIDS Unit, Mumbai, Newsletter # 6, August
2000, p.4.
” UNFPA Training Modules o Gender and Reproductive Health, United Nations Population
Funds, India, 2002.
20
Shah, Pravina “Psychological Aspects of Epilepsy”, Journal of Indian Medical Association,
Vol. 100, No. 5, May 2002, p295-298.
21
Gamer, Diana and Susan Mercer (Editors^ Women as They Age, The Haworth Pres, New york,
2000, p.91.
22
23
Vardhana The Women ofAge- Women and Ageing in India, Vacha, Mumbai, 1999, p.l.
Krishnakumar^Asha “Beyond Erwadi”, Frontline, August, 2,2002, pp. 113-114.
S
24
Pathare, Soumitra “Beyond ECT: Priorities in Mental Health Care in India”, Issu es in Medical
Ethics, Vol. XI, No.l, January-March, 2003, pp.11-12.
25
Davar, Bhargavi “Women-centred Mental Health: Issues and Concerns”, VikalpaAltematives,Special Issue, Gender and Transformation, Vikas Adhyayan Kendra, Mumbai, Vol.
IX, No. 1&2, 2001.pp.117-130.
26
Joshi, Lalita “At the Fag End... A Visit to Yervada Mental Hospital ”, Aaina-a mental health
advocacy newsletter, Vol.2, No.l, Pune. Pp.7-8.
27
Kapoor, R.L. “Mental Health”, in Regional Consultation on Public Health and Human Rights,
National Human Rights Commission, New Delhi, 2001, p. 187.
28
Shatrughna Veena’s Forward in Bhargavi Davar Mental Health ofIndian Women, Sage
Publications, Delhi, 1999.
29
Dinkmeyer, Don and Edson Caldwell Developental Counselling and Guidance- A
Comprehensive School Approach, Harvard University, USA, 1970, p.87.
30
Patel, Vibhuti “ Women and Health- An Indian Scenario”, Perspectives in Social Work, College
of Social Work, Nirmala Niketan, College of Social Work, Mumbai, VoI.XVII, No.l, January-April
2002,pp.22-29.
31
Nelson-Jones, Richard Practical Counselling and Helping Skills, Better Yourself Books,
Bombay, 1994, p.12.
32
Amar Jyoti “Improving Approaches to People with Communication Disabilities”, Disability
Dialogue, Issue III, January-April 2002, pp 1-12.
33
Shetty, Harish “Prevet Suicide, Save Life”, One India, One People, Special issue on
Prescriptions for Healthcare, Vol.4, No.I2, July 2001, pp.21-22.
34
Ligon, Mary G. and Sarah W. Me Daniel The Teachers’ Role in Counselling, Prentice-Hall, INC,
New Jersey, 1970, p.82.
35
Seden, Janet Counselling Skills in Social Work Practice, Open University Press, Buckingham
and Philadelphia, USA, 1999, p.142.
36
Perez, Joseph The Initial Counselling Contact, Guidance Monograph Seriesp II Counselling,
Houghton Miffin Company, Boston, 19968, p.28.
37
Astbury, Jill “Mental Health: Gender Bias, Social Position, and Depression”, in Engendering
International Health- The Challenge of Equity edited by Gita Sen, Asha George and Piroska
Ostlin, Massachusetts Institute of Technology, Cambridge, 2002, pp.165-166.
WHO/MSD/MSB/01.5
What
do people
Think
they know about
Substance
Dependence
Drug dependence is simply a
failure of will or of strength of
character
People who have drug dependence can
easily move back to occasional use
CD
O
r-t-
Dependence is a brain disorder and people with drug
dependence have altered brain structure and function. It is true
that dependence is expressed in the form of compulsive behavior,
but this behavior is strongly related to brain changes occurring
over time, with repeated use of drugs. In recent years genetics
was found to be associated with the predisposition of individuals
to be more or less susceptible to develop drug dependence.
Drug dependence is difficult to control due to compulsive drug
use and craving, leading to drug seeking and repetitive
use, even in the face of negative health and social consequences.
Once dependent, the individual often fails in his or her attempts
to quit.
People in my country do not have
drug-related problems
It's not worthwhile to invest in
treatment for individuals who
have drug dependence - it is a
waste of public funds
CD
Investing in evidence-based treatment for substance dependence
<—t- decreases negative health consequences and social effects
(e.g. crime, economic burden and HIV infection). For every
dollar spent on treatment 7 dollars are returned in cost-savings.
Treatment is proven to be cost-effective in both developed and
developing countries. It costs less than imprisonment.
No country is immune to substance related problems. Substance
r-t" users are found worldwide among men, women and youth.
Incidence of substance dependence are on the rise, and in
many countries substance use is the driving force for other
epidemics. Currently, 114 countries have reported HIV infections
related to injection drug use.
■W JI
I
I w I
is the Management of Substance
1"® Dependence team in WHO's
Iv Department of Mental Health and
Substance Dependence, Noncommunicable Diseases and
Mental Health Cluster, Our team is concerned with the
management of problems related to the use of all psychoactive
substances; regardless of their legal status. It is concerned with
the epidemiology of alcohol and drug use, neuroscience of
addiction, brief interventions for alcohol and drug problems,.
drug use and HIV/AIDS (including injecting drug use), response^l
to the problems related to amphetamine-type stimulants,
evaluation of treatment and other interventions for drug/alcohol
users and capacity building in the area of research and treatment.
It seeks an integrated approach to all substance use problems
within the health care system, in particular primary care.
Co-ordinator: Dr Maristela Monteiro
Some of the areas we are currently working on include:
Neuroscience of addictive behaviors
Alcohol and Injuries
Amphetamine type stimulants
WHO Drug Injecting Study
People living with HIV/AIDS who are substance dependent
Early interventions for drug and alcohol problems
Agonist pharmacotherapies for opiate dependence
Stop exclusion - Dare to care9
Contact:
Dr Maristela Monteiro,
Management of Substance Dependence
World Health Organization
20 Avenue Appia
1211 Geneva, Switzerland
Tel +41 22 791 47 91
Fax+ 41 22 791 48 51
email: monteirom@who.int
Drug and alcohol related problems
only affect individuals in developed
countries
n
r-+ There is strong evidence showing an increase in drug-related
problems in developing countries with a significant impact
on mortality, disease and injury. These problems affect more
the poor, and are more prevalent among the poor in developed
countries too.
There is already enough research
for policy making on drug and
alcohol related problems, there is
no need for more
CD Drug and alcohol using behaviors are dynamic, with emergent
patterns changing depending on factors such as:
D availability of drugs, introduction of new drugs, new modes
of administration and rapid social changes. More research is
<-*■ necessary to develop new treatments and preventive strategies,
support services and to understand the associations between
substance dependence and other risky behaviors. The new
challenges of HIV related to injecting drug use pose a new
focus for further research.
All that is needed to cure
dependence is treatment centers
- once you are in, you are cured
Substance users do not receive
sufficient punishment
Tl
Qj
People with health problems should receive and benefit from
D health services and not punishment. The possible short and
long term consequences of substance use include: mortality,
<-+ morbidity, comorbidity, social isolation and stigma. People with
substance dependence are among the most marginalized in
societies and are in need of treatment and care. To incarcerate
offenders for drug use and dependence is not an effective
prevention or treatment strategy.
There is no magic solution in treating substance dependence.
It is a long process, with varying services, not always adequately
available or provided. This is a chronic recurring illness, needing
repeated treatments until abstinence is achieved. Aftercare is
essential to successful recovery, as well as compliance and
responsibility of the patients themselves.
WORLD HEALTH ORGANIZATION
Mental Health in Emergencies
Mental and Social Aspects of
Health of Populations Exposed to Extreme Stressors
Department ofMental Health and Substance Dependence
World Health Organization Geneva
2003
Mental Health in Emergencies
Background
General principles
The World Health Organization (WHO) is the United
Nations agency responsible for action to attain the
highest possible level of health for all people. Within
WHO. the Department of Mental Health and Substance
Dependence provides leadership and guidance to close
the gap between what is needed and what is currently
available to reduce the burden of mental disorders and
to promote mental health.
Informed by a range of documents by acknowledged
experts on guidelines, principles and projects, the
Department of Mental Health and Substance
Dependence draws attention to the following general
principles:
1.
This document summarises the present position of the
Department of Menial Health and Substance
Dependence on assisting populations exposed to
extreme stressors, such as refugees, internally displaced
persons, disaster survivors and terrorism-, war-or
genocide-exposed populations. WHO recognises that
the number of persons exposed to extreme stressors is
large and that exposure to extreme stressors is a risk
factor for mental health and social problems. Principles
and strategies described here arc primarily for
application in resource-poor countries, where most
populations exposed to disasters and war live. The
mental health and well-being of humanitarian aid
workers also warrant attention, but their needs are not
addressed in this document.
In this document the term social intervention is used
for interventions that primarily aim to have social
effects, and the term psychological intervention is used
for interventions that primarily aim to have
psychological effects. It is acknowledged that social
interventions have secondary psychological effects and
that psychological interventions have secondary social
effects as the term psychosocial suggests. WHO in its
constitution defines health as a state of complete
physical, mental and social well-being and not merely
the absence of disease or infirmity. Using this definition
of health as an anchor point, this statement covers the
Department’s current position regarding the mental
and social aspects of health of populations exposed to
extreme stressors.
Our objectives, with respect to the mental and social
aspects of health of populations exposed to extreme
stressors are:
1.
to be a resource in terms of technical advice for field
activities by governmental, nongovernmental and
intergovernmental organizations in coordination
with the WHO Department of Emergency and
Humanitarian Action.
2.
to provide leadership and guidance to improve
quality of interventions in the field.
3.
to facilitate the generation of an evidence base for
field activities and policy at community and health
system level.
Preparation before the emergency.
National preparation plans should be made before
occurrence of emergencies and should involve:
(a) development of a system of co-ordination with
specification of focal persons responsible within
each relevant agency, (b) design of detailed plans to
prepare for an adequate social and mental health
response, and (c) training of relevant personnel in
indicated social and psychological interventions.
Return of refugees from
Ttuvr. Pict’ avrtety ef UNHCRfM. Kc’hifJth
2.
Assessment.
Interventions should be preceded by careful
planning and broad assessment of the local context
(i.e, setting, culture, history and nature of problems,
local perceptions of distress and illness, ways of
coping, community resources, etc). The Department
encourages in emergency settings a qualitative
assessment of context with a quantitative assessm^P
of disability or daily functioning. When assessment
uncovers a broad range of needs that will unlikely be
met, assessment reports should specify urgency of
needs, local resources and potential external resources.
3.
Collaboration.
Interventions should involve consultation and
collaboration with other governmental and
nongovernmental organizations (NGOs) working in
the area. Continuous involvement preferably of the
government or, otherwise, local NGOs is essential to
ensure sustainability. A multitude of agencies
operating independently without co-ordination
causes wastage of valuable resources. If possible,
staff, including management staff, should be hired
from the local community.
4.
Integration into primary health can.
Led by the health sector, mental health interventions
should be carried out within general primary health
care (PHC) and should maximise care by families and
active use of resources within the community.
Clinical on-the-job training and thorough supervision
and support of PHC-workers by mental health
specialists is an essentia! component for successful
integration of mental health care into PHC.
Access to services for all
Setting up separate, vertical mental health services
for special populations is discouraged. As far as
possible, access to services should be for the whole
community' and preferably not be restricted to
subpopulations identified on the basis of exposure to
certain stressors. Nevertheless, it may be important
to conduct outreach awareness programmes to
ensure the treatment of vulnerable or minority
^jjtroups within PHC,
5.
6.
Training and supervision.
Training and supervision activities should be by
mental health specialists - or under their guidance for a substantial amount of time to ensure lasting
effects of training and responsible care. Short
one-week or two-week skills training without
thorough follow-up supervision is not advised,
Intervention strategies for
health officials in the field
Informed by the literature and the experience of
experts and with the aim to inform current requests
from the field, the Department of Mental Health and
Substance Dependence advises on intervention
strategies for populations exposed to extreme stressors.
The choice of intervention varies with the phase of the
emergency'. The acute emergency phase is here defined
as the period where the crude mortality rate is
substantially elevated because of deprivation of basic
needs (i.e. food, shelter, security, water and sanitation,
access to PHC, management of communicable diseases),
due to the emergency. This period is followed by a
reconsolidation phase when basic needs arc again at a
level comparable to that before the emergency or, in
case of displacement, are at the level of the surrounding
population. In a complex emergency, (a) different parts
of a country may be in different phases or (b) a location
may oscillate between the two phases, over a period
of time.
7.
Long-term perspective.
In the aftermath of a population’s exposure to severe
stressors, it is preferable to focus on medium-and
long-term development of community-based and
primary mental health care services and social
interventions rather than to focus on the immediate,
short-term relief of psychological distress during the
acute phase of an emergency. Unfortunately,
impetus and funding for mental health programmes
highest during or immediate after acute
^^emergencies, but such programmes is much more
effectively implemented over a protracted time
during the following years. It is necessary to
increase donor awareness on this issue.
8.
Monitoring indicators.
Rather than as an afterthought, activities should be
monitored and evaluated through indicators that
need to be determined, if possible, before starting
the activity.
1. Acute emergency phase
During the acute emergency phase, it is advisable to
conduct mostly social interventions that do not
interfere with acute needs such as the organization of
food, shelter, clothing, PHC services, and, if applicable,
the control of communicable diseases.
1.1 Valuable early social interventions may include:
• Establish and disseminate an ongoing reliable flow of
credible information on (a) the emergency;
(b) efforts to establish physical safety for the
population, (c) information on relief efforts,
including what each aid organization is doing and
where they arc located; and (d) the location of
relatives to enhance family reunion (and, if feasible,
establish access to communication with absent
relatives). Information should be disseminated
according to principles of risk communication: e.g.,
information should be uncomplicated
(understandable to local 12-year olds) and empathic
(showing understanding of the situation of the
disaster survivor).
Organize family tracing for unaccompanied minors,
the elderly and other vulnerable groups.
1,2 In terms ofpsychological interventions in the acute phase the
following is advised:
Brief field officers in the areas of health, food
distribution, social welfare and registration regarding
issues of grief, disorientation and need for active
participation.
• Establish contact with PHC or emergency care in
the local area. Manage urgent psychiatric complaints
(i.e., dangcrousness to self or others, psychoses,
severe depression, mania, epilepsy) within PHC,
whether or not PHC is run by local government or
by NGOs. Ensure availability of essential
psychotropic medications at the PHC level. Many
persons with urgent psychiatric complaints will
have pre-existing psychiatric disorders and sudden
discontinuation of medication needs to be avoided.
In addition, some persons will seek treatment
because of mental health problems due to exposure
to extreme stressors. Most acute mental health
problems during the acute emergency phase are best
managed without medication following the
principles of‘psychological first aid’ (i.e., listen,
convey compassion, assess needs, ensure basic
physical needs are met, do not force talking, pro^|
Organize shelter with the aim to keep members of
families and communities together.
Consult the community regarding decisions where
to locate religious places, schools and water supply
in the camps. Provide religious, recreational and
cultural space in the design of camps.
If at all realistic, discourage unceremonious disposal
of corpses to control communicable diseases.
Contrary to myth, dead bodies carry no or
extremely limited risk for communicable diseases.
The bereaved need to have the possibility to conduct
ceremonious funerals and - assuming it is not
mutilated or decomposed - to see the body to say
goodbye. In any case, death certificates need to be
organized to avoid unnecessary financial and legal
consequences for relatives.
or mobilise company from preferably family or
significant others, encourage but do not force social
support, protect from further harm).
Encourage the re-establishment of normal cultural
and religious events (including grieving rituals in
collaboration with spiritual and religious practitioners).
Encourage activities that facilitate the inclusion of
orphans, widows, widowers, or those without their
families into social networks.
• Encourage the organization of normal recreational
activities for children. Aid providers need to be
careful not to falsely raise the local population’s
expectations by handing out types of recreation
materials (i.e., football jerseys, modern toys) that
were considered luxury items in the local context
before the emergency.
Encourage starting schooling for children,
even partially.
Involve adults and adolescents in concrete,
purposeful, common interest activities (c.g.,
constructing/organizing shelter, organizing family
tracing, distributing food, organizing vaccinations,
teaching children).
Widely disseminate uncomplicated, reassuring,
empathic information on normal stress reactions to
the community at large. Brief non-sensationalistic
press releases, radio programmes, posters and
leaflets may be valuable to reassure the public.
Focus of public education should primarily be on
normal reactions, because widespread suggestion of
psychopathology during this phase (and
approximately the first tour weeks after) may
potentially lead to unintentional harm. The
information should emphasise an expectation of
natural recovery.
Assuming the availability of voluntecr/non-voluntc't
community workers, organize outreach and
Tx
non-intrusivc emotional support in the community
by providing, when necessary, aforementioned
‘psychological first aid'. Because of possible negative
effects, it is not advised to organize forms of single
session psychological debriefing that push persons
to share their personal experiences beyond what
they would naturally share.
If the acute phase is protracted, start training and
supervising PHC workers and community workers
(for a description of these activities, sec section 2.2).
2, Reconsolidation phase
2.1 In terms ofsocial interventions, the following activities
are suggested:
• Continue relevant social interventions outlined
above in section 1.1.
• Organize outreach and psycho-education. To
educate the public on availability or choices of
mental health care. Commencing no earlier than
four weeks after the acute phase, carefully educate
the public on the difference between
psychopathology and normal psychological distress,
avoiding suggestions of wide-scale presence of
psychopathology and avoiding jargon and idioms
that carry stigma.
‘psychological first aid', providing emotional
support, grief counselling, stress management,
‘problem-solving counselling’, mobilising family
and community resources and referral.
Collaborate with traditional healers if feasible. A
working alliance between traditional and allopathic
practitioners may be possible in certain contexts.
Facilitate creation of community-based self-help
support groups. The focus of such self-help groups is
typically problem sharing, brainstorming for
solutions or more effective ways of coping (including
traditional ways), generation of mutual emotional
support and sometimes generation of community
level initiatives.
• Encourage application of pre-existing positive ways
of coping. The information should emphasize
positive expectations of natural recovery.
0 Over time, if poverty is an ongoing issue, encourage
economic development initiatives. Examples of such
initiatives are (a) micro-credit schemes or (b)
income-generating activities when markets will
likely provide a sustainable source of income.
12 In terms ofpsychological interventions during the reconsolidation
phase, the following activities are suggested:
• Educate other humanitarian aid workers as well as
community leaders (e.g„ village heads, teachers,
etc) in core psychological care skills (e.g.,
‘psychological first aid’, emotional support,
providing information, sympathetic reassurance,
recognition ofcorc mental health problems) to raise
awareness and community support and to refer
persons to PHC when necessary.
• Train and supervise 1’HC workers in basic mental
health knowledge and skills (e.g., provision of
f appropriate psychotropic medication, ‘psychological
first aid', supportive counselling, working with
families, suicide prevention, management of
medically unexplained somatic complaints, substance
use issues and referral). The recommended core
curriculum is WHO/UNHCR’s (1996) Mental Health
of Refugees.
• Ensure continuation of medication of psychiatric
patients who may not have had access to medication
during the acute phase of the emergency.
• Train and supervise community workers (i.e„
support workers, counsellors) to assist 1’HC workers
with heavy case loads. Community workers may be
volunteers, paraprofessionals, or professionals,
depending on the context. Community workers
need to be thoroughly trained and supervised in a
number of core skills: assessment of individuals’,
families' and groups' perceptions of problems,
GftTtjij I Abl/u:iJ RepuHicjn Hwptial. PIvu ceurieiy of UNHCR[A IMtirun
Above interventions are
suggested for implementation
in synergy with ongoing mental
health system development
priorities:
• Work towards developing or strengthening feasible,
strategic plans for national-level mental health
programmes. The long-term goal is to downsize
existing psychiatric institutions (‘asylums’),
strengthen 1’HC and general hospital psychiatry
care, and strengthen community and family care of
persons with chronic, severe mental disorders.
• Work towards proper and relevant national mental
heath legislation and policy. The long-term goal is a
functional public health system with mental health
as a core element.
WHO resource materials
The following list of WHO resource materials covers:
(i) mental health documents that are likely relevant to
all populations whether or not exposed to extreme
stressors and (ii) specific mental health documents
relevant to populations exposed to extreme stressors.
WHO (1990). Fhe introduction ofit mental health component
into primary care. WHO: Geneva.
http://www5.who.ini/nicntaljiealih/download.cfmtid=0000000040
Note: This classic document covers integration of
mental health care into PHC.
WHO (1994). Quality assurance in mental health care.
Checklists, glossaries, volume 1. WHO: Geneva.
http://whqlibdoc.who.inl/hq/1994/WHO_MNH_MND_94.17.pdf
WHO (1996). Mental health of refugees. Geneva: World
Health Organization in collaboration with the Office of
the United Nations High Commissioner for Refugees.
http://whqlibdoc.who.int/hq/l996/a49374.pdf
WHO (1999). Declaration of cooperation: Mental Health of
refugees, displaced and other populations affected by conflict and
post-conflict situations. WHO: Geneva.
hllp://www.who.inl/disastcrs/cap2002/lcch.htm
Note: This declaration summarises guiding
principles for projects for populations exposed to
extreme stressors.
WHO (1999, revised 2001). Rapid assessment of mental health
needs of refugees, displaced and other populations affected by conflict
and post-conflict situations: /I community-oriented assessment.
WHO: Geneva.
http://www.who.inl/disasters/cap2002/lech.htm
Note: This document outlines qualitative assessment of
the context of the refugee situation. The document
focuses on preparation, scope of assessment and
reporting.
•
WHO (2000). Preventing suicide: A resource for primary health
care workers. WHO: Geneva.
Note: This document is written for PHC and community
workers to treat a variety of mental health disorders
and problems in refugee camp settings.
http://www5.who.int/mcntal_hcallh/download.cfniiid =0000000059
WHO (1997). Quality assurance in mental health care. Checklists,
glossaries, volume 2 WHO: Geneva.
WHO (2000). Women's mental health: An evidence based review.
WHO: Geneva.
hllp://whqUbdoc.who.int/hq/l997/WHO_MSA_MNII_MND_97.2.pdf
htlp://www5.who.int/mcntal_heallh/download.cfmlid=0000000067
Note: These two documents cover quality assurance,
monitoring and evaluation of mental health services in
Note: This report provides the latest research evidence
pertaining to the relationship between gender and
mental health, with a focus on depression, poverty,
social position and violence against women.
a variety of settings.
WHO (1997). Promoting independence ofpeople with disabilities
due to menial disorders: A guide for rehabilitation in primary
health care. WHO: Geneva.
Note: This booklet summarises basic knowledge on
suicide prevention for the PHC worker.
WHO (1998). Mental disorders in primary care.
WHO (2001). World Health Report 2001. Mental health: New
understanding, new hope. WHO: Geneva.
Note-This is an authoritative and comprehensive review
on the epidemiology, burden, risk factors,
prevention and treatment of mental disorders
|
world-wide. This report provides the framework for
organizing country mental health programmes.
WHO: Geneva.
http://www.who.int/whr2001 /2001 /mam/en/pdf/whr2001.cn pdf
http://whqlibdoc.who.int/hq/1998/WHO_MSA_MNHIEAC_98.l.pdf
(English version) or
Note: This document contains an educational
programme to assist PHC providers in the diagnosis
and treatment of mental disorders.
(French version)
WHO (1998). Diagnostic and management guidelines for mental
WHO (2001). The effectiveness of menial health services in
primary care: The view from the developing world
WHO: Geneva.
http://whqlibdoc.who.inl/hq/1997/WHO_MND-RHB_97.1. pdf
Note: This is a manual with guidelines for treatment of
mental disability by the PHC worker.
disorders in primary care: ICD-10 Chapter V Primary
Care Version. WHO: Geneva.
http://www.who.int/msa/mnh/ems/icdlO/icdlOpc/icdlOphc.him
Illlp://www.who.inl/whr2001/2001/main/fr/pdf/whr200l.fr.pdf
http://www5.who.int/mental_hcalth/download.cfmlid=0000000050
Note: This is a review and evaluation of the
effectiveness of mental health programmes m PHC in
developing countries.
WHO (2002). Wbrting with countries: Mental health policy and
service development projects. WHO: Geneva.
hltp://*v\Av5.who.int/mcnul_heallh/download.cfm?id=000000(H(H
Note: This document describes a variety of technical
assistance activities of mental health policy-making and
service development at the country level.
WHO (2002). Nations for Mental Health: Final report.
WHO: Geneva.
hllp.7/«Tvw5.»ho.int/menlal_heallh/download.cfni ’id=000000<M(X)
Note: This document summarises WHO’s recent
strategics: to raise awareness to the effects of mental
health problems and substance dependence, to
promote mental health and prevent disorders, to
generate capital for mental health promotion and care
provision and to promote service development.
■k'HO (2002). Atlas: Country profiles of mental health resources.
W'HO: Geneva.
hltp://mh-atlas.ic.gc.ca
Note: This updated, online searchable database provides
available information on mental health resources in
most countries of the world, including countries with
large populations exposed to extreme stressors.
Further information and feedback
For further information and feedback, please contact Dr Mark Van Ommercn
(vanommercnm@who.int, fax: +41-22 791 4160), resource person within WHO on
mental health in emergencies, in the team Mental Health: Evidence and Research
(Coordinator: Dr Shekhar Saxena).
WHO regional advisors
WHO mental health emergency activities are implemented in collaboration with
WHO’s Regional Mental Health Advisors, namely:
Dr Vijay Chandra
WHO Regional Office for South-East Asia
New Delhi, India
chandrav@whosca.org
Dr Xiangdong Wang (a.i.)
WHO Regional Office for the Western Pacific
Manila, Philippines
wangx@wpro.who.int
Dr Custodia Mandlhatc
WHO Regional Office for Africa
Brazzaville, Republic of Congo
mandlhatcc@whoafr.org
Dr Claudio Miranda
WHO Regional Office for the Americas I
Pan American Health Organization
Washington, USA
mirandac@paho.org
Dr Ahmad Mohit
WHO Regional Office for the Eastern Mediterranean
Cairo, Egypt
mohita@who.sci.eg
Dr Wolfgang Rutz
WHO Regional Office for Europe
Copenhagen, Denmark
wru@who.dk
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