WORKSHOPS TRAINING PROGRAMMES ON -MENTAL HEALTH
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World
| Health
Forum
■'*
Leon Eisenberg
Preventing mental, neurological and
psychosocial disorders
Printed from World Health Forum. Vol. 8, 1987 with the support from WHO Country Funds,
MNH/001 1988-89.
Prevention
Leon Eisenberg
Preventing mental, neurological
and psychosocial disorders
Mental, neurological and psychosocial disorders constitute an enormous
a public health burden. A comprehensive programme directed against their
biological and social causes could substantially reduce suffering, the
destruction of human potential, and economic loss. It would require the
commitment of governments and coordinated action by many social
sectors.
a
In the early decades of the twentieth
century, claims that the mental hygiene
movement would prevent adult psychiatric
disorders proved to be unfounded. Even
today we know so little about such disorders
as schizophrenia, parkinsonism and senile
dementia that we cannot design programmes
for their prevention. Nevertheless,
prevention is important in some areas. At
the turn of the century, mental hospitals
were full of patients with general paresis
and pellagra; today, both diseases are rare in
the developed world, the first because of
effective treatment for syphilis and the
second because of improved diet. Many
other neuropsychiatric disorders can be
tackled effectively. In the schizophrenias and
affective disorders, the frequency with which
there is troublesome behaviour or a chronic
inability of patients to look after themselves
The author is Maude and Lillian Presley Professor and
Chairman, Department of Social Medicine and Health
Policy, and Professor of Psychiatry, Harvard Medical
School, Boston, MA 02115, USA.
World Health Forum Vol. 8
1987
can be reduced if the health team,
community and family respond promptly
and constructively. The public should be
educated about the nature and extent of
mental health problems and, where possible,
about their treatment and prevention.
Without an informed public there is little
hope of persuading governments to make
the necessary policy decisions.
An underestimated problem
The magnitude of the mental, neurological
and psychosocial disorders is usually
underestimated because:
— vital statistics measure mortality rather
than morbidity;
— even where morbidity is recorded, the
extent of neuropsychiatric morbidity is
not properly monitored;
— the tabulation of causes of death
according to disease entities does not
indicate the underlying behavioural
Prevention
causes, e.g., alcohol abuse as the cause of
cirrhosis or motor vehicle accidents.
Mental and neurological disorders
Mental retardation. The prevalence of severe
mental retardation below the age of 18 is
3-4 per 1000; that of mild mental
retardation is 20-30 per 1000. In the
developing world in particular, faulty
delivery methods can lead to birth traumas
and the central nervous system can be
damaged by bacterial and parasitic
infections. Of particular importance is the
mild mental retardation and maladaptation
associated with severe social disadvantage.
Acquired lesions of the central nervous system.
Damage to brain tissue resulting from
trauma, infection, malnutrition, hypertensive
encephalopathy, pollutants, nutritional
deficiency and other factors is a major
source of impairment. It has been estimated
that 400 million persons suffer from iodine
deficiency; their offspring are at risk of
brain damage in utero (1). Particular attention
must be paid to the debilitating effects of
It is wrong to use potentially toxic
drugs when what is needed is
social support, or to rely on
institutional care for patients who
can be restored to function while
in the community.
cerebrovascular accidents secondary to
uncontrolled hypertension, a rapidly
increasing problem in developing countries.
Cerebrospinal meningitis, trypanosomiasis
and cysticercosis are major causes of brain
damage. Persistent infections, even when
the brain is not directly invaded, impair
cognitive efficiency.
2
Peripheral nervous system damage. Inadequate or
unbalanced diet, metabolic diseases,
infections, traumas and toxins can cause
incapacitating peripheral neuropathies with
numerous social and psychiatric
consequences.
Psychoses. The prevalence of severe mental
disorders such as schizophrenia, affective
disorders and chronic brain syndromes is
estimated to be not less than 1%; somewhat
more than 45 million mentally ill persons
suffer compromised social and occupational
function because of these conditions. The
annual incidence of schizophrenia is
approximately 0.1 per 1000 in the
population aged 15-54 years. The rate for
depressive disorders is several times higher.
Dementia. Dementia can be caused by
metabolic, toxic, infectious and circulatory
diseases. The burden on health services rises
as an increasing proportion of the
population survives to older ages and
becomes vulnerable to senile dementia of
the Alzheimer type.
Epilepsy. The prevalence of epilepsy in the
population is 3-5 per 1000 in the
industrialized world and 15-20 or even
50 per 1000 in some areas of the developing
world. This tenfold difference in prevalence
provides a measure of what could be
accomplished by a comprehensive
programme of prevention in the developing
countries. The extent of social handicap
resulting from epilepsy varies with its type,
the adequacy of medical management, and
community acceptance of or support for
patients.
Emotional and conduct disorders. Such disorders
are estimated to affect 5-15% of the general
population. Not all cases require treatment
but some can lead to major impairment.
Disorders of conduct, which are frequent
World Health Forum Vol. 8 1987
Mental, neurological and psychosocial disorders
among schoolchildren and interfere with
learning in the classroom and with social
adjustment, often respond well to simple
treatments (e.g., behaviour therapy and the
counselling of parents), although recurrence
is common. Learning disorders, whether or
not they are associated with other
psychiatric symptoms, require special help in
the classroom in order to avoid secondary
emotional problems and occupational
handicaps.
Drug abuse. Drug abuse and dependence have
increased in most countries (2). There are
some 48 million drug abusers in the world,
including 30 million cannabis users,
1.6 million coca leaf chewers, and 1.7 and
0.7 million people dependent on opium and
Mental deterioration in the elderly
can also be prevented by avoiding
unnecessary hospitalization.
Behaviour injurious to health
Alcohol-related problems. Recent decades have
witnessed considerable increases in alcohol
consumption and a parallel increase in
alcohol-related problems, including cirrhosis
of the liver, difficulties at work and home,
and alcohol-related traffic accidents. Alcohol
abuse by the individual has devastating
effects on the family. A particularly tragic
consequence of drinking during pregpancy is
the fetal alcohol syndrome.
In the WHO European Region, the number
of countries with an annual per capita intake
of more than 10 litres of pure alcohol
increased from three in 1950 to 18 in 1979.
Countries in the WHO Western Pacific
Region have reported that there were sharp
increases in alcohol-related health damage,
- crime and accidents during the 1970s.
Although some countries in Europe and
North America are now reporting a levelling
off or even a modest decline in alcohol
consumption, the global trend is still
upwards, with particularly sharp increases in
commercially produced alcoholic beverages
in some developing countries in Africa,
Latin America and the Western Pacific.
However, it is notable that in Australia
between 1978 and,1984 a 10% reduction in
per capita consumption of alcohol was
accompanied by a 30% reduction in deaths
caused by alcohol.
World Health Forum Vol. 8
1987
heroin respectively. Cocaine abuse is
widespread and increasing. Amphetamines,
barbiturates, sedatives and tranquillizers are
consumed in most countries and their abuse,
as well as multiple drug abuse, is increasing
throughout the world in parallel with their
increasing availability. Large regions have
become dependent on the income derived
from growing cannabis, the opium poppy
and the coca shrub, and this adds to the
difficulty of implementing control measures.
Psychotropic drug abuse. The ready availability
of psychotropic substances, insufficient and
often misleading information and
unjustifiable prescribing practices have led to
the overuse and abuse of psychotropic drugs.
Tobacco dependence. Smoking is a socially
induced form of behaviour maintained by
dependence on nicotine. It causes a high
proportion of cases of cancer, chronic
bronchitis and myocardial infarction.
Between 1976 and 1980 tobacco
consumption decreased annually by 1.1% in
the industrialized countries but increased by
2.1% annually in the developing countries.
Besides premature deaths, which have been
estimated at over 1 million per annum,
innumerable cases of debilitating diseases,
such as chronic obstructive lung disease, are
3
Prevention
caused by smoking. The proportion of
women of reproductive age who smoke
regularly, already high in most industrialized
countries, has been increasing rapidly in the
developing world.
Conditions of life that lead to disease
Many health-damaging circumstances are
beyond the control of the individual:
homelessness, unemployment, lack of access
to health and social services, the loss of
social cohesion in slum areas, forced
migration, racial and other discrimination,
forced idleness in refugee settlements, war,
and the threat of nuclear war.
In addition to these factors, individual
life-styles can influence the risk of disease.
Although the significance of excess animal
fat in the diet, insufficient physical exercise
and psychosocial stress in the epidemic of
cardiovascular disease affecting the
industrialized world cannot be precisely
quantified, most authorities agree that these
are important risk factors. Behavioural
patterns certainly influence disease
pathogenesis and it is important to make full
use of our knowledge of mental health
and our psychosocial skills to design
interventions aimed at preventing disease
that is secondary to unfavourable behaviour.
Disorders of conduct are frequent
among schoolchildren and often
respond well to simple treatments.
In this connection, methods of dealing with
excessive stress merit further study; stress
becomes a pathological agent when it is
intense, persistent, and beyond the coping
capacity of the individual.
Violence. Violence, including accidents,
homicide and suicide, is one of the main
causes of death in most countries.
Psychosocial factors and mental disturbance
play an important role in its occurrence.
Child abuse and wife battering are among
the particularly dramatic indicators of
violence in the family.
Excessive risk-taking by young people.
Experimenting with drugs and alcohol,
sexual activity without precautions against
sexually transmitted diseases, adolescent
pregnancy, driving at excessive speed, and
challenging established guidelines for health
and safety result in serious morbidity and
mortality. Pregnancy in girls aged 15 or less
leads to a cycle of disadvantage. The
immature mother is unable to care properly
for her child, while her maternal
responsibility is a barrier to the education
and employment essential for her own
development.
Eamily breakdown. Family breakdown
interferes with the upbringing of children. A
household headed by a woman is more
likely to be below the poverty threshold
than one headed by a man, adding to the
mother’s difficulty in raising a family.
Weakened family units also contribute to
community disorganization and a variety of
psychosocial and other health problems.
Somatic symptoms resulting from psychosocial distress
Many patients who consult primary health
care w-orkers either have no ascertainable
biological abnormality or, if they have one,
complain disproportionately about their
discomfort and dysfunction. Unless the
psychosocial source of physical symptoms is
recognized, the people affected are likely
to be inappropriately investigated and
treated, cause excessive cost to the health
system'or themselves, and become chronic
World Health Forum Vol. 8
1987
Mental, neurological and psychosocial disorders
patients vainly seeking relief. The inclusion
of basic mental health care as part of
primary care reduces the cost of treatment
and improves its outcome.
Proposals for action
It should be noted that intersectoral
coordination is essential for the success of
the measures outlined below.
Measures to be undertaken
by the health sector
Success in carrying out preventive and
therapeutic measures depends greatly on the
psychosocial skills of primary health care
workers, i.e., on their sensitivity, empathy
and ability to communicate, as well as on a
thorough knowledge of the community, its
culture and its resources. Training in these
skills is therefore no less essential than is the
customary technical training. In their
absence, diagnostic errors multiply,
adherence to treatment recommendations
declines, health workers exhibit “burn-out”,
and the health facility fails to achieve its
goals.
Prenatal and perinatal care. In view of the need
to protect the fetus and the newborn child
and to provide optimum conditions for
ji development, and given the high mortality
and morbidity associated with prematurity
and low birth weight:
— high priority should be given to the
provision of adequate food and to
education about nutrition to all pregnant
women;
— direct counselling of pregnant women
should be practised to reduce the
prevalence of developmental anomalies
and low birth weight caused by cigarette
smoking and the consumption of alcohol
during pregnancy;
World Health Forum Vol. 8 1987
— in areas where neonatal tetanus is
prevalent, pregnant women should
receive tetanus toxoid after the first
trimester and birth attendants should be
trained in sterile techniques for cutting
the umbilical cord;
— in iodine-deficient areas, women of
child-bearing age should be given iodized
oil injections or iodized salt in order to
prevent the congenital iodine deficiency
syndrome;
— birth attendants should be trained to
recognize high-risk pregnancies and to
refer deliveries that are expected to
be complicated to specialist facilities,
since the prevention of obstetrical
complications can reduce the number of
children with central nervous system
damage;
— the promotion of breast-feeding should
be an integral component of primary
health care.
Programmes for child nutrition. These should be a
major component of prevention because
malnutrition can impair cognitive and social
development.
Immunisation. The immunization of children
against measles, rubella, mumps,
poliomyelitis, tetanus, whooping-cough, and
diphtheria could make an important
contribution to the prevention of brain
damage.
Family planning. Child development is
adversely affected when mothers have too
many children at unduly short intervals or
when they are too young or too old.
Education on family planning and access to
effective means of contraception are
therefore essential elements in maternal and
child care.
5
Prevention
Measures against abuse of and dependence
on psychoactive substances
Primary Health care workers should
routinely counsel patients against smoking.
Although only 3-5% will respond by
stopping smoking, there is a large gain from
the public health standpoint because of the
high prevalence of the habit. Repeated
efforts to quit have cumulatively higher rates
of success and a low initial response should
not discourage subsequent efforts.
Health workers can be trained to recognize
the early stages of alcohol and drug abuse,
using WHO manuals and guidelines. Brief
counselling can help a significant number of
patients to alter their behaviour before
dependence and irreversible damage occur.
Crisis intervention in primary health care
course of evaluating new patients. This
enables them to recognize symptoms that
indicate psychological distress and to avoid
the overuse of psychotropic and other drugs
and the iatrogeny that results from such
practices. Brief counselling and, where
necessary, referral to social welfare or
mental health workers can significantly
diminish the number of clinic visits.
Behavioural disorders that are the iatrogenic
effect of prolonged or repeated
hospitalization can be prevented by
minimizing the hospitalization of children,
encouraging family participation when
hospital care is unavoidable, and introducing
certain organizational arrangements in
hospitals (e.g., assigning a primary nurse to
each child). Mental deterioration in the
elderly can also be prevented by avoiding
unnecessary hospitalization.
In the event of acute loss (e.g., the death of
a spouse, which increases morbidity and
mortality among survivors), there is some
evidence that group and individual
counselling of the bereaved can diminish
risk. Self-help and mutual aid groups can
improve health at minimum cost to the
health services. Well-trained crisis
intervention units can handle a variety of
acute mental health problems and thus
prevent chronic difficulties.
Although measures to prevent dementia
must await the results of further research,
cognitive impairment resulting from
depression and infection can be reversed
by prompt treatment. At present, the
distinction between dementia and depression
in the elderly is not recognized by the family
doctor in four out of five cases. A relatively
short period of training can enable
physicians and other health workers to
improve their diagnostic skills in this area.
Prevention of iatrogenic damage
Minimizing chronic disability
Failure to diagnose and correctly treat
psychosocial disorders results in iatrogenic
damage. Thus it is wrong to use potentially
toxic drugs when what is needed is social
support, or to rely on institutional care for
patients who can be restored to function
while in the community.
Education of primary care workers in the
recognition of sensory and motor handicaps
in children, the use of prosthetic devices to
minimize handicaps, and the referral of
handicapped children to the educational
authorities can prevent both cognitive
underachievement and social maladjustment.
Properly-fitted spectacles and hearing aids
can reduce the likelihood of mental and
social handicap in children.
Health workers can be trained to inquire
routinely about psychosocial problems in the
World Health Forum Vol. 8 1987
Mental, neurological and psychosocial disorders
Because the incidence of cerebrovascular
disease can be reduced by the effective
treatment of hypertension, primary care
workers should be trained in the diagnosis
and treatment of hypertensive disease;
similarly, acquired lesions of the central
nervous system can be reduced by prompt
treatment of, for example, meningitis.
Health workers should be trained to manage
febrile convulsions, recognize epilepsy, and
control seizures with low-cost anticonvulsant
drugs in order to minimize damage to the
central nervous system, as well as reduce
accidental injury and reduce the psychosocial
invalidism and isolation that result when
treatment is not provided. An uninterrupted
supply of drugs of assured quality is of
paramount importance.
Primary care workers should be trained to
recognize schizophrenia and to manage it
with low-dose antipsychotic drugs, to
counsel relatives with a view to minimizing
chronicity and avoiding the social
breakdown syndrome, and to diagnose and
treat patients suffering from depression.
Such patients, who commonly present
multiple somatic symptoms, may be
inappropriately investigated and treated for
somatic disorders, and are at risk for suicide.
Effective treatment with antidepressants and
prevention using lithium salts can be
provided at relatively low cost.
Action at community level
and in other social sectors
Better day care for children. Retarded mental
development and behavioural disorders
among children growing up in families that
are unable to provide suitable stimulation
can be minimized by early psychosocial
stimulation of infants and by day-care
programmes of good quality, particularly if
the parents participate. However, day care
World Health Forum Vol. 8
1987
must be of adequate quality; child-minding
in crowded quarters by people who are too
few in number and inadequately trained may
retard development, not facilitate it. Among
useful measures that could be taken are:
— surveys of existing day-care facilities and
assessment of the need for them;
— establishment of quality standards and
appropriate regulatory measures;
— setting of targets for quality and for
training staff in the psychosocial
development and needs of children.
Upgrading long-term care institutions. Although
the use of institutions for long-term care can
be minimized by providing alternatives in
the community, they will continue to be
necessary. The quality of the institutional
environment is a major determinant of the
way the patients function. It is therefore
important to subject such institutions to
regular evaluation and to improve their
architectural design and the content of work
programmes where necessary.
Self-help groups and support services. Self-help
groups, organized by lay citizens, are
effective in reducing the chronicity of
In Australia between 1978 and
1984 a 10% reduction in per capita
consumption of alcohol was
accompanied by a 30% reduction
in deaths caused by alcohol.
certain disorders (e.g., Alcoholics
Anonymous), in enabling the handicapped
to improve their functional ability (e.g.,
societies that help epileptics), in educating
the community about the nature of
disorders, and in advocating changes in
Prevention
legislation, better resource allocation, and
satisfaction of the needs of people with
specific disorders. Furthermore, community
self-organization for local development has
been shown to reduce the psychopathology
associated with anomie (a state of alienation
from the community) and helplessness (3).
Support services provided at community
level can enable people to care for relatives
with chronic illnesses who would otherwise
require more expensive and less satisfactory
institutional care. An excellent example is
the organization of “home beds” for
chronically handicapped mental patients in
China: neighbourhood volunteers who are
retired workers care for patients while
their relatives are away at work. To
maintain residual function and to avoid
institutionalization, chronic mental
patients must be provided with housing,
opportunities for sheltered employment, and
recreation.
Schools. The progressive extension of
compulsory schooling provides new
opportunities to broaden people’s
understanding of how they can protect their
health. At the same time it leads to the
identification of child health problems not
previously known to health authorities.
A variety of risks to mental health and
psychosocial development can result from a
lack of parental skills and from parents’
insufficient knowledge of their children’s
needs. Urbanization and other social changes
result in a growing number of young parents
not possessing such skills. Education for
parenthood may well have to become a
public responsibility. Creches and nursery
schools can be sited next to secondary
schools, whose students can be assigned to
work in them under supervision. Trained
leaders for groups of new mothers can guide
discussion on child-rearing and thus provide
a valuable form of self-help.
8
Instruction about family planning, sex, child
development, nutrition, accident prevention
and substance abuse are among the subjects
that are most frequently recommended for
inclusion in school curricula. A particularly
promising way of preventing substance
abuse among early adolescents is to
encourage them to acquire the behavioural
skills necessary to resist pressure to use
cigarettes, drugs and alcohol.
If trained properly, teachers can identify
children with sensory or motor handicaps or
with mental health problems that have not
been detected by the health sector.
Collaboration between teacher, parent and
health worker is central to the rehabilitation
of children with chronic handicaps and to
the avoidance of social isolation and other
untoward consequences.
Public health measures for accident prevention. In
view of the high mortality and morbidity
resulting from accidents and poisoning,
measures for their prevention must be
given high priority. Brain damage caused by
toxic substances in the workplace can be
prevented by imposing strict limits on
exposure; untoward effects of shift work
can be avoided using the principles of
chronobiology; child-proof safety caps on
medicine bottles and containers of
household chemicals can reduce the
ingestion of poisons and consequent damage
to the central nervous system; lead
poisoning in children can be prevented by
prohibiting paints containing lead for
household use and by decreasing the lead
content of petrol.
The media. Radio, television, newspapers and
comic strips can play a major role in public
health education—for the better (e.g., by
explaining why sanitation is essential for
health) or for the worse (e.g., by advertising
cigarettes).
World Health Forum Vol. 8
1987
'OU
Mental, neurological and psychosocial disorders
Cultural and religious influences. Cultural factors
are among the principal determinants of
human behaviour. A knowledge of cultural
and religious forces can be applied by health
workers in their efforts to reduce
health-damaging practices.
Government action
_
Prevention works only if governments want
it to work: action must be planned not only
in the health sector but in all other sectors
important for health, such as education,
agriculture, environment, etc. Any country
undertaking a prevention programme should
have a national coordinating group on
mental health with the authority to assign
tasks to the appropriate sectors. The
coordinating group should have at its
disposal an information centre that can
collect and feed back data on changes in the
nature and trends of problems and on the
effects of intervention and task performance.
One of the first duties of the centre should
be to conduct a comprehensive review of
legislation affecting such matters as mental
health, family life, health services, drug
control and schools.
In the area of prevention, government
actions in various spheres may have
*21 implications for health; housing projects may
worsen mental health because of bad design;
industrial development projects may destroy
local culture and lead to family disruption,
child neglect and substance abuse; and the
widespread use of pesticides without
safeguards may lead to brain damage.
results obtained in one country to another
may be entirely misleading. It is therefore
important to foster research programmes of
two kinds:
— studies on the distribution of problems in
specific populations and on changes in
the pattern with time;
— investigations to enable assessments to be
made in particular countries of measures
that have been proposed for large-scale
application.
Both types of study should be carried out at
the national or subnational level. An urgent
task that should be included in programmes
of technical cooperation between countries
is the development of methods for
conducting such studies. The involvement of
institutions in developing countries in
multi-centre research, research training
courses and information exchange should be
used to create and/or strengthen the basis
for a further growth of knowledge in this
field.
Acknowledgements
The author acknowledges with gratitude the helpful
comments provided by staff members of the WHO
Regional Offices and of the Division of Mental Health at
WHO headquarters. He also thanks the members of
Expert Advisory Panels, and others too numerous to
list individually.
References
Hetzel, B. & Orley, J. Correcting iodine
deficiency: avoiding tragedy. World health forum,
6: 260-261 (1985).
2.
Hughes, P. H. et al. Extent of drug abuse: an
international review with implications for health
planners. World health statistics quarterly, 36:
394—497 (1983).
3.
Eisenberg, C. Honduras: mental health awareness
changes a community. World health forum, 1:
72-77 (1980).
1.
There is a need for research into the causes
and mechanisms of disease in order to
develop new and better means for
prevention and control. Data on prevalence
and the effectiveness of interventions
frequently do not exist, particularly in
developing countries. The extrapolation of
World Health Forum Vol. 8
1987
World Health Forum
Leon Eisenberg
Preventing mental, neurological
and psychosocial disorders.
For copies of this reprint, please write to:
The Director, NIMHANS, P.B. No. 2900, Bangalore-560 029.
pin -*>•
WORKSHOP ON PREPARATION OF TRAINING MATERIALS FOR THE
NATIONAL MENTAL, HEALTH PROGRAMME
26-27 June, 1989
* '
REPORT
The session began with welcome and introduction by the
Director, NIMHANS.
He briefly explained the aims and
objectives of the National Mental Health Programme.
Subse
quently other staff memoers of NIMHANS recounted the genesis
of the programme, particularly the development of the train
ing aspect.
Details of present training programmes, avail
able training materials and the need for more audio visual
materials were discussed.
Finally the purpose of this work
shop was aiso elaborated upon.
Apart from reviewing the audio visual material - video
and slides, members felt it is important that a guide book/
training manual be prepared.
This would help the trainer
to use the training material appropriately and effectively.
A decision on the concent of the training guide should be
included in the recommendations of the workshop.
The
members noted that the audio visual materials would not
stand on their own out comprise a part of the total train
ing process which .should emphasise participatory learning
and include demonstration ano field area practice.
1.
1.1
Review of the video on Rural Mental Health Centre.
While noting that this video might be good for orien
ting trainees on the SaKalwara Rural Mental Health
Centre. It did not adequately show the integration
of mental health into primary health care. This
video could just serve as a case study.
for such a video isinot great.
Trie need
Instead another
video should focus on integration.
1.2
Several ways of showing the integration of mental
health in primary health care was suggested
- the depiction of work at Solur PHC or Bellary
Dist.
- incorporation ot mental healtn in<_o on going
National Programmes sucn as Immunisation, IcDS
- Portrayal of PHC staff carrying on mental health
activities.
- Message snould be that mental Health promotion
and treatment can be part of any PHC activity
..2/-
2
- Visuals snoula Snow ideal rather tnan actual
- Team work in the primary health care setting
which includes mental health.
1.3
The reviewers felt that the interviews were too
directive and suggestive.
1.4
The narration dominated the visuals ana there was
no synchronisation between the narrations and
visuals.
1.5
The visuals could be more effective, colour quali
ty could be improved, captions were difficult to
read, visuals should show more of the interactions.
The captions could be interspersed with visuals of
people.
1.6
To overcome these problems it was suggested that
the "ideal’ doctors and patients be chosen for
interviews.
Certain amount of stage managing is
necessary, to get best quality video, e.g. the
matter on black board should be written before
hand.
1.7
The video need not emphasise already known facts
such as the difficulties of living in rural areas
and the video snould also not decry or denigrate
traditional meaicine but high light the positive
aspect.
1.0
It is suggested that the video could start in a
dramatic manner beginning with the problems faced
by mental patients in tne rural area or the diffi
culties doctor faced treating such patients.
1.9
The video needs closer editing, the total duration
of the viueo could be reduced to 60% of the present
length.
1.10 To make the video more amenable to wider distribu
tion visuals from other parts of India need to oe
included.
2.
Review of Clinical cases:
Although each case was reviewed separately mucn of
the comments- were similar for each case, so, here
the comments will be presented together.
3
2.1
The reviewers agreed that a short introduction to
each case would prepare the viewer.
It may or may
not include details of relevant symptoms.
Without
this'introauction the cases start very abruptly.
The doctors introduce patients ana give a short
case description before beginning the interview.
2.2
The interviews should be less directive and more
crisp.
2.3
There is need to evolve a format for interviewing-
2.4
. Spontaneity would be lost if actors were employed.
Patients rights should be protected by asking their
consent on tape or by running a caption througnout
the video stating the video is only for professional
use.
2.5
In terms of visuals, shots from different angles,
more close ups, reactions shots are necessary.
For
effective communication two cameras are imperative.
Later these could be mixed during editing.
2.6
The summaries should aiso be less didactic and more
conversational.
Treatments such as psychotnerapy
should also be included and might also include the
effect of treatment and patients recovery.
This
summary mignt also include other visuals rather
than just doctors such as clips from the interview
which illustrate the symptoms or other illustrations
and charts, to enhance the points made by the
narrator.
2.7
Fine editing is required to maxe the cases educat
ive and effective.
The psychiatrist need to
review it to make sure the only information relevant
to PHC doctors is inciuaed.
2.8
With modifications this material could also be made
into self-instruction material.
2.9
One of the major draw backs of these cases are that
the heavy representation of middle class, English
speaking patients.
These cases may not be relevant
to the health workers in health professionals in
rural PHCs. Effort should be made to include rep
resentative cases from rural area.
It need be it
can be dubbed in English or other regional languages.
2.10
Specifically in the manic depressive psycnosits
(MOP) case only tne information on mania should
be presented and the depressive reatures which
are not present at that time should not be
included.
Many questions and issues were raised in this session
regarding the methodology that needs to be adopted.
Concrete suggestions ana recommendations should be forth
coming in the final round up session.
The group also viewed video cassettes produced by
other agencies, this included two videos on prevention
of oral cancer in Kannada and one on mental retardation.
The group did not have an opportunity to review these
videos as yet.
The group planned to meet in the next day to review
slides, epilepsy vi^eo and videos produced by other
agencies before working out final guidelines.
Tuesday 27-6-1989
3.
The session began with tne review of sliaes.
The
reviewers reviewed siiues for one chapter - Mental
Retardation.
3.1
Reviewers felt that the siiaes should be a visual
accompaniment to the manual, therefore, there is no
need to present much of the written content.
They
suggested :
- to make the content mucn more prescise by dropping
prepositions, adjectives, adverbs
- spacing the words oetter, three dimensional por
trayal of concepts
- including line diagrams, pictures, charts etc.
to supplement written words
- using a variety of siiaes including line diagrams,
photographs, graphs, charts etc.
- adding more in'formacion than what is present in
the manual
- presenting only one idea for each frame
- giving more weightage to visuals which present
information not available to the trainer such as
pictures of.clinical cases, pictures of the
anatomy or the Qrain etc.
-5- the photographs snoula be present classical,
clinical cases
- when content of slices is continued in the
following slice a continuation caption snould
come on top.
3.2
Overall, in producing sli^s, priority content
for communication should be identified.
The slide
set should form a visual supplement to communicate
difficult concepts.
4.
briefly reviewing the manual for the medical
officers and multi-purpose workers the reviewers
noted that ooth the manuals were very similar,.
The manuals did not ta-.e in to cwsisiueration
communication concept in the lay out and design.
Particularly, the manual for multi-purpose workers
needs to be specially designed for the educational
level of such workers.
The manual needs to focus
on existing programmes such as family planning,
ICDS, immunisation, antenatal care and identify
where men ..al health in-put is needed and how the
worker can do this, i.e. the manual needs to be
much more skills oriented.
5.
Next,.the group reviewed the video on epilepsy.
Prof. 11. Gouri Devi and Dr. Satish Chandra, from
the Department of Neurology, NIKHAilS, joined the
group. This video was reviewed section by
section.
At the outset there was little agree
ment whether the same video could be used for both
medical officers and multi-purpose workers.
The
neurologists felt that the meaic-il officers need
to know more details and statistics.
Public
health professionals, however, thougnt that
many/offleers are not conversant with epilepsy
and also need to be educated from the oeginning.
6
5.1
Specific comments on each section:
Section I - Introduction and Types of; Epilepsy
There is a need to demonstrate epilepsy or fits
so that the viewer is clear about the content.
- for the PHC scene more community shots
are needed
- for explaining grandmal epilepsy, figures
(from Netter) need to be enlarged and
depicted in an Indian style
- delete - hot water epilepsy is not
dangerous
- captions on differentiating hysteria
from epilepsy needs to be redrawn
- while mentioning febrile convulsion
include the picture of the child
wi th fever.
•5.2
Section 3 - Causes and Prevention
- Generally, some viewers felt that cause
and prevention suould be separated, that
the cause snould be shown in
the
beginning and prevention after
the
follow up section.
...7/-
- 7 _
- Life cycle approach tofene causal factors of epilepsy
may be more meaningful for the community level workers,
so factors causing epilepsy - occurring before birth,
during the birth, infancy in chile hood ano adult hood
coule be shown.
- The visuals should be more oriented to a rural area
- In intoxication only include alconol as a cause and
delete drugs.
- Realistic, actual scenes rather than pictures should
be used.
- To show that epilepsy is not contagious, show a patient
frothing at rhe mouth ano say that this froth is not
contagious.
— In narration X-ray should come before EEG because of the
visual order
5.3
Section 4 - Treatment
- Abbreviations should not be useu in captions.
- In treatment, the drug dosage snould be emphasised as
most mistakes occur in prescribing
- In showing dosage divide the captions into three parts.
(emphasise should be on tORing the tablets rather than
having the meals) .
- Visual of patients sleeping is not necessary
- For showing keep medicine away from children use a
actual situation.
- Include section with says : the patient snould come back
for more drugs; a week or ten days before exhausting the
drugs.
5.4
Section 5 - First Aid
- Change the caption "do not hold" to "hold the patient
gently do not use force".
- Instead of just roll the kerchief, say roll' a small piece
of cloth and show other types of cloth also
- It was suggested split screen should be used to for the
captions as well as the picture.
After status epilepti-
cus show ICU or consultancy
- Often patients know, that they will have an attack, ask
them to take precautions.
- 8 -
Follow up:- The patients need to be prepared for the interview
- Show that the patient himself coming rather than the
relative.
5.6
Living with epilepsy;
- Again in this section actual scenes need to be depicted.
5.7
Overall participants felt that this video communicated the
message adequately with changes as suggested and better
synchronisation of the narration ana sound with the visuals
this video can be produces.
6.
The group reviewed towards light and the film and the video
schizophrenia produced by SCARF
6.1
Towards Light :-
The group agreed that this is a good introductory video which
could be used by all the centres,
could be further discussed.
it raised many issues which
The only change may be to modify
the institution based creatm^nt to a more community oriented
treatment.
6.2
Again,, thisvideo could be good a introduction to general con
cepts of psychoses.
As it depicts three patients of different
social classes, the urban bias is not obvious.'
6.3
Over all decision, that the film both technically correct and
professionally made so that snould be used.
7.
7.1
Overall round up:
The group emphasised that the teaching aids should not only
provide the content but also improve the teaching process.
This is particularly important in psychiatry because approach,
and interpersonnel relationship, and communication is critical.
7.2
The non-electronic media'such as flip charts, role plays, sti
mulation games, all can enhance the process the pacKages on
whole should be reviewed.
The pacKage also should utilise
multi-media approach and depict multi situations.
It was
suggested that voluntary agencies with social orientation
who are involved in media production should to be contacted
and their help sought in preparing the medial
7.3
The media should help to integrate the National Mental
Health Programme as a part of the overall primary health
centre activities which include of the other national
health programmes.
7.4
The package should help the trainer to be creative, it
should be flexible, so that the trainer can use it as a
resource. It should not become the constricting variable f°r
the trainee.
7.5
The synopsis for the video on integration of Mental Health
was briefly reviewed. The group agreed with the content
and suggestedjdramatic approach be adopted to aiouse audience
interest.
Either difficulties of a mental patient or of
the health personnel in treating a mentally ill person could
serve as a starting point.
7.6
The session concluded with recognition of tne invaulable
input from the multi-disciplinary team of reviewers. Their
thoughtful and practical suggestions would enhance the pro
duction of relevant and appropriate education media.
Considering the comments and suggestions given by the
expert review panel, decision is to be made on -
1.
Finalisation and production of epilepsy video
2.
Video on integration of mental health
3.
Video on clinical cases
One of the major lessons learnt from this review is
that much thought needs to be given to clearly defining obj
ectives and planning the educational material.
For each
video a small group needs to be set-up which includes specia
lises and generalists.
ing the videos.
The group needs to be active in plann
The synopsis and the script have to be app
roved by the group before proauction begins.
-10The group noted several times- that much of these
training materials will be used in semi-rural areas
which have frequent power shortage/cuts.
Considering
this, and the fact that much electronic and other
sophisticated equipment need constant maintenance and
repair and are seldom in good working condition, the
group suggested that at least 50-60 per cent of the
teaching aids should be non-electronic/electric.
So, much thought should be given to preparing
relevant and appropriate simple teaching aids such
as flip cnarts, posters, charts, display materials
etc.
In addition, trie trainers should learn to
utilise other training methodologies such as role
play, simulation games, stories, proverbs to
encourage participation and to maxe the training
more responsive to trie specific needs of the ’train
ees.
Folk media, such aS songs, dramas, Harikatha
0 ,
could also be effectively employed for this
purpose.
COj^
mvb
o^j
In this way ths trainees, exposed to
difficult concepts in a way which makes sense to
them, but are also armed witn- health education
metnods.
This .again underlines the need for preparing
a well planned trainers guiue book which will
educate the trainer on these more interactive
methods,
in this regard the group also emphasized
the need tor a section' on health education and
media in the manual.
This should emphasize the
need for, and the methodology for planning health
education component of the mental health progra-
mmej relative merits of each health education
method/and media should be considered, and
selection of appropriate methodology/strategy
tailored to specific problem should be highlighted,
...11/-
-11-
Suggest ways of using them.
In addition to the trai
ners guiue book,- the training of the trainers in
training methodology is essential, only in this
way we can ensure that the training material
prepared will be adequately and appropriately
used.
VIDEO ON RURAL MENTAL HEALTH CENTRE
Evaluation Proforma
Objectives:
1.
To create awareness among the medical and paramedical personnel
working in primary health care o£ the need to integrate mental
health care with other PHC services
2.
To provide information on one model for integration -
The Rural Mental Health Centre - Sakalwara
1.
Content : Adequate
7
Inadequate £~7_
What needs to be added/deleted/modified/clarified/elaboratedo
2.
Visuals : Good 7
7
Fair 7SJ
Camera movements : Smooth /~~7
Close ups : Adequate /_
7
Inadequate /_
Captions ; prefer hand written 7^~7
Captions on visual 7~_J
3.
Duration : Too long /~_ 7
Specify 7
Poor 7J~7
Jerky /_ 7
7
Specify
Specify
Specify
Camera captions /~~7
Specify
Sufficient /~7777
Inadequate /
7
Give e.g.
7
4.
Narration: Good 7~~7
5.
General comments & suggestions.
Fair 7^7
Poor £_7
Thank you for helping us evaluate this training video„ Your
suggestions and comments will be taken into consideration while
preparing the final version.
Clinical Case Presentations :
One of the main difficulties of training health profess
ionals in mental health in the primary case setting
the lack of clinical material.
is
It is hoped that these
videos will expose them to relevant clinical material
OBJECTIVES:
To help medical officers and other health professionals
identify cases by:
a)
Providing information on characteristic symptomatology
of specific mental illness
b)
Giving an idea on how to elicit this information
c)
Showing what criteria is used to make a diagnosis
Cases:
1.
Anxiety Neurosis
Manic Depressive Psychosis
-"5. Phobia and Depressive Neurosis
/4. Paranoid schizophrenia
Sexual Neurosis with Hysterical Conversion
6.
Chronic Schizophrenia
7.
Obsessive Neurosis
8.
Hysterical Possession Syndrome
M0r
DEPARTMENT OF HEALTH EDUCATION
NATIONAL INSTITUTE OF MENTAL HEALTH & NUfukO SCIENCES
BANGALORE- 560 029
VIDEO INTERVIEW ASSESSMENT
1. What physical characteristics do you notice ?
Mannerisms/
Expressions
Easily visible
yyyy
Not visible
yyyy
2. picture;
Clarity
; Good
C~~J
Fair
Colour
; Good
yyyy/
Fair
ZZZZ7
Sufficient numbers
/_
Too few close ups
4.
Patient
/"“"7
Doctor
7
7
Relative
7
Smooth
7~~_7
/"_y
Jerky
5.
/_
7~~~J
Camera movements ;
yyyy
7.
Details not clear
/
yyyy
Poor
/ZZZ7
Close-ups ; Too many,close-ups
3« Focus more on ;
Poor
Sound ; Patient's voice ; Clear/Audible
/^JV
Not audible at times
Inaudible at times
/
7
/-- y
; Clear/A.udible
Doctor's voice.
7
/
Not audible at times
/7~Z7
Inaudible at times
/Z~Z7
77ZZ^
Patient's relatives ; Clear/Audible
voice
Not audible at times /" "7
/~ /
Inaudible at times
6.
7.
Could the patient/relative
communicate well in English
Kell
/
7
Adequate
/7
7
Inadequate /’
7
Did you clearly understand the patient's accent;
Yes yyyy
8.
:
Duration ;
no
yyyy
Too long
Z~ZZ7
Sufficient
' /_
7
Inadequate
/
7
- 2
9.
How does this compare to a live interview ;
Effective
/
Kot so effective
7__ 7
y
(Please elaborate on your opinion)
10.
Hould you like to have captions.
Yes
No C~~J
/___ 7
Captions 3 Separate
As conversations
continue
11.
is a concluding summary necessary
Yes /2~7
12.
/__ 7
No
C~~J
Suggestions/comments
Qualifications. .
Course/Training . .
Date.
/Jo 3
PA oh i c-~
DEPARTMENT OF HEALTH EDUCATION
NATIONAL INSTITUTE OF MENTAL HEALTH & NEURO SCIENCES
BAi'GALORE- 560 029
VIDEO INTERVIEW ASSESSMENT
1.
What physical characteristics do you notice ?
Mannerisms/
Expressions
H
2.
3.
4.
Easily visible
.
Not visible
/
7
.--- 7
/
7
Pictures
Clarity
; Good
/~~~7
Fair
/~~~7
Poor
Colour
: Good
7_~_J
Fair
/_
Poor
Close-ups s Too many close-ups
/
7
Sufficient numbers
/
7
Too few close ups
/
/
Details not clear
/_
7
Focus more on :
7
/
/
7
/“
7
Camera movements s
/
/
7
Patient
Doctor
Relative
Smooth
7
/
7"~J
Jerky
5.
7
Sound s Patient's voice s Clear/Audible
7.7
Not audible at times
Inaudible at times
Doctor1s voice
/
7
/-- y
: Clear/Audible
/
7
Not audible at times
/ 2_7
Inaudible at times
/
7
7
7J_~J
Patient's relatives ; Clear/Audible
72
voice
Not audible at times
Inaudible at times
6. Could the patient/relative
communicate well in English
Well
C—.J
Adequate
/
7
Inadequate /
7
7. Did you clearly understand the patient's accent/
Yes /~~~7
8.
Duration ;
No
7"~7
/~
Too long
7
Sufficient
/
7
Inadequate
/
7
/
7
- 2 -
9.
How does this compare to a live interview ?
Effective
/
Not so effective
7__ 7
y
(Please elaborate on your opinion)
10,
Would you like to have captions.
Yes £~~7
No /~~~7
Captions : Separate
/__ 7
As conversations
continue
11.
Yes /~~~7
12.
/__ 7
is a concluding summary necessary
No
-Suggestions/comments
Qualifications. .
Course/Training . .
C~~7
DEPARTMENT OF HEALTH EDUCATION
NATIONAL INSTITUTE OF MENTAL HEALTH & NEURO SCIENCES
BANGALORE- 560 029
VIDEO INTERVIEW ASSESSMENT
1. What physical characteristics do you notice ?
Easily visible
Mannerisms/
Expressions
Not visible
2. Pictures
7
Clarity
? Good
7~~~J
Fair
/^_ 7
Poor
/
Colour
s Good
7
Fair
/~~~7
Poor
/ _ /
/"„7
Close-ups ? Too many close-ups
Sufficient numbers
3.
Too few close ups
/~~7
Details not clear
C7J
Focus more on :
7
/
Patient
7
Doctor
Relative
/"7
4.
Camera movements :
Smooth
Jerky
5.
/
7
/~Z7
/
Sound s Patient's voice s Clear/Audible
Doctor's voice
J
/
7
,y
Not audible at times
inaudible at times
/
7
Not audible at times
/
7
Inaudible at times
/;
7
; Clear/Audible
Patient's relatives : Clear/Audible
7~~J
vo’i’ce
Not audible at times /
“7
/
/
Inaudible at times
6.
7.
Could the patient/relative
' communicate well in English
/.’ell
/
7
Adequate
/^
7
Inadequate /
7
Did you clearly.understand the patient's accents
Yes /“V
8.
s
Duration s
No
/~~~7 .
Too long
Sufficient
/
7
Inadequate
/_
7
- 2 -
9.
How floes this compare to a live interview ?
Effective
/
Not so effective
7__ 7
y
(please elaborate on your opinion)
10.
Would you like to have captions.
No C"J
yes C~J
Captions : Separate
As conversations
continue
11.
/__ 7
is a concluding summary necessary
Yes /_~7
12.
/___ 7
No
Suggestions/comments
Qualifications. .
Course/Training . .
DEPRESSIVE
ILLNESS
This is different from "noraal" depression by being severe, persistent
and disabling.
SIGHS AND SYMPTOMS
(1)
Severe feelings of misery and depression - out of character and out of
proportion to any stress. Possibly with hooelessness and self blame.
(2)
boss of interest in family, work, hobbies, sexual life.
the most obvious signs of depression.
(3)
Physical aspects - these can be specifically asked for:--
These may be
(a)
regular pattern during each day - for example, much worse
during the first few hours of each day and much better by
evening;
(b)
sleep disturbance - for example, waking several hours
earlier than usual:
(c)
loss of appetite ~ possibly with weight loss of 5 kg or more;
(d)
depression produced by some drugs - for example, hypotensives,
phenobarbitone.
(4)
Suicidal thoughts and actions - see separate sheet.
5)
Physical symptoms of emot .tonal distres5S - for <■example ? palpitations,
fatigue, headaches.
explanation, clarification;
reassurance - after above;
changing patterns of emotional reaction more difficult;
modifying patterns of thinking which
prolong depression.
Antidepressants
tricyclics (e.g. Tofranil, TryptizolProthiaden);
newer, safer drugs (e.g. Merital, Ludiomil).
Electroconvulsive treatment (E.C.T.electrical
treatment).
- artificial fit whilst under an anaesthetic
and caving muscle relaxant.
Used only in severe, drug resistant
depression.1
changing or helping with problems with spouse
children, parents, work, housing, finance.
PREVENTION
(1}
Social treatments above.
(2)
Antidepressants can prevent relapse in first few months and possibly later.
(3)
Lithium can reduce risk of repeated manic depressive attacks.
be taken for years.
May need to
HGE/IMT 1986
Psychotropic Drugs (continued^
ANTIDCP3 ISSA'rS
Tricyclics - ISipramifie (t'’franil), Araitrioytline (tryptizol),
Inipranine - widely used and proven value in treatment of severe depression
end prevent!-n of relapse
cepress1 t..
Much less affective in depression
arising fr~.m stress.
Oral
Dose:
30-225 rag. per day.
Side-effects*
Single or divided doses.
Common but n' t usually sori *us:.
constipation etc.
e.g. dry m>uth,
More serious are cardiac arrhythmias,
aggravation glaucoma, dangerous in overdosage.
Maybe cabined with electroconvulsant treatment (electrical treatment ECT).
'lower antidepressants with fewer side-effects and safer in overdosage, e.g.
Mianserin (b-vlvidon) 30-90 rag. per day.
ANXIOLYTICS (Minor tranquillizers)
Denzodiazepines - Diazepam (valium), Chlprdiazep *.xide (librium),
Oxazepam (serenid, Lorazepam (otivan).
Effective in reducing the symptoms of anxiety but only for a few weeks and
rarely influencing the underlying cause.
personal and social problems.
with alcohol.
Often misused as a solution t?
Risks of dependency, drowsiness, interaction
Epidemic increase of use in developing ns well as the more
developed countries.
Dose:
5-30 ng. per day in divided doses,.
AMTI-CONVULSANTS
Eye witness or other evidence of mare than one grand mal fit before starting
treatment.
Community attitudes and social effects important,
Problems of
patient compliance occur whdn fits controlled.
Phenobarbibone - effective, cheap, can control 90% -,*f epilepsy.
Dose:
30-180 mg, per day in single or divided doses.
Side-effects:
Dr wsiness, dangerous in over-dosage, interacts with alcohol
Phenytoin (epanutin),
Dose:
100-600 mg. per day in single or divided doses.
Side-effects:
Ata*:ia, gur. overgrowth.
Primidone (myscline).
Doses
750-1500 rag. per day in single or divided doses.
Side-effects: ATaxia common, lessened by slowly increasing dose.
Sodium Valproate (epilim) - a more recent anti-c-onvulsant, effective and
well t-lerated.
Sulthiarae ( sp.l.t) and Carbamazepine (tegretol) of value in the uncommon
temporal lobe epilepsy.
HGE/IMT 1936
rlrt- >- 6
PSYCHOTROPIC
DROSS
INTRODUCTION
The discovery of the psychotropic drugs has transformed psychiatric care.
There are now treatments for most psychiatric illnesses.
The most effective
are those for the psychoses and for severe depression.
This is important as
world-wide studies have shown that serious, incapacitating mental disorders
are likely t~ affect 1% of any population at one time and 10% at some time
in their life.
PRINCIPLES OF USE
Provision of psychotropic drugs is only part of a complex process which
includes presentation of illness, its recognition by a person trained in
diagnosis and drug use, access to stocks of the drugs, the patient under
standing instructions and following them, and the monitoring of the effects
of the drugs.
National decisions have to be made as to which drugs are
available, where and who can prescribe them.
Drugs are usually only a part answer to problems.
They cannot make
decisions for patients, alter the personality or s lvo interpersonal or
social problems.
If a drug does not relieve symptoms then the diagnosis
should be reconsidered before another drug is started.
.NEUROLEPTICS (Hej-r tranquillizers)
Phenothiazines - Chlorpromazine (lorgactil), Trifluoperazine (stelazine),
Thioridazine (melleril), Fluphenazine decanoate (modecate long-acting
dep-t ‘injections).
Thioxanthines - Flupenthixol decanoate (depixol depot injection).
Butyrophenones - Haloperidol (serenade, haldol).
Chlorpromazine - widely used, effective as antipsychotic for treatment of acute
illness er prevention of relapse or for symptomatic control of agitation.
Dose;
Oral up to 600 og. per day.
Injections
Single or divided d-'\ses.
25-100 ng.
Side-effects:
include hypotension, over-sedation, extrapyramidal
reactions (akathisia, Parkinsonism, dystonia).
Treatment side-effects;
Reduce dose.
Anti-Parkinsonism drugs, e.g. Berizhexol
(artane).
Depot injections are nbs rbed very slowly and have the advantage of needing
t.o be given only two tn four weeks, therefore requiring less patient
compliance.
Contd
Mil '
•^>-
100005.3.
Ps°H sjfjpyj'’ ,
)iao K.;-.■
COMMUNITY PSYCHIATRY UNIT
DEPARTMENT OF PSYCHIATRY
NATIONAL INSTITUTE OF MENTAL HEALTH & NEURO SCIENCES, BANGALORE.
April 1983.
PROGRAMME OF TRAINING IN COMMUNITY PSYCHIATRY FQ1, POSTGRADUATES
IN PSYCHIATRY, PSYCHOLOGY AND SOCIAL WORK. ;
(Field experience_)
.,r3rKs^oad
INTRODUCTION:
goN'1'-' .
'^AfY/g
'UiNni^03
:»SV ‘ oOl
Organisation of mental health services hasfed^ived special
attention in the country in the last one decade. Notable
developments.since 1970, have been the various workshops and
conferences relating to these matters by the different categories
of mental health professionals.
- .
During the last decade two centres, Bangalore and Chandigarh,
focussed their attention on developing models for organisation of
rural psychiatric service. Research efforts of these two centres
have resulted in a number of epidemiological tools and Manuals
for training of primary health care personnel. The other
important development has been; the ICMR multicentred study'
’Severe Mental Morbidity' located at Bangalore, Baroda, Calcutta .
and Patiala. This.latter project focussed on the role of
primary health care personnel (MPWs and doctors) in mental
health care.
A Further development.in this area of mental health care has been
the formulation of a National Mental Health Plan for the country.
This plan document was considered by the health policy making
body, namely, Central Council of Health and Family Welfare, in
August 1982 and recommended for implimentation.
The national plan envisages integration' of mental health as
port of the general health services by' involvement of the exist
ing primary health care infrastructure (GDI, 1982).
Thus, it is likely that in the near future efforts will be
directed to achieve the goal of mental health care to all,
especially to those living in the rural areas and underprovilagod areas,
1
Internationally too there is growing awareness of these needs
and a number of practical approaches have been recommended
(>»HO-, 1975).
It is in this context'that the training’in Community Psychiatry
at NIMHANS has been planned. Being a centre for training a large
number of mental health professionals, the Institute has a
responsibility to prepare them, as well as suggest how best tne
different categories of mental health professionals will be
trained, so that they are well equipped to play their roles in
the broader national planning of mental health care program-ties.
The following training has been drawn out keeping the above
aoals in mind.
/2/
Ono gliding principle in planning .the objectives and the
activities has been the need.for all categories ■ of mental health
profession to play a multi-faceted role in a flexible manner.
This has been brought out most aptly by the WHO EXpert Committee .
Recommendation (No. 10 & 11) as follows? (WHO, 1975).
.... '
"The Committee.recommends..that specialised mental health
workers should devote only part of their working hours to the
clinical care of patients;
the-' greater part of their time ■
should be spent in training and supervising non-speciolised .pt
health workers, who will provide the basic mental health
care in the community.
The committee further, recommends
that the training of mental health professionals should
include instruction and supervised experience in this new task of •training and supporting non-specialised healths
workers".
■
' ■
It is with this common approach, that a common programme -has been
drawn up for all-the students, with .about:25 % time loft for the
specialised, needs-, of. each of the disciplines.
..... ,.
SPECIFIC OBJECTIVES;
1.
To provide :.an orientation to the health and welfare prganisation
in the rural areas, especially the roles and functioning of the
different categories of health facilities and staff and the
relevant national policies.
,.
2.
To expose the trainees to skills and methodology oV psychiatric
epidemiology and obtain an understanding .of the problems of
field studies.
3.
To .orient. to the principles of planning of community mental
health' services within -the existing health, and • fwelfare infra
structure’,(decision about priorities, felt needs of the commu
nity, role and training of auxilliaries and-community
involvement)-.
4.
To get an overview of the importance of the rural' environ
ment on the presentation of mental health problems, their
response to treatment and course of the illness..
5.
To develop an awareness and familiarity with ongoing programmes
and research projects in the unit.
ACTIVITIES PLA' !NED:
1., Teaching by the staff of the Unit, in regard to the
theoretical aspects of community psychiatry, .in the
farm of lectures, seminars and journal club.
2.
Visits to the health and welfare facilities (PHC, PHU, Sub
centre, Anganwadi centre, schools) to be familiar with
their structure and functioning including the rolees
of environment on causation, treatment and outcome.
3.
Follow up, over the period of training, a set number of
families with mental health problems to obtain an under
standing of the role of environment on causation, treatment
and outcome.
4.
Observation of', the ongoing monthly training programmes for
health workers, medical officers a nd other mental health
professionals.
5.
Examination of the research designs, the epidemiological
tools utilised for the various projects of the Unit to
gain first hand knowledge about their u.se,.
6.
Initiate efforts to carry out a simple field work to
obtain experience of epidemiological work. Some of the
activities can be (Optional)
Screening of the clinic population for mental disorders
Identification of ill persons in a virgin area (Community
(survey)
(3)
Preparing teaching programmes for the non-specialists
(4)
Management of ’problem families' with mental disoiders,
(5)
Study of attitude of population
(6)
Training family members of mentally ill and handicapped
persons.
(5) Preparation of-health education material.
(1)
(2)
7.
Discussions with the staff members of the Unit.
The training programme is planned for a duration of one month.
The weekly time table is given in Appendix-I.
/4/
DETAILS OF THE VARIOUS. ACTIVITIES;
1.
.Seminar-Discussion;
discussion by''the group;
One of the students will review for
(i)
(ii)
Primary Health .Care in India
Organisation of mental health services in developing
countries. WHO (1975) TRS 564.
(iii)
Epidemiological studies in India (Ona study in detail)
4<iv) Public attitude to mental disorders
2.
Lectures;
1.
2.
3.
4.
Selection of priorities
National Mental Health Plan
Selection of essential drugs
Principles of training of non-spocialists.
3.
Case Conferences; Each student in rotation will present'any
one of these cases namely (i) one of the families followed up by
the student, (ii) an intervention/treatment experience and
(iii) patients from OPD with clinical symptomology of interest.
4.
Field work? Each student on joining the posting, will bo ■
given 5 families (two with.a psychotic patient, two with a
mentally.handicapped person, and one with epilepsy) for care
during the four weeks of, training. Students will visit these
families weekly to obtain a detailed understanding of the
impact of the. illness, the coping styles of the families,
effect on social life and community attitudes as well as 'providehelp that is needed.
This activity will provide the student, an lopportunity to know
the way-, mental illness affects family and' community life,, along
with an opportunity to experience field work. Detailed records
will be maintained by the students for submission to the
respective faculty members- for discussion and guidance.
5.
Health Education: The trainees besides observing the health
education activity, will carry out at least one 15-20 minute
health education work in the ©PD of Sakalawara or at Anekal.
This would include preparation of the text and illustrations
with the help of the staff members.
6.
Journal club: Each- staff member of the unit will in turn
review a chosen article from journals and discuss the mothodology and relevance to ongoing work.
7.
Visit to the health and welfare organisations:
This will
be organised by" a faculty member and the aim is to provide
an understanding as to the structure and functioning of
health and welfare services in the rural areas.
It’is hoped
that this practical experience will provide the student a'
background to the community psychiatry programmes. Adequate
background material regarding these will be made available.
h/
8.
Training programmes for non-specialists: Due to the limited
time available it is unlikely that the students will take an
active part in the training.
They will bo observers to some
of the sessions, they will review the manuals and the/ will
prepare some model lectures and deliver it in front of the
unit members.
9.
Epidemiological tools;
Each student will develop familiarity
with at least one instrument in terms, of its construction,
its use, its translation. If possible they will administer to
a small number of subjects.
IQ’ Assessments: All the students will be assessed about their
competence in knowledge and skills in a chosen number of areas
at the end of the training. Feed back about the training will
al so be obtained.
Students who do not know Kannada;
Field work and interaction
with the non-spocialists will be' less satisfactory for those
students who do not have a working knowledge of Kannada. These
students will take part in all academic programmes and the guided
field work. In addition they will be given greater expertise
in the following areas;
Translation of research/epidemiological to’ols
Preparation of health education material and presenting to
the staff "members.
3)
Preparation, of lectures and presentation to the staff members.
"4) Review a topic of epidemiological work of interest to the
speciality with the help of the faculty member.
5) Work in the Sakalawara OPD, where more faculty staff are ■
available for help and guidance.
1)
2)
Govt, of India (1982) National Mental Health Programme for India.
Director General of Health Services, Nirman Bhavan, New Delhi
(Mimco)
WHO (1975) Organisation of Mental Health .Services in developing
countries. tTechnical Report series No. 564. Geneva.
Phase
j
Phase
1
Amount
St John's_Medical College, Bangalore 560034
Directorate of Rural Health Services and
Training Programmes
CONTENTS:
1.
WHO IS A PENTALLY HEALTHY PERSON?
2.
ROLE OF CHWs IN PENTAL HEALTH SERVICES.
3.
WHAT YOU SHOULD KNOW ABOUT HUMAN BEHAVIOUR AND
MENTAL HEALTH?
4.
EDUCATION FOR PENTAL HEALTH:
(a)
(b)
(c)
Prevention of maladjustment and mental
illness;
Correcting common misconceptions;
Planagement of the mentally ill and the
mentally retarded.
5.
SITUATIONS OF HIGH RISK FOR PENTAL HEALTH.
6.
MANAGEMENT OF PERSONS FACING CRISIS SITUATIONS
7.
IDENTIFICATION OF EARLY MALADJUSTMENT ANb MENTAL
ILLNESS IN COMMUNITY.
8.
MANAGEMENT OF PATIENTS WHO HAVE SIGNS AND SYMPTOMS
OF PENTAL ILLNESS.
prepared by professor s.v. rama rao
director of rural health services and training programmes
2
1. WHO IS fl MENTALLY HEALTHY PERSON?
One who is well adjusted as regards his emotions or feelings,
thoughts and behaviour in his day to day activities.
Most workers concentrate on the physical health of the person.
You should be aware that emotional problems that burden a patient
will affect his physical health also and may result in changes in
his behaviour. Eg; young child’s mother died; it refuses to eat;
its health deteriorates;' gets a feeling of abandonment, loss of
love, loss of security.
2. ROLE OF CHWs in MENTAL HEALTH SERVICES
a.
To teach individuals and informal groups about mental health
and to correct'common misconceptions about mental illness;
b.
To recognise the common situations of stress which have the
potential of upsetting mental health of individuals;
c.
To identify and refer persons who have signs and symptoms of
emotional maladjustment or mental .'disease. ■
d.
Assistance to problem patients who are mentally ill.
■
a.
3. WHAT'YOU SHOULD KNOW ABOUT HUMAN BEHAVIOUR
AND MENTAL, HEALTH
There is a reason.behind all human behaviour (even if it
appears irrational to others). The person finds that it is not
safe or possible in a specific situation to show his feelings of
anger, fear, embarassment or wotthlessness. Suddenly he
behaves in a very unexpected way.
Eg: Whole day the husband has been working hard in the
office/bank. His boss was very inconsiderate—criticised,
commented and abused and humiliated him. He comes home
..finds -that his child is crying for something. He releases his
anger on his child and gives it a good beating.
So it is Important for such people to.find ways of releasing
their feelings of stress, anxiety etc., without hurting anyone.
Eg: by strainous exercise (physical activity), listening to
.music, or talking about his feelings, with a person who is
hill well wisher and friend.
*
b.
When a person is deeply troubled - eg., looses all money in race,
gambling etc., and becomes bankrupt—his thinking may be affected.
He is unable to cooe with the problem. In such a situation a
loving husband/wife/brother/sister/well-wisher/friend can give
emotional support. HOW?
i.
ii.
iii.
iv.
c.
by listening;
by helping him to look at the problem from a different angle;
by pointing out alternate solutions;
by avoiding'telling him what to do.
Any help offered to someone who is in trouble must arise from
a person who can understand him, who is genuinely concerned
for him, otherwise assistance will not be effective.
3
3
d.
Every person needs love, affection, respect of others who are
important to him - for mental health and for leading a well
adjusted life.
MENTAL ILLNESS IS DIE TOs
ABSENCE OF OR DI S’ORBED HUMAN RELATIONSHIPS
OVER A PROLONGED PERIOD OF TIME.
e.
Planning the daily life is important : relaxation to reduce
stress which can lead' to maladjustment should be avoided.
AS A CHW, you must be aware of the many kinds of
human behaviour which are common to most people and
are rooted inthe culture of the family, community
and religion. Before you label a behaviour as unexpected,
different, unfamiliar or abnormal or maladjusted BE VERY
VERY’CAREFUL.'
f.
Physical ailment in a person could be due to a feeling of
anxiety or tension, Eg: head-ache, diarrhoea, vomiting etc.,
often are temporary. If they are persistant they need referral.
g.
Any person who has threatened to comit suicide must be taken
seriously and not ignored. IT IS HIS WAY OF ASKING FOR HELP.
WITHOUT TREATMENT, HE MAY KILL HIMSELF.
4.
EDUCATION FOR MENTAL HEALTH
You should TEACH : individuals, families of patients, informal
groups in the community about how they can
• practise simple mental health concepts in their
daily life.
You should also CORRECT their misconceptions about mental illness
You should TELL THEM ABOUT PREVENTION AND TREATMENT OF mental illness.
Prevent ion of maladjustment ..and mental illness
(a)
i.
Tender, loving care and genuine,, concern from
members of the'family and others especially at
times of emotional stress and crisis.
ii.
Individuals and families can learn to recognise
signs and symptoms of maladjustments and mental disease.
iii.
A loving mother care is absolutely essential for
a healthy personality growth and develooment of child'.,
iv.
A loving-substitute to child must be provided if
mother dies or deserts.
Correcting common misconceptions
(b)
i.
ii.
Mental illness is like any other illness.
It is not due to evil spirits, bhutas, witch craft etc.
Marriage is not a cure for mental illness. Stress
of married life for people who are-not mentally adjusted
■may even aggravate.
4
4
iii.
If someone in the family is'mentally ill
or mentally retarded,"- it is not a shame.
iv.
Any person who has threatened to comit suicide should
not be ignored. He must be treated.
v.
Mental illness can be cired. Recovery.can be rapid and
complete if treatment'begins very early.
i.
Treatment of mental illness is often prolonged and must be
continued according to medical advice sometimes even after
patient becomes apparently normal.
ii.
There is no cure for mental retardation. Parents and well
wishers should avoid unrealistic expectations. A retarded
person can be' trained to carry out simple task's and with
supervision he can take care of himself.
iii.
Mentally disturbed or mentally retarded patient must be
kept busy with whatever activity he can perform. Keeping
them idle will worsen the condition.
(c)
•
'■/
Management of the mentally ill and mentally retarded
/
iv.
One must not'' make fun of mentally' ill or retarded persons;
it makes the condition worse.
v.
Patient's family and others have an important role to play
in assisting mentally ill and retarded. Their interest and
support is very essential in overcoming illness and to recover.
5.
SITUATIONS OF HIGH RISK FOR MENTAL HEALTH
CHWs should make systematic efforts to identify families in their
area who are undergoing severe emotional stress or have had crisis
in family so that they may b? referred early. These are the families
prone to develop physical ailments as well as symptoms of emotional
maladjustment. Eg;- •
IRRITABILITY.FOR NO REASON;
SUDDENL” AVOIDING -CONTACT WITH FRIENDS;
INABILITY TO SLEEP FOR SUCCESSIVE NIGHTS.
COMMON TYPES OF-PREDICTABLE CRISIS-PROVOKING SITUATIONS
a.
A death in the family (an only male child, bread winner,
mother,' both parents etc)
b.
Birth of a defective or mentally retarded baby or birth
of another female child when male child was needed.
c.
d.
e.
f.
A suicide/attempted suicide in the family.
Sexual assault/rape.
Permanent physical changes in the body/deformity due to
accident (surgical, removal of breast, genital organs,
amputation of a limb etc).
Sudden unemployment.
5
5
g.
Difficulties in one’s work situation.
h.
Break up of a marriage (divorce/annulment/separation)
i.
.
Sudden forced migration (due to dam construction, exodus,
earthquake etc).
j. Imprisonment/jail term.
k. Retirement.
1. Marriage or addition of family members.
6.
a.
MANAGEMENT OF PERSONS FACING CRISIS SITUATIONS
Listen and offer sympathy. Avoid false reassurance.
b.
Help them to focus their thoughts and feeling on something
positive (mother if child is dead vice versa, compare with
si+uations or persons who are worse off).
c.
After building up rapport, friendship and trust, you may
be able to answer r uestions, clarify doubts on sexual matters,
diseases etc.
d.
Encourage close and important members of family to talk
to them about their, sense of loss, feelings, anxiety, worry etc.
e.
Demonstrate/suggest alternatives for their day-to-day work.
f.
Guide them to seek and use all avoidable resources.
g.
Explain to family that the person behaves as he does for
reasons which makes sense to’him though it does not to others.
h.
Help the family to learn and accept the person's right to
feel as he does.
SHARING FEELINGS ABOUT CRISIS SITUATION WITH CLOSE MEMBERS CF THE
FAMILY OR TRUSTED FRIENDS IS A HEALTHY WAY TO PROVIDE EMOTIONAL
SUPPORT NEEDED.
i.
Plan for a second visit within a week.
7.
IDENTIFICATION OF EARLY MALADJUSTMENT■AND
MENTAL ILLNESS ,inJJEE COMMUNITY.
You are neither qualified or are you expected to treat. It requires
special skill and training. But you should be able to recognise
signs and symptoms so that you can promptly refer.
Signs and symptoms: Sudden loss of appetite, weight:—no physical
complaints.
Sleeplessness which is persistant;
usual daily activities not a'tended to;
no concern for personal hygiene, personal appearance;
•carelessness in: job, looking after children,
cooking etc.
Sexual problems (refusing to sleep with wife/husband, dyspaerunia.
Difficulty in talking, expression, disorientation of time, day of
the week, relationship etc.
6
Anti-social behaviour—stealing, lying, abusing, cursing.
Distressing feelings - over-excitement, anger, inferiority, depression,
guilt, laughing,, crying.
Morbid fears - obsession/phobias/illusions, hallucinations.
Neglect of school, wrk etc.
Excessive use of alcohol/drugs.
Injury to self or to others.
Peculiar mannerisms - running away, excessive bathing, exaggerated gestures.
ON CHILDREN:
i.
wetting
the bed at night/stpols in clothes.
ii; extensive cruelty-to other childrcn/pets/animals etc.
iiij disobedience of a high order.
iv.- developing sudden s+rong dislike towards one or more
members of the family.
v.
'saying that no one cares for him.
Vi. unable to get along with others.
CHARACTERISTIC SIG NS _M©
AFJJENT.tL. ILLNESS
IN THINKING
IN_FEELING
Uses words, says things'
cannot be understood,
mutters. Hears voices,■
sees things. Claims that
he is possessed by evil
spirits. Concerned very
much about his body pains/
aches with no basis.
Threatens to commit suicide.
Lost his memory or is
loosing. Disoriented,
confused, pre-occupied.
Difficulty in understanding
others.
Become very quiet.
Avoids people. Does
not talk to people.
Become unusually
cheerful. Says he
is a big man. Becomes
sad; cries; suddenly
laughts. Very
suspicious of people'
around him. Claims
that they are all
against him.
8.
IN BEHAVIOUR
He is aggresive.
Violent wi+hout
apparent reason.
Behaves strangely
in a socially
unacceptable
mann er. Attempt s
suicide. Drinks
alcohol
excessively.
MANAGEMENT OF PATIENTS WHO HAVE SIGNS AND
SYMPTOMS OF MENTAL .ILLNESS_____
Fefer patients to appropriate doctors/institutions. Offer only first
aid or emergency aid to the extent possible (ensure that a family
member stays with patient when you are giving first aid or transporting
patient to institutions or doctor). Explain to patient that ho is
being taken to the doctor for his own safety and treatment.
CIRCUMSTANCES WHEN YOU SHOW ..OFFER YOIPASSISTANCE
(a)
Vorv excited patient: Patient may have been brought tied
up since he turns violent. Violent
behaviour is the result of his fear that others may harm
him. lying up only increases his fear.
,7
*
7
i.
reassure relatives and those 'accompanying. 'Release the.
bonds of patient and free him after speaking directly to
him and getting his verbal response.
ii.
try and calm the patient and his relatives. Talk to
patient smoothly. Instill confidence.
iii.
iv.
Offer food and fluids.
observe patient carefully. Supervise any request such
as use of toilet, to move about, to go to bed etc.
v.
create quiet surroundings.
vi.
remove harmful objects (knife, rope etc.)
vii.
ensure that his clothes are not tight.
viii.
(b)
recognise your own limitations and have sufficient help
at hand and of members of family.
Very dull patient:
i. talk to patient continue even if he docs not respond.
Use a natural sincere voice.
(c)
ii.
gently coax him to eat and drink and feed him if necessary.
iii.
Ask family to help you in cleaning him up.
v.
ask family to ensure that he is taken to toilet regularly
if referral is delayed.
vi.
accompany patient with responsible members of the family
when he is taken to doctor/institution.
Suicidal pat ic nt: Take threats seriously.
i. patient, should have always somebody wi+h him.
ii.
remove all objects which can be used on himself—knife,
match box, blade, rope, fire, clectricitv, water, towel etc.
iii.
While at home do not tie him up. He can move about and
his energies can be diverted to constructive activities.
(d)
Person is, drunk:
He may be irritable; he may use abusive language;
he may become violent.
i. let him sleep
ii.
do not agitate him. Do not restrain him physically.
iii.
do not put him into a dark room because his mental confusion
will increase.
iv.
observe closely (no harm should come on him).
(e)
Patient yjit.h .othcr_signs_and ..symptoms j>f .mental .illness.
If the signs and symptoms have appeared immediately or soon
after : CHILD BIRTH; HIGH FEVER; HE’D INJURY; ^ITS CF DOG BITE
accompany patient along with a family member to the nearest
doctor/institution/primarv health centre.
WORKSHOP ON PREPARATION OF TRAINING MATERIALS FOR THE
NATIONAL MENTAL HEALTH PROGRAMME
MINUTES
•
The session began with welcome and introduction by the
Director, NIMHANS.
He briefly explained the aims and ooject-
ives of tne National Mental Health Programme.
Subsequently
other staff members of NIMHANS recounted the genesis of the
programme, particularly the development of the training aspect.
Details of present training programmes, availaole training
materials and the need tor more auuio visual materials were
discussea.
Finally the
purpose of this workshop was also
elaborated upon.
v
Apart from reviewing the auaio visual material - video
anu slices, members felt it is important: that a guide book/
training manual be prepared.
This would help the trainer to
use tne training material appropriately.
It was felt,that
the content of tne training material should form a part of
recommendations of the workshop.
The members noted that the
audio visual materials would not stand on their own but when
comprise a part of the total training process which should
emphasise participatory learning and include demonstration
and field area practice.
1.
1.1
Review of the video on Rural Mental Health Centre.
While noting that this video might be good for orienting
trainings on the SaKalwara Rural Mental Health Centre. It
did not adequately show the integration of mental health
into primary health care. This video could just serve as
a case study.
The need for such a video is not great.
Instead another video should focus on integration.
1.2
Several ways of showing the integration of mental health
in primary health care was suggested
- the depiction of work at Solur PHC or Bellary Dist.
<= incorporation of mental health into ongoing National
Programmes such as immunisation
- Portrayal 'of -PHC staff carrying on mental health acti
vities.
- Message should be that Mental-Health- Promotion and
treatment can be part of any PHC activity
- Visuals should show ideal rather tnan actual
- Team work in the primary health care setting which
includes mental health.
...2/-
•3-
2.5 In terms of visuals, shots from different angles, more
closeups, reactions shots are necessary. For effective
communication to cameras are imperative.
could be mixed during editing.
Later these
The summaries should also be less didactic and more con
2.6
versational.
Treatments such as psychotherapy should also
be included, might also include the effect of treatment
and patients recovery.
This i-s^atehe- summary might also
include other visuals rather than just doctors such as
clips from the interview which illustrate the symptoms
or other illustrations and charts, to enhance the points
made by the narrator.
Fine editing is required to make the cases effective.
2.7
The psychiatrist need to review it to make sure the only
information is relevant to PHC doctors is included.
2.8
With modifications this material could also be made into
self-instruction material.
One of the major draw backs of these cases are that the
2.9
heavy representation of middle class, English speaking
patients.
These cases may not be relevant to the health
workers in health professionals in rural PHC's. Effort
should be made to include representative cases from rural
area.
If need it can be dubbed in English or other
regional languages.
2.10
Specifically in the manic depressive psychoses case only
the information on mania should be presented and the dep
ressive features which are not present at that time e±
should not be included.
Many questions and issues were raised in this session
regarding the methodology that needs to be adopted.
Concrete
suggestions and recommendations should be forthcoming in the
final round up session..
The group also viewed video cassettes produced by other
agencies this'included to videos on prevention of oral cancer
in Kannada
and one on mental retardation.
The group did not
have an opportunity to review these videos as yet.
The group planned to meet in the next day to review
slides, epilepsy video and videos produced by other agencies
before working out final guidelines.
WORKSHOP ON PREPARATION OF TRAINING MATERIALS FOR THE
NATIONAL MENTAL HEALTH PROGRAMME
.
MINUTES
The session began with welcome aud introduction by the
Director, NIMHANS. He briefly explained the aims and object
ives of tne National Mental Health Programme.
Subsequently
other staff members of NIMHANS recounted the genesis of the
programme, pCEticularly the development of the training aspect.
Details of present training programmes, availaole training
materials and the need ror moie auuio visual materials were
discussed.
Finally the
purpose of this workshop was also
elaoorated upon.
v
Apart from reviewing the audio visual material - video
anu slices, members felt it is important that a guide book/
training manual be prepared.
This would help the trainer to
use the training material appropriately.
It was felt.that
the content of tne training material should form a part of
recommendations of the workshop.
The members noted that the
audio visual materials would not stand on their own but when
comprise a part of the total training process which should
emphasise participatory learning and include demonstration
and field area practice.
1.
1.1
Review of the video on Rural Mental Health Centre.
While noting that this video might be good for orienting
trainings on the SaKalwara Rural Mental Health Centre. It
did not adequately show the integration of mental health
into primary health care. This video could just serve as
a case study.
The need for such a video is not great.
Instead another video should focus on integration.
1.2
Several ways of showing the integration of mental health
in primary health care was suggested
- the depiction of work at Solur PHC or Bellary Dist.
- incorporation of mental health into ongoing National
Programmes such as immunisation
- Portrayal "'of-PHC staff carrying on mental health acti
vities.
- Message should be that Mental-Health" Promotion and
treatment can be part of any PHC activity
- Visuals should show ideal rather tnan actual
- Team work in the primary health care setting which
includes mental health.
...2/-
I
1.3
•2-
The reviewers felt that the interviews were to directive
ana suggestive
1.4
The narration dominated the visuals and there was no
synchronisation between the narrations and visuals.
1.5
The visuals could be more effective, colour quality coula
be improved, captions were difficult to read, visuals
should show more of the interactions.
The captions could
be interspersed with visuals of people.
1.6
To overcome these problems it was suggested that the 'ideal'
doctors and patients be chosen for interviews.
Certain
amount of stage managing is necessary, to get best quality
video, e.g. the matter on black board should be written
before-hana.
1.7
The viaeo need not emphasise already known facts such as
the difficulties living in rural areas and the video should
also not decry or denigrate traditional medicine but high
light the positive aspect.
1.8
It is suggested that the video could start in a dramatic
manner beginning with the problems faced by mental patients
in the rural area or the difficulties doctor faced treating
such patients.
1.9
The video needs closer editing, the total duration of the
video could be reduced to 60% of the present length
1.10
To make the video more amenable to wider distribution
visuals from other parts of Inuia need to be included.
2.Review of Clinical cases:
Although each cases was reviewed separately much of the
comments were similar for each case so here the comments
will be presented together.
2.1
The reviewers agreed that a short introduction to each
case would prepare the viewer,
it may or may not include
details of relevant symptoms,
without this introduction
the cases start very abruptly.
The doctors introduce
patients and give a number of descriptions before beginn
ing the interviews.
2.2
The interviews should be less directive and more crisp
2.3
There is need to evolve a format for interviewing.
2.4
Spontaneity would be lost if actors were enployed. Patients
• rights should be protected by asking their consent or by
running a caption throughout the video stating the video is
only for professional use.
..3/-
■3-
In terms of visuals, shots from different angles, more
closeups, reactions shots are necessary. For effective
2.5
communication to cameras are imperative,.
could be mixed during editing.
Later these
The summaries should also be less didactic and more con
2.6
versational.
Treatments such as psychotherapy should also
be included, might also include the effect of treatment
and patients recovery.
This is-._thc- summary might also
include other visuals rather than just doctors such as
clips from the interview which illustrate the symptoms
or other illustrations and chats, to enhance the points
made by the narrator.
Fine editing is required to make the cases effective.
2.7
The psychiatrist need to review it to make sure the only
information is relevant to PHC doctors is included.
With modifications this material could also be made into
2.8
self-instruction material.
2.9
One of the major draw backs of these cases are that the
heavy representation of middle class, English speaking
patients.
These cases may not be relevant to the health
workers in health professionals in rural PHCs. Effort
should be made to include representative cases from rural
area.
If need it can be dubbed in English or other
regional languages.
2.10
Specifically in the manic depressive psychoses case only
the information on mania should be presented and the dep
ressive features which are not present at that time sf
should not be included.
Many questions and issues were raised in this session
regarding the methodology that needs to be adopted.
Concrete
suggestions and recommenaations should be forthcoming in the
final round up session.
The group also viewed video cassettes produced by other
agencies this included to videos on prevention of oral cancer
in Kannada
and one on mental retardation.
The group did not
have an opportunity to review these videos as yet.
The group planned to meet in the next day to review
slides, epilepsy video and videos produced by other agencies
before working out final guidelines.
INTEGRATION OF MENTAL HEALTH CARE WITH THE EXISTING GENERAL
HEALTH CARE SYSTEM
It is estimated that 1% of the population suffer from
severe mental disorders, 2-3% from mental retardation, 5-10%
from neuroses and 1% from Epilepsy (visualsj)
Since 80% of our population living in rural areas, most of
the mental^ill people live in our villages.
The facilities
available to treat these pfcients are located in big cities in
the form of mental hospitals, psychiatric departments. They
are few in number and more than 90% of the mentallyill do not
get a modem treatment. (Visuals)
It is also known that most of th&se patients are taken to
tradition healing places for care.
If they do not become
better they are neglected and they become chronic patients.
(Visuals)
It is found that people do not make use of the existing
mental care facilities available because of poverty, long
distance, ignorance, social stigma. (Visuals) ■
The alternative approaches to deliver^ mental health care
to patients in the rural areas were designed and developed in
centres like Bangalore (Rural Mental Health Centre - SaKalwara)
Chandigarh (Raipurani block), Vellore and Jaipur etc.
One of
the feasible method is to integrate mental health care into
existing general health care facilities, the primary health
care doctors and para-medical workers giving basic mental
health care to the needy. (Visuals)
Pilot studies in the above centres have revealed that
1.
Mentally ill can oe easily identified by para medical
workers, villageteaders or anyVolunteers
2.
50-60% of this identified mentally ill can be treated effect
ively with 5-6 drugs, counselling and rehabilitation in their
own home
3.
Home care is better than hospital care in terms of cost, and
rapid improvement.
4. Rehabilitation is faster and .easier in the community set up
using the available resources in the community (Visuals)
Health
National Mental/Programme for India wnich was approved by
Government of Inoia in 1982 as the following objectives:1.
2.
3.
-2The approaches are:
1.
Integration of mental health care into general healthcare system.
2.
Task orieitited training to PHC personnel and in delivering mental
health care.
3.
Referral system i.e., PHC - general hospitals - district hospitals-
psychiatric consultation hospitals, mental health -institutions.
4. Multi Sectoral approach involving the departments of social welfare education, labour, etc (Visuals)
1. Mental Health Cahe envisaged at the suo-centre level by the
paramedical workers (visuals)
Identirication,referral, follow up,education
2„ At primary health care througn the doctors and his team
a. Management of tipical cases of psychoses, epilepsy, neuroses,
and mental retardation
3.
b.
Refer difficult cases to higher centres
c.
Followup education.
At district hospitals by trained psychiatrist and his team,
inpatient care for difficult cases and monitoring of the
4.
programme (visuals)
At department of psychiatry and mental health institutions
- investigations
inpatient care and long term care to the
needy patients, training of various personnel in mental
health care (visuals)
Sensitisation and involvement of Anyanwadi workers and
other staff of ICDS programme, school dissk teachers, voluntary
agencies and is also envisaged in educating mental health care
into community (visuals)
Conclusions:
With visuals it is shown how mentql health care occurs at
different levels SmeL department of health, it is demonstrated
that it is possible to inregrate mental health care into
existing general care system.
esixhx
Different levels of appropriate
care will be made available by establishing good referral
system.
In a recent meeting of the National Advisory Group on
the National Mental Health Programme of India, the immed
iate need for a Mental Health Training Educational Package
for trainers of PHC personnel was identified.
This package
should help trainers to conduct training in mental health
for PHC doctors and paramedical workers in an organised^nd
systematic manner through-out the country.
At present, the
community mental health unit of Department of Psychiatry
has developed the following teaching and educational mater
ials for this purpose.
1. Manual of Mental Health for Medical Officers
2.
3.
Manual of Mental Health for Health Workers
Case history taking proformae for doctors and
health workers
4.
Case records for doctors and health workers
5.
Monthly report forms for PHC
6.
Review proforma for PHC doctors and health
workers
7.
Poster on mental disorders
8o Video film on Schizophrenia (Towards Light)
PROPOSAL FOR TRAINING PACKAGE
In addition to the materials already available the package
should contain the following items :
A.
A set of colour slides for each chapter of the manuals.
The slides contain written materials or diagrams or
pictures or photographs.
B.
Video tapes on
1. History taking and mental state examination
2 cases of psychosis
2 cases of neurosis
2.
3.
Different signs and symptoms of mental
disorders (40-60 minutes)
10 minutes tapes on
i)
4.
(15 minutes for each case)
Schizophrenia (4 cases)
ii)
Mania (2 cases)
iii)
Depression (2 cases)
iv)
Organic psychosis (3 or 4 cases)
v)
Neurosis (6 cases)
Mental Retardation
6 cases (each case 5 minutes)
5.
Epilepsy
different types (10 minutes)
difference between epilepsy and
h.'gstericai fits (5 minutes)
6.
Childhood problems '
Interviewing a child with its parents (15 minutes)
Hyperactivity (2 minutes)
Neurosis (10 minutes)
7.
Management of an excited patient (10 minutes)
8.
Severe side effects of neuroleptics (10 minutes)
9.
ECT modified (5 minutes)
10.
Inpatient care (closed/open/family)
11.
Home care of the patient (10 minutes)
12.
Rehabilitation (15 minutes)
(10 minutes)
-3-
13.
First aid in Epilepsy, Suicidal attempt,
excited patient (15 minutes)
14.
Treatment of status epilepsy (5 minutes)
15.
Do's and Don’t in epilepsy (15 minutes)
16.
Management of febrile fits (5 minutes)
17.
Counselling techniques (3 cases)
18.
(60 minutes)
Mental retardation training for different
stages (30 minutes)
19.
Case identification and referral in the
village (15 minutes)
20.
Follow-up (15 minutes)
21.
Mental health clinic at a PHC (10 minutes)
22.
Monitoring of the programme at PHC (15 minutes)
23.
Group health education (10 minutes)
C.
Posters/flip charts on M.R. and epilepsy
(already designed and being finalised in
the unit)
D.
A guide book regarding how to use the kit.
WORKSHOP ON PREPARATION OF TRAINING MATERIAL FOR NATIONAL
MENTAL HEALTH PROGRAMME
AGENDA
Monday 2 6th June ' 89
9.30
to
10.00
Welcome and Introduction
Dr. G.N. Narayana Reddy
10.00
to
10.30
National Mental Health Programme
Dr. R. Srinivasamurthy
10.30
10.45
to
to
10.45
Coffee Break
11.15
Purpose, Aims and Objectives of
Training Material and of the
Review Session
Dr. Jayashree Ramakrishna
&
Dr. C.R. Chandrashekar
11.15
to
1.00
Review of Video on Community Care
of Mental Illness Presentation
and Discussion
1.00
to
2.00
Lunch
2.00
to
4.00
psychiatric Case Presentation,
Video Review and Discussion
4.00
to
4.15
Coffee
4.15
to
5.00
Review of Slides
Tuesday, 27th June 1989
9.00
to
11.00
Epilepsy Video Review
11.00
to
11.15
Coffee
11.15
to
12.00
Educational videos produced by
other agencies (Schizophrenia and
Mental Retardation)
12.00
to
1.30
Round Up - Preparation of Guidelines
for Preparing Training/Educational
Package for NMHP
Community Health CejI
From:
To:
Sent:
Subject:
N M Shantha <shanta@ncbs.res in>
-'Undisclosed recipients: :>
Friday, February 21,2003 9.37 AM
Colloa,uium_21_2_03_4 p.m.
NA i iONAL CEN i RE rOK BIOLOGICAL SCIENCES
TATA INSTITUTE OF FUNDAMENTAL RESEARCH
GKvK CAMPUS, BANGALORE
LECTURES IN SCIENCE, PHILOSOPHY & HISTORY
Madmen and specialists: The history of psychiatry' in India and the lunatic
asylum, Bsngsior©
Professor Sanjeev Jain
Department of Psychiatry
National Institute of Mental Health and Neurosciences
at 4.00 p.m. on Friday, 21st February, 2003
in the Ground Floor Lecture Hall (LH 1)
The advent of Asylum based psychiatry two centuries ago began the
influence of the Western systems or classifying, and caring, ror the
mentaiiy ill. Modern psychiatry in India is a combination of Western
medical piactlce grafted onto an older medical and social tradition.
Diagnoses and methods of care, as practised in Britain and Europe at the
time were employed in most instances At the National Institute of Mental
Health and Neurosciences
i'N!MHAN-S\ Bangalore medical records reveal a close congruence to
classification used in the UK. in the early part of the 19th century,
infections, intoxicants and iniury were considered important causes of
insanity. At the end of the century, it was specifically recommended that
future medical care follow Western models in the Kingdom of Mysore.
Analysis of records of the Hospital, during the first half of the 20th
century, indicates a steady change in the description of psychopathology,
methods of diagnosis and treatment practice. These suggest a rapid spreac
of ideas and technologies in psychiatry. As the only Asylum maintained by
q
Kingdom, -t wss dssicjnod with particular attention. Th© need for
specialists was felt, and doctors were sent to the UK for training.
However at the same time concerns were also voiced about the need to
develop more locally relevant models. The need io reform the Asylums and
to improve the professional standards was acutely felt from time to time.
The growth of this hospital, and the medical and social history of
Bangalore, is a microcosm of the larger British-Indian encounter.
Analysing the records at this hospital, and other sources, we have been
able io trace the contrasting influences on the development of psychiatry
at this institution, and in India. This subsequently became the first
post-graduate training facility in independent India, and has played an
important role in the development of psychiatry in the country.
Prof. Sanjeev Jain is an Additional Profes'sor at the Department of
Psychiatry at the NIMHANS. He completed his M.B.B.S. at Delhi University.
anci his MD from NIM! !A\'S. lie has been a Visiting fellow at the University
of Cambridge, and at the Wellcome Institute of history of Medicine in
':
His research includes moleculat genetics of psychiatric disorders,
and the nistory of psycniatry in India.
i ea at 5. Io p.m.
ALL ARE WELCOME
PS. ■ Mazda leaves from the parking lot in front of the Main Library in
IISc. 3.30 p.m.
VISION INDIA
WORLD MENTAL HEALTH DAY
10th October 2004
I WORKSHOP |
Then?*?: Current trends in Mental Health
PROGRAMME SCHEDULE
Time
Session
Registration
09.30to 10.00
Arrival
10.00 to 10.30
Welcome Address
Dr. James Joseph
Inauguration Address
Dr K.T .Thomas
Lightning the Lamp
Releasing Souvenir
Tea
10.30 to 11.15
Mental Retardation & Rehabilitation
11.15 to 12.00
Mental Illness & Rehabilitation
12.00 to 01.00
Panel Discussion -
01.00 to 02.00
Lunch
Mental Illness & Legal Dimension
02.45 to 03.45
Myth & Miracle
Tea
04.00 to 04.30
Valedictory Session'
Closing Remarks
Vote of Thanks
Ms Sapna C.B
Ms. Sunaina Srcedharan &
Ms.Gayathri.S
02.00 to 02.45
03.45 to 4.00
Dr.Romatc John
Ms Anuroopa
Mr. Hulikal Nataraj
Mr. Thulasinathan
Mr. Emerson Samuel
DAV ONE
12-12-98
AM To 9 AM
8.30
Registration
AM To 10 AM INAUGURATION
Welcome
Dr.R.Raguram, Organizing Secretary, ISOCP
Inauguration of the symposium & Inaugural Address
Dr. M.Gourie Devi, Director, Nimhans
Chief Guest’s Address
Dr.A.Venkoba Rao
Cultural Psychiatry: A Clinician’s Musings
9
10
AM To 11AM KEYNOTE ADDRESS
Cultural Psychiatry;
Past, Present & Future
Professor Roland Littlewood
11
11.30
To 11.30 AM Coffee Break
AM To 1.30 PM SESSION ONE
Perspectives in Cultural Psychiatry
Chairperson: Dr.R.L.Kapur
Why cultural psychiatry?
Dr.R.Raguram
Approaches to the study of folk models in psychiatry
Dr.Sushrut Jadhav
A third world perspective on mental health: view from Africa
Dr Yemi Olloyodi
1.30
To 2.30 PM
Lunch
2 PM To 4.30 PM SESSION TWO
Cultural Psychiatry in Clinical Practice
Chairperson: Dr.S.M.Channabasavanna
Cultural formulation in clinical psychiatry
Prof Mitchell Weiss
Clinical Case Discussion
Resource Person: Dr.Sekhar Seshadri
•Case Presentation (video)
• Small group discussion and development of cultural formulation
• Plenary discussion of small group deliberations
PANELLISTS
Prof Mitchell Weiss Prof Roland Littlewood, Dr Raguram & Dr.Sushrut Jadhav
7.30
PM
DINNER
At Rudraksha Centre For Performing Arts
Preceded By Yakshagana : “Kamsa Vadhe”
DAV TWO
13-12-98
9.00 AM To 11.30 AM
SESSION THREE:
Research methods in cultural psychiatry
Chairperson: Dr. Jayashree Ramakrishna
Introduction to methodologies in Cultural Psychiatry
Prof Mitchell Weiss
Cultural study of depression at NIMHANS:
Dr.Raguram
Cultural study of depression among the white British
Dr.Sushrut Jadhav
11.30
AM To 12 PM Coffee Break
12To1PM
SESSION FOUR
Issues of training and practice in Cultural psychiatry.
A North-South Dialogue
Chairperson: Dr. A. Venkoba Rao
SPEAKERS:
Dr. Gerdje Van Hoecke BELGIUM
Dr. M.V.Ashok INDIA
1 TO 2 PM
2 To 3.30 PM
Lunch
SESSION FIVE: Panel Discussion
Domains of Influence of Cultural Psychiatry:
The Emerging Scenario
Moderator: Prof Roland Littlewood
SPEAKERS
•Dr. Mohan Isaac: Cultural psychiatry and psychiatric epidemiology
•Dr.R.L. Kapur: Cultural issues in Psychotherapy
•Dr.Chittaranjan Andrade: Culture and Psychopharmacology
•Dr.Bhargavi Davar: Gender, culture and mental health
3
To 3,30PM
Coffee
4
PM SESSION SIX
Valedictory Function
Chairperson: Dr. Ajit Bhide
Feedback from participants
Vote of Thanks: Dr.R.Raguram
The decision to seek, medical consultation is a request for
interpretation.. Patient and doctor together reconstruct the
meaning of events in a shared mythopoesis. Once things
fall in place, experience and interpretation appear to coincide;
once the patient has a coherent ‘explanation’ which leaves
him no longer feeling the victim of the inexplicable and the
uncontrollable, the symptoms are usually exorcised..
Leon Eisenberg (1981 )
CULTURAL FORMULATION
OF
PSYCHIATRIC DISORDERS..
Over the years, advances in psychiatric nosology have been quite
considerable. Increasing attention to precision in the description
clinical phenomena will hopefully redress the issue of poor
reliability of diagnosis that has plagued psychiatry for a long time.
At the same time, professionals in the field also recognize that
symptoms constitute only one dimension of expression of
psychological suffering. The manner in which people perceive,
categorize and respond to distress is also governed by cultural
notions concerning the body in health and disease. Symptoms
invariably are interpreted within a particular context of individual
life situation. In addition, cultural orientation influences our
perceptions about how to understand and treat illnesses. Illness
experiences are therefore undeniably culturally shaped.
In some manner can we attempt to incorporate this perspective in
the arid landscape of psychiatric nosology?
Indeed, attempts have been made to evolve a cultural description of
psychiatric illnesses. The guidelines outlining one such approach
are enclosed with this document.
In the afternoon session on the 12th let us explore in an interactive
manner, the issue of culturally configuring psychological distress of
Pt K according to these guidelines.
Unexammed worlds of patients
Often reflect
Our unexamined thoughts
Cultural Formulation for DSM-IV
•
Description of cultural identity of the patient
This involves specifying the patient's cultural reference group or groups. Important
cultural elements are language abilities, use and preferences as well as
multilingualism, if present. This should be understood within the larger frameworks
of acculturation and biculturalism. For migrants and ethnic minorities, degrees of
involvement with the culture of origin and the host culture should be separately
appraised.
o
Cultural explanatory model of the patient’s
illness
An attempt should be made to clarify: 1) The predominant illness idioms through
which symptoms are communicated (e.g., "nerves.'' possessing spirits, somatic
complaints, inexplicable misfortune, etc.), 2) the relation of the patient's signs.
symptoms, and illness experience to both relevant cultural norms and standard
diagnostic categories and criteria, 3) any local illness category used by the patient's
family and community to identify the condition at hand, (See Appendix G for
definitions of cultural terms and syndromes,) and 4) the perceived causes that the
patient and the reference group employ to explain the illness, and the current
preferences and past experience with various professional and non-professional
sources of help.
®
Stressors and supports in the social and
cultural environment
Addressed here should be the personal meaning and cultural context of social
stressors, of available social resources and emotional, instrumental, and
informational supports (including familial, religion, and community-at-large), and of
forms and levels of disability. Examples may include the personal meaning of
familial losses and legal norms.
•
Intercultural aspects of the relationship
between the clinician and the patient
The formulation should conclude with an examination of the differences in culture
and status between clinician and patient (e.g., difficulty in communication, in
negotiating an appropriate relationship or level of intimacy, in determining whether a
behavior is normative or pathological, etc.).
CLINICAL HISTORY FOR CULTURAL FORMULATION
PATIENT IDENTIFICATION
Mr.Kariyappa. a 52 year old farmer was brought by his son and son-in-law on
to Nimhans for consultation. Kariyappa lives in the village of Machenahalli. in Hosadurga
taluk of Karnataka. He was brought with the complaints that he has been overactive,
restless for the previous two months and the villagers who were quite upset with his
behaviour suggested that he be taken to a ‘mental hospital'. He was brought tied up to the
hospital and looked disheveled and untidy. He was pleading with his relatives to ‘free’ him
and when the doctor advised admission, did not protest. Later in the day when seen in the
ward, he looked fresh after a bath, had applied the holy vermillion on his forehead and was
eager to talk to the doctor. He told the doctor that he wonders why he was brought to the
hospital, even though he has no objections to being admitted here. Added that the God
■Jinjappa' is inside his body, though people do not believe in this anymore. He went to the
other beds in the ward and blessed the patients saying that they would recover from their
illness quite soon.
HISTORY OF PRESENT CONSULTATION:
Over the past twenty years, the patient has been periodically ‘possessed' by the God
‘Jinjappa’. The first such episode occurred in 1978 during the suggi(harvest) season. The
patient had let the cattle for grazing one night and they accidentally strayed into the
neighbouring field. The owner of the land got angry and took custody of the cattle. When
the patient protested, he was assaulted with bamboo sticks and he sustained injuries over
his head and back. The next morning the village elders met in the temple of the local
Goddess ( Golimaradamma) and decided that grazing of cattle in the night was an offence.
The patient was admonished, fined Rs 5 and was asked to offer a coconut with betel leaves
to the Goddess. The cattle were released immediately.
Three days after this event, while lying down in the bed in the afternoon, patient suddenly
got up, went outside the house apparently searching for the persons who assaulted him.
He was saying in a loud voice, “ Why did you assault Kariyappa, who is my greatest
devotee? I Jinjappa is now in Kariyappa’s body and will punish those people who abused
him.” All the villagers came and ‘begged’ Jinjappa to calm down and forgive the persons
who have been disrespectful to him. Kariyappa calmed down after this, but Jinjappa stayed
on him for six weeks. During this period of time, every morning , villagers used to visit him,
do puja to him and offer cow’s milk, fruits, sweets etc. They also requested his assistance
in solving their personal problems. Patient used to offer advice and occasionally would give
money and other valuables to the needy and poor. He was also found to be working for
long hours in the field, grazing cattle for times at stretch. Over the course of six weeks,
these activities slowly came down and as the patient started feeling tired he felt that
Jinjappa was leaving him.
Since then once in a year or two, patient used to get similar ‘episodes’, often after any
insult or threat to his family or himself. Over a period of time, villagers used to ask for
more and more favours from Jinjappa. Consequently, Kariyappa had been instrumental in
settling land disputes, marital problems, alcohol dependance and minor medical problems
1
of children and problems involving the cattle. He also used to forecast about the rainfall
and seasonal changes. Whenever he walks in the streets, people used to prostrate
themselves before him, seeking his blessings.
During the last five years, these 'episodes’ have occurred on the background of land
disputes involving him and his paternal cousin's family. He was primarily angry with his
cousin for his attempts to sell a part of the ancestral land. The cousin who is also the
village leader currently, did not heed to his request. The patient was also angry with the
villagers for supporting his cousin. Prior to the current consultation, patient heard from
others, that his cousin is in the process of finalizing the land deal. He went to his house
and challenged him to complete the deal without his consent On his return to his home,
he started talking like Jinjappa. This time he was restless, verbally abusive towards the
people who were supporting his cousin and was abusing them in public. He also threw
stones at these peoples houses. Hence, he was tied up and brought to the hospital with
the help of the police.
PREVIOUS 'TREATMENT
Two years before these episodes started, a Golla ( cowherd) came to the patient’s village
as a migrant worker. Patient asked him to look after his lands and keep a watch over it. He
had brought with him two idols of Jinjappa and Beerlinga in a brass pot. These two were
immersed in the holy water of Kenchamma inside the pot. He installed these three gods
near a anthill under the neem tree in Kariyappa’s field. After a year the Golla wanted to
leave the job and he advised the patient to worship these Gods as they would protect him
and his family. He also added that if Kariyappa did not follow his advice, adverse
consequences might follow for the family. Since then the patient has been worshiping the
Gods everyday and has also appointed his nephew to do regular pujas.
On this background, the family did not view the patient's behaviour as a problem and were
offering pujas to him every time he got possessed. It was only during the last five years
when they noticed Kariyappa to get more angry during the episodes, the family had sought
help from other faith healers. On their recommendations, pujas and offerings were made
to the main temple in the next village whose main deity was Jinjappa ( Krishna). They had
also arranged for a massive poor feeding and distributed money and clothes to the poor
people in the village. They also consulted many temple priests who used to get possessed
and one of them advised the family to transfer the idols from their lands to the main
temple. Even after this, the patient continued to have the episodes. Since the current
episode was more disruptive, people in the village advised consultation at Nimhans.
SOCIAL & DEVELOPMENTAL HISTORY
Kariyappa was born in a joint family. His father was the eldest in a family of six sons. And
Kariyappa was his eldest son. They belong to the Kuruba ( shepherd), community, which is
considered as a backward caste in Karnataka. They are devotees of Lord Krishna and are
primarily non-vegetarians.
Patients paternal grand father had thirty acres of wet lands in Machenahalli and also had
large herd of cows and buffaloes. Towards the end of his life, he divided this property into
six equal parts. Each son had five acres of arable land, which they have been cultivating for
many years. Kariyappa himself has two brothers and hence the five acres of his family, was
2.
in turn divided among the three of them. Kariyappa's uncles had also divided their land
among their family. The particular cousin with whom Kariyappa has been having
problems, is the only son to his father and hence has been 'enjoying' the benefit of having
five acres of land. This includes a portion to which Kariyappa is immensely attached, as it
has a small pond where he had spent many hours with his grandfather. As Kariyappa’s
cousin had taken a large loan after pledging his land and was not in a position to repay it,
he has been keen that the lender take away his land in lieu of the money he owes to him.
Moreover, since he is actively involved in politics, he has not been keen on cultivating and
looking after the land. This has angered Kariyappa as he is against the selling of the
ancestral property.
Kariyappa never attended the school and has been working in the lands since an young
age. He got married at the age of 21 and has two sons, who assist him in farming. The
interpersonal relations between him and his wife as well as his son is reportedly very
cordial. His wife is reported to be a very quite, soft-spoken, hard-working woman.
Whenever Kariyappa has these episodes, he sends his wife away to her parent's house as
he feel that he has to maintain his 'purity' during these episodes.
Between these episodes, Kariyappa has been functioning well. He has no major monetary
problem, nor does he have any debts.
FAMILY HISTORY
Within the community, Kariyappa’s family has always been respected. They have been the
community leaders for many decades. The patient’s father was the village leader ( gowda)
and later Kariyappa himself .assumed this position for a long time. Since the past six years,
his cousin has taken over his position.
Kariyappa's paternal grand uncle also had ‘possession’ attacks, the nature of which is not
very clear.
No other history of any other illness in the family.
COURSE & OUTCOME
After his admission in the hospital, Kariyappa was found to be cheerful, talking freely with
all the inmates of the ward. Sometimes he would bless them, wishing them a faster
recovery from their illness. He was a popular figure in the ward and many patients and
their attendants enjoyed talking to him. He slept poorly during the initial few days, waking
up often in the night.
During the interview, he was found to be dressed immaculately, wearing flowers over his
ears and with a prominent vermillion mark over his forehead. He was smiling all through
and was gesticulating with his hands to emphasize his narration. His speech output was
increased. He was talking spontaneously and would continue to do so unless stopped. He
was telling that it was not he but Jinjappa who was talking and described at length about
his powers, “ I could do the work of many people without feeling tired. I can face any
number of people who come to control me. I can tell you when it will rain. And I can cure
people of their illnesses.” When queried about his powers as to when and how he got
them, he replied “ it is not Kariyappa who is talking to you. I am Jinjappa, Lord Krishna. I
have immense powers to help and assist people." He had no perceptual anomaly and his
cognitive functions were within normal limits. He did not feel that he had any illness and
rejected the suggestion that he could be mentally ill.
3
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SCHIZOPHRENIC RESEARCH FOUNDATIlJh (INDIA )
WORLD HEALTH ORGANISATION
COLLABORATING CENTRE
FOR MENTAL HEALTH RESEARCH & TRAINING
Towards a better future for the mentally disabled
A MALADY OF THE MIND
The eldest son of a temple priest,
he was brilliant at school and nurtured
great ambitions about becoming an
engineer. His family shared his dream,
and not withstanding the great finan
cial stress they were facing were pre
pared to make any sacrifice to enable
him to join the IIT. All went well for a
year and a half at I.I.T. until he started
hearing voices accusing him. His
friends began to feel that he was a
different person and no longer enjoyed
his company. His family sought the
advice of astrologers, magicians and
faith healers, but he seemed to move
further and further away from them - a
pale shadow of his exuberant, flashy
self. Why did this bright youngster
stop attending classes, start failing in
his exams and ultimately drop out from
the course itself crushing the fond
hopes of his family?"
agony?"
She used to get up everyday at 5
in the morning and go about her work
with the precision of a clock. She was
an ideal mother and wife, friendly and
helpful. Gradually her husband no
ticed that she was becoming moody,
temperamental and given to periods of
intense preoccupation and silence. She
did not seem to enjoy anything, be it
his company or the children's or cook
ing her favourite dishes and neglected
her self care. She became irritable,
suspicious, kept awake the whole night
and insisted on all doors and windows
closed all the time in mortal fear of an
enemy who she thought was going to
attack her. She felt that everybody was
looking at her and talking about her
and slowly stopped cooking, and look
ing after the home. Why did this lov
ing wife and mother decide to end her
life unable to bear the inner pain and
These are not born out of a writer's
imagination, but true descriptions of
tragic transformations in people's lives,
changes so painful to those near and
dear and hard to understand and
fathom. What is the common feature in
these stories?
Both these people suffered from an
illness called Schizophrenia, an illness
afflicting the mind in the most produc
tive years of people's lives. They are
not alone in this.
Nearly 6-7 million Indians suffer from
this disorder variously described as the
"cancer of the mind" and the "greatest
disabler of youth". Cosmopolitan in its
occurrence, it cuts across barriers of
gender, educational and socio - eco
nomic classes. Although the causes of
this disorder are not clearly established,
significant advances have been made
in its treatment and rehabilitation.
However in order to reduce or prevent
the disability caused by schizophrenia,
it is essential to identify it early and
treat it vigorously.
How does one identify this illness
and what is the treatment?
Does it run in.families? Does it have a
total cure?
These and several questions which
plague the minds of families have an
answer. You just have to write to
SCARF and get all the information you
require, all the support you need and
the professional expertise to tackle this
challenge.
But what is SCARF?
SCARF is the acronym for the
Schizophrenia Research Foundation, a
non-governmental, non-profit organi
sation in Madras, India which since
1984 has committed itself to schizo
phrenia care and research. Founded by
a group of philanthropists and mental
health professionals, SCARF has estab
lished itself as a centre of repute in
rehabilitation of the illness and
research.
What does SCARF offer to patients
suffering from this illness?
SCARF offers a comprehensive treat
ment package comprising of :
* Out patient care manned by a multi
- disciplinary team of psychiatrists,
social workers and psychologist.
* Free medication for those who
cannot afford it
* A well worked out, individually
tailored rehabilitation programme
consisting of occupational therapy,
group therapy, social skills training
and cognitive training.
* A special emphasis on the family by
EARLY SIGNS AND SYMPTOMS
* Lack of concentration in work,
studies.
* Confused thinking; strange or
grandiose ideas.
* Prolonged severe depression;
apathy; mood changes Excessive
anxieties, fears, or suspiciousness.
* Withdrawal from society, friend
lessness; appears lost in thoughts,
brooding a lot.
* Denial of obvious problems;
Strong resistance to help.
* Thinking or talking about suicide.
* Numerous, unexplained physical
ailments; marked changes in
eating or sleeping patterns.
* Anger or hostility out of proper
tion to the situation.
* Delusions, hallucinations,
hearing voices.
* Abuse of alcohol or drugs; neglect
of self care.
* Growing inability to cope with
problems and daily activities such
as school, job or personal needs.
the family cell to support, counsel
them and involve them in treatment
programmes.
An employment bureau which seeks
to find jobs for the disabled.
And above all SCARF sees in each
client a human being disabled in
various ways, but yet deserving
the self respect, dignity like his
brethren.
Brought out books and training
manuals.
* Trained over 50 students of social
work and psychology.
* Has been recognised by the M.G.R.
Medical University as a centre for
PhD training.
* Has had some of its faculty trained
in certain special programmes such
as cognitive retraining.
RESEARCH
AWARENESS, EDUCATION
SCARF has forged research links
with several national and international
bodies of repute.
* Has completed over 20 research
projects
* Published over 80 scientific papers
in national and international jour
nals.
* Organised 4 international and 18
national conferences
SCARF has been equally active in
the field of awareness and education.
Myths and misconceptions abound in
the understanding of mental illness
leading to delay in seeking treatment.
SCARF therefore identified this as an
important area of work and has organ
ised several awareness programmes not
only in urban areas, but in rural pockets
using indigenous modes of communi
cation. Video films, Audio visual
materials have been produced on the
illness and its management.
* Out patient treatment at Anna
Nagar for nearly 4,000 mentally
ill.
* Cared for 1,200 rural patients at
Karnambut and Thiuporur and
200 from urban slums.
* Found jobs for 82 mentally
disabled.
* In recognition of outstanding
services for the welfare of the
handicapped, SCARF received
the "National Award to Outstand
ing Employer 1995" from the
President of India Dr. Shankar Dayal Sharma on December 3,
1995 at New Delhi.
* Reintegrated 165 women into
their families after rehabilitating
them.
* Provided free transport to patients
reaching our centre.
* Assisted 210 children of the
'mentally ill with their education.
* Engaged over 300 patients in
work units.
TRAINING
Training various levels of health
workers in the basic principles of detec
tion and management of mental health
problems and promotion of positive
mental health is another important area
of activity. In fact, with the develop
ment of manuals, training aids and kits,
SCARF is well poised to become a
focal agency for training in
psychosocial rehabilitation techniques.
COMMUNITY MENTAL HEALTH
Work has been confined not just to
institutions, but has been taken to the
community as well. Thiruporur in
Chingelpet district, Karnambut in
North Arcot District, Thiruverkadu and
the urban slums at Vyasarpadi have all
benefitted from SCARF'S community
based programmes, a rubric of activi
ties including treatment, rehabilitation,
awareness etc. A.key element in these
programmes has been the extensive
participation of the community in all
our activities.
RESIDENTIAL CARE
SCARF'S COLLABORATORS,
_________ SPONSORS
I
* World Health Organisation,
Geneva ;WHOSEARO,
Recognising that the path of
rehabilitation is long and tedious and
involves several levels of intervention,
SCARF has established two residential
centres at Thiruverkadu and
Mahabalipuram. Manned by a profes
sional, multi - disciplinary team, these
centres offer varying, need based
periods of stay and intensive efforts at
improving the skills lost by the
patients.
The centre at Thiruverakadu was built
in 1991 (on land donated by the temple
trust with donations from Helpage
India, IDBI, Madras Round Table I) and
houses 55 mentally disabled women
and elderly. Just outside the town of
New Delhi.
* World Association For
Psychosocial Rehabilitation
(WAPR)
* Johns Hopkins University, U.S.A.
* International Development
Research Centre (IDRC) Canada.
* Royal Crichton Hospital,
Dumfries, Scotland.
* Royal Perth Hospital, Australia.
* Oxfam.
* Helpage.
* Tata Institute of Social Sciences.
is the centre for men
donated by Sri Sankaracharya
of Kanchi with Sri Sugalchand, Jindal
Trust & Sri G.N. Damani being the
major donors for the construction of
buildings. People from all over the
country have availed of these facilities.
* Support from the public, donors,
governments of Tamil Nadu and
India.
* A great number of beneficiaries
who have reposed faith and trust
in us.
POLICY & LEGISLATION
OUR OWN HOME
SCARF has also gone beyond
microlevel planning and has been ac
tively engaged in influencing legisla
tion and welfare programmes for the
mentally disabled at the level of the
state and central governments.
Our next mission is to have a building
on land donated by the Govt, of
Tamil Nadu. This will house the
following :
All this has been possible because of
* A high degree of commitment to the
cause of mental illness.
* An excellent multi - disciplinary
team
* Out patient clinic
* Limited inpatient beds
* Day Care Centre
* Vocational units for men and women
* Research wing with a computer cell,
library and auditorium
* Training and education centre
* Special services for women and eld
erly mentally disabled.
* Administration and accounts
* Guest rooms
. FUND RAISING FOR THIS IS ON A
WAR FOOTING SINCE AN AMOUNT
OF A CRORE OF RUPEES is required
to complete the COMPREHENSIVE
MENTAL HEALTH FACILITY Which
will be a centre of excellence and re
pute in all aspects of mental health care
an^i research, a centre which will do the
country proud and bring solace and
comfort to the mentally disabled and
their families.
At this point in time, we make a
special and specific appeal to help us
complete our centre. The various ways
in which you can contribute towards
this are detailed in this brochure.
Since its humble beginning in 1984,
SCARF has established itself as an
Fund raising programme organised by
'Friends of SCARF &
hosted by the Prince of Arcot. 1996
Research Seminar 1989
f
SCARF residential centre
for men at Mahabalipuram.
unique and nodal centre for mental
helath care and provided relief to thou
sands of mentally disabled and their
families. It is only with your support
and encouragement that we can con
tinue and expand these activities into
the 21st century. The following are
some of the ways in which you can help
us do this :
* Make donations to SCARF and avail
of a 100% tax relief under 35 (i) (ii)
of the I.T.Act.
* Become a life member / institutional
member of SCARF.
* Sponsor the education of the chil.
dren of patients, especially if
they are the bread winners of Hie
family.
* Help generate employment for our
improved clients.
* If your communication skills arc
J good, you can write in the general
press about schizophrenia and
SCARF and improve awareness.
* Above all you can be a friend and
well wisher and be part of us in our
mission to work for a brighter future
for the mentally ill.
SCARF has been desig
nated aS a World Health
Organisation Collaborat
ing Centre for Mental
Health
Research &
Training - the first Indian
NGO dealing with Men
tal Health to be accorded
this status.
J
SCARF
REHABILITATION
RESEARCH
1. Out Patient Care
2. Community Homes
1. Intramural Projects
2. Collaborative Projects
3. Residential Facilities
4. Rehabilitation Package
5. Employment
6. Education of Children
3. Seminars & Symposia
4. Publications
5. Books, Manuals
6. Recognised PhD Centre
7. Family support
8. Community Based Work
7. Influencing Policy & Legislation
AWARENESS &
TRAINING
1. Awareness Programmes
2. Mental Health
Awareness Week
3. Audio - Visual Aids
4. Films
5. Training
6. Training Package for
Health Workers &PSR
Personnel
PEOPLE BEHIND SCARF
Patron-in-Chief: Honourable Sri K.R.Narayanan, Vice President of India, President: Mr. V.T. Somasundaram
Vice-Presidents : Mr. M.A. Vellodi, Dr. M.S. Valiathan, Mr K.P. Mahalingam Secretary : Dr. R. Thara
Founder & Adviser : Dr. M. Sarada Menon , Members : Mr. K.R. Baliga, Dr. S. Rajkumar, Dr. T.R. Govindachari, Mrs. C.K. Gariyali,
Dr. Subash Phaterpekar, Mr. Rajiv Raj, Mr. Habibullah Badsha, Dr. S.M. Channabasavanna, Mr. Jayaram Rangan
J
FUNDING OPTIONS
A. For the Proposed New Building
1. Sponsoring one particular room or wing
(This will be named as per the wishes
of the donor)
Rs.
3,00,000
f) 4 of tables and Chairs for Doctors
and Nurse in acute care ward
(4 x 3,000)
Rs.
12,000
g) Medical Equipments
Rs.
25,000
h) 1 Petrol driven Autorickshaw for
transporting acute patients to other
hospitals in emergencies (1 x 70,000)
Rs.
2. Furniture for the Acute Care Ward
a) 2 Accaire Air Conditioner
1 tonne each for Computer Rooms
with Voltage Stabiliser
(2 x 35,000)
b) 4 Cots for acute care ward
(4 x 1,500)
70,000
2,17,000
3. Furniture & Fittings
Rs.
Rs.
70,000
a) P.V.C Chairs (12 sets) for the lobby
and acute care ward.
Rs.
16,200
6,000
b) P.V.C. Chairs (50 sets) for the
conference hall.
Rs.
1,45,000
c) Head Table and Chair for the
Conference hall
Rs.
21,000
d) Executive Table and Chair
Rs.
15,000
c) 4 Cupboards for acute care ward
(4 x 2500)
Rs.
10,000
d) 4 Mattresses, Pillows, Pullover etc.
(4 x 1000)
Rs.
4,000
e) 4 Cupboards (big size) for acute
care pharmacy (4 x 5,000)
Rs.
20,000
4. Fans and Tube Lights
J
C. Support to Research Activities
a. Fans for I and II floors (50 Nos)
Rs. 46,500.00
b. Box type tube lights for I and II
floors (50 Nos)
Rs. 28,100.00
1. A Research Fellowship endowment
for one research staff.
Rs.2.00,000.00
74,600.00
B. Client Support for one year
1. Cost of Medicine Rs.800/- x 12
Rs.
9,600.00
Rs.800/- x 12
Rs.
9,600.00
3. Cost of other support
services
Rs. 200/- x 12
Rs.
2,400.00
2. Cost of Food
Rs. 21,600.00
Sponsoring a poor client for life in
one of our residential centres
Rs. 1,50,000.00
Please note that all donations to SCARF are exempted fully
(100%) from taxable income under Section 35 (i) (ii) of the
Income Tax Act.
JOIN SCARF (INDIA) in the c^Jade. Donations to SCARF are fully exempted ui^r sec 35 (I), (II) of the I.T. Act
To
The Secretary
Schizophrenia Research Foundation (India)
C-46, 13th Street, East Anna Nagar,
Madras - 600 102.
INDIA.
Tick where applicable
Kindly enroll me as a Life / Institutional member.
0
Name
I wish to support the activities of your Foundation. Please accept my enclosed contribution
..........................................................................................
Address ...................................................................................... ...............................................................
Cheque/Demand Draft No.:
Date :
................................ Drawn on
....................
Cheques may be drawn in the name of
SCHIZOPHRENIA RESEARCH FOUNDATION (INDIA).
* Life Member Fee Rs. 2,000/* Institutional Member Fee Rs. 10, 000/-
Proposed building for SCARF Centre at
Anna Nagar
- Media
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