CHRONIC MENTAL ILLNESS & DISABILITY MENTAL HEALTH
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- CHRONIC MENTAL ILLNESS & DISABILITY MENTAL HEALTH
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Indian J. Psychiat., 1993, 35(1), 33-35
NATURE AND COURSE OF DISABILITY IN
SCHIZOPHRENIA
R.THARA, S.RAJKUMAR
SUMMARY
Sixty eight Feighner positive schizophrenic patients were followed up prospectivelyfor a period ofsix years using
standardized instruments. Disability was assessed in this sample using the Schedule for the Assessment of
PsychiatricDisability at the end of4,5 and 6 years offollow up. It wasfound that the three year course ofdisability
tended to be stable andfluctuations were minimal. Disability did not seem to be related to relapses. The implications
of these findings in planning intervention programs for chronic schizophrenicpatients are discussed.
INTRODUCTION
Traditionally, disabilities have been associated with
conditions, physical and mental, where a handicap or
impairment has been tangible and obvious such as physi
cal and sensory handicap or mental retardation. In the
recent past, however, certain chronic illnesses are being
increasingly recognized as a source of great disability in
the community. Cardiac diseases, arthritis and chronic
mental illnesses are among the most prominent of these
(Thara & Menon, 1991).
Disabilities are defined as an inability or limitation to
perform tasks expected of an individual within a social
environment. The disabilities of persons with
schizophrenia can be very severe, encompassing the entire
gamut of an individual’s personal, social and occupational
functioning. The need to measure, quantify and under
stand disability gave rise to a major WHO initiative of a
multi-site study (Jablensky et al, 1981). One significant
contribution of the study has been the development of the
Disability Assessment Schedule (DAS) which has been
modified as the Schedule for the Assessment of
Psychiatric Disability (SAPD, Thara et al, 1988).
As an offshoot of the ICMR sponsored multi-site study
of the course and outcome of schizophrenia, disability was
measured at the end of the fourth and fi ft h years of follow
up at Madras and Vellore. The SAPD was developed
during the course of this exercise (ICMR, 1988). In
Madras, disability assessments were repeated at the end of
6 years as well, giving rise to three successive yearly
measurements of disability. This, therefore provided an
opportunity to study the nature of disability longitudinally
and its course over time.
AIMS AND OBJECTIVES
To study the nature and severity of disability in
schizophrenia.
2.
To assess the course of disability in chronic
schizophrenia.
1.
METHOD
The ICMR sponsored study on "Factors affecting the
course and outcome of schizophrenia" was a major mul ti site study conducted at Madras, Vellore and Lucknow
between 1981 and 1988.
At Madras, 96 patients were included for the five year
follow-up. The following instruments were administered
during follow-up. They were:
1. The Present State Examination (PSE, 9th edn; Wing et
al, 1974). This measured symptoms at inclusion and at
every year of follow-up.
2. The Personal and Psychiatric History Schedule
(PPHS): This recorded sociodemographic details at
inclusion and the follow up version was used at the end
of every year to assess changes.
3.
The Interim Follow-up schedule was given every three
months to record main psychotic symptoms and treat
ment details.
4.
The Schedule for the Assessment of Psychiatric Dis
ability (SAPD) (Thara et al, 1988) was administered at
the end of the fourth, fifth and sixth years of follow-up
at Madras. The follow up at six years was done at the
initiative of the research team at Madras center after
the main study was completed. This instrument, which
is a modified version of the DAS II, measures disability
in the areas of personal, social and occupational
functioning as well as Global Disability. Interviews
with the patient and a key informant were used to
complete the SAPD.
All these instruments were administered to 68 patients
who were available for follow-up after attrition of the
sample over the 6 year period (Thara et al, 1991). For the
purpose of this paper, data from the SAPD alone is con
sidered.
SAMPLE CHARACTERISTICS: Of the 68, 36 were
males and 32 were females. All of them hailed from the
city of Madras and the peri-urban areas, and were between
the ages of 15 and 45 at inclusion, fulfilling modified
Feighner’s criteria for schizophrenia. They were all from
middle and lower socioeconomic groups. More details of
the cohort can be had from the report of the ICMR study.
RESULTS
Severity of disability: The mean scores of disability in
all the three years of assessments were not high, rang
ing from a low of 0.67 in the area of social contact
friction to a high of 1.63 in occupational functioning.
This implies a mild to moderate degree of disability
(0=absent, l=mild, 2=moderate, 3=severc).
Personal Disability: The items of scif-carc, spare time
B.
activity, speed of performance, interest and informa-
A.
33
R.THARA & S.RAJKUMAR
Table-1
Mean Dtsabfiiy Scores
PERSONAL DISABILITY
SOCIAL DISABILITY
OCCUPATION DISABILITY
GLOBAL DISABILITY
4th yr
5Uiyr
6L-yr
1.18
091
1.39
1.39
1.07
1.11
1.63
1.63
1.03
0.79
1.35
1.35
tion and deali ng with an emergency si ruation consti tute
personal disability. The scores for the 4th, 5th and 6th
years of follow-up were 1.18,1.07 and 1.06 respective
ly. The maximum disability perceived was in the area
of functioning in emergency situations.
C.
Social Disability: This indudes household activities,
communication, friction in social contact, marital and
parental role functioning. The scores for the three vears
were 0.91,1.11, and 0.79.
D.
Occupational Disability: Occupational performance,
interest in getting back to work and number of days of
work make up this item. Of all the three areas of
disability, maximal scores were seen in this, though
still being only mild to moderate degree of disability.
The disability scores were 139,1.63,135.
E.
Global Disability: This was the interviewer’s assess
ment of the overall disability on a 4 point scale. The
highest score of 1.16 was in the 5th year of follow-up.
The scores in the 4th and 6th years were 1.11 and 0.91
respectively.
F.
Course of Disability: Table 2 shows the changes in
disability scores over a two year period. It can be
observed that disability tends to be stable in more than
FK3.1 CHANGES OF DISABILITY
S INCREASE E DECREASE ■ STABLE
DISCUSSION
The most striking observations in this study are the
rather low levels of disability throughout the three years it
was measured. This could be due to several factors, the
most important being that it was a closely followed up and
well treated cohort. At Madras, most patients were seen
once in two weeks or at least once a month by the same
investigator(RT), and hence it was possible in many cases
to aven severe relapses. Besides, in all these patients,
treatment had been initiated early in the course of the
illness, between 3 and 24 months after the onset.
This is in contrast to the findings of rather high dis
ability in a Madras based community study, wherein the
average duration of illness was longer, about 35% of the
cohort was untreated and attrition rates were higher (Rajkumar, 1990).
The highest disability was in the area of occupational
Table-2
functioning. We have found that the informants are able
Change In Disability
to respond more precisely to questions on this area of
YEARS
INCREASE DECREASE STABLE
functioning, since it is more objective and less hypotheti
cal. It is also true that loss or lack of gainful activity could
4-5
9 (132%)
6(8.8%)
53(772%)
be perceived as more disabling than deficiencies in certain
5-6
7(103%)
14(20.5%)
47(69.1%)
other activities such as communication, self care etc. It is
4-6
11(161%)
15(220%)
42(61.7%)
also interesting to note that the course of disability tends
to be stable over a three year period. Other studies have
also found similar results (Giel et al, 1984).
In order to gain a true picture of the course of disability
60% of the pati ents. The difference between those who
in schizophrenia, it would be ideal to start with acute, first
had an increase and a decrease in disability was not
substantial.
onset cases, and to follow them up at steady intervals. This
G.
Relationship between Disability and Course of Illness: would gave a clearer picture of the ‘plateauing off’ effect
of disability.
The relationship between disability and relapses was
In any case, the finding that disability tends to stabilize
studied. Between the 4th and 5th years of follow-up, 19
after a 5 year period is relevant to the planning of interven
patients had recorded a relapse, while only 9 showed an
tion programs for the chronically mentally ill. What ap
increase in disability. 14 patients had relapsed between the
pears to be important is the area of disability, rather than
5th and 6th years of follow-up, but only 7 had an increase
mild fluctuations in the total scores themselves. Hence,
in disability scores.
intervention personnel would do well to focus their ener
This seems to indicate that disability scores are not
gies on specific areas of dysfunction, such as occupation
related to the clinical pattern, especially with regard to
etc.
relapses.
34
DISABILITY IN SCHIZOPHRENIA
The findings of this study cannot be genetaiized to that
of any chronic schizophrenic cohort for the reasons
pointed out. Nevertheless, it is an indicator of the trends
in disability research.
CONCLUSIONS
This study of social disabilities in a prospectively
followed up cohort reveals mild to moderate disability
scores, with occupational functioning being the area of
maximal disability.
Disability tends to be stable over a period of 3 years
and seems to be independent of fluctuations in clinical
course. The findings are relevant to planning intervention
programs for the chronic mentally ill.
REFERENCES
Giel, IL, Wiersma, D., Dejong, A. & Sloof, C. (1984)
Prognosis and outcome in a cohort of patients with
non-affective functional psychosis. European Ar
chives of Psychiatry and Neurological Sciences, 234,
97-101.
Indian Council of Medical Research (1988) Final
Report of the study on "Factors affecting course and
outcome ofSchizophrenia". New Delhi: Indian Coun
cil of Medical Research.
Jablensky, A., Schwarz, R & Tomov, T. (1980) WHO
Collaborative study on impairments and disabilities in
schizophrenicpatients: Apreliminary CommunicationObjectives and methods. Acta Psychiatrica Scan
dinavian, 62, Suppl. 285,152-163.
Rajkumar, S. (1990) Final Report of the "Study ofFunc
tional Psychosis in an Urban Community in Madras".
New Delhi: Indian Council of Medical Research.
Thara, R & Rajkumar, S. (1991) Sample attrition in the
follow-up of Schizophrenia. Indian Journal of
Psychiatry, 32,3,217-222.
Thara, R., Rajkumar, S. & VaIecha,V. (1988) Schedule
for the Assessment of Psychiatric Disability - A
modification of the DAS II. Indian Journal of
Psychiatry, 30,1,47-53.
Thara, R & Menon, M.S. (1991) A new perspective of
disability - Chronic Mental Illness. Indian Journal of
Disability and Rehabilitation, Jan-June, 33-36.
Wing, J.K. & Cooper, J.E.(1974) The management and
classification of psychiatric symptoms. London:
Cambridge University Press.
R.Thara , Joint Director, Schizophrenia Research Foundation, C-46,13th Street, Anna Nagar East, Madras
- 600102; S.Rajkumar, Professor ofPsychiatry, Madras Medical College, Madras - 600 003.
Correspondence
35
INDIAN JOURNAL OF DISABILITY AND REHABILITATION
JANUARY-JUNE, J991
Mental Illness
A New Perspective of Disability: Chronic Mental Illness
Dr. R. Thara
Joint Director, Schizophrenia Research Foundation, C-46, 13th Street, East Anna Nagar,
Madras-600 102.
Dr. M. Sarada Menon
Director, Schizophrenia Research Foundation, Madras-600 102.
A bstract
While disability caused by physical illnesses, sensory deprivation and mental
retardation have long been recognised by professionals, public and policy
planners, it is only in the last decade that attention has been focussed on chronic
mental illness as one of the conditions which can produce severe disability.
This paper discusses the conceptual issues of chronic mental illness, the
extent of the problem in India, the nature of the disabilities produced and the
factors which have limited their understanding. The need to determine and
measure disability for the implementation of various intervention programmes
is stressed upon.
Introduction
Traditionally, disabilities have been associated with conditions, physical and
mental where a handicap or impairment has been tangible and obvious such as physical
and sensory handicap and mental retardation. In the recent past, however, certain
chronic illnesses are being increasingly recognised as a source of great disability to
the individual as well as the community. Cardiac diseases, arthritis, and chronic mental
illnesses are among the most prominent of these.
J
Disabilities are defined as inability or limitation to perform tasks expected of
an individual within a social environment. The disabilities of persons with mental
illnesses such as schizophrenia can be very severe encompassing the entire gamut of
IJDR, January-June 1991
34
R. Thara, M. Sarada Menon
an individual’s personal, social and occupational functioning. The need to measure,
quantify and understand disability gave rise to a major WHO initiative of a multisite
study. One of the important contributions of this study has been the development
of the instrument Disability Assessment Schedule (DAS) which has since then
undergone two revisions. (Jablensky, 1980). The DAS has been modified by the author
to the Indian setting as the Schedule for Assessment of Psychiatric Disability. (Thara
1988).
Mental health professionals find the profile of disabilities caused by chronic
mental illness to be essentially similar to that caused by mental retardation, though
there may be qualitative differences. Social and occupational disabilities form a major
cluster of behaviours that both reflect and influence the course and outcome of a
psychiatric disorder.
The fact that mental illness can produce severe disability is not well appreciated
both by the general public as well as the policy planners. This is borne out by the
general lack of understanding and sympathy towards the mentally ill—almost a denial
of the problem, and the lack of any disablement benefits for this group of people
in India. While the State has been quick to recognise the disability experienced by
the mentally retarded, it has only been in the very recent past that chronic mental
illness has succeeded in focussing attention onto itself.
Chronic Mental Illness?
Chronic mental illness essentially includes psychotic disorders, primarily
schizophrenia. According to WHO estimates, upto two-fifths of all disability in the
world is related to psychiatric conditions. 74% of the 540 patients identified in the
WHO study on “Assessment and reduction of psychiatric disability” had a clinical
diagnosis of schizophrenia. These patients suffer from a wide spectrum of personal,
social and occupational disabilities.
After recovery from the acute phase of the illness, they could encounter major
difficulties in socialisation, maintaining a peer group, holding on or acquiring a job
and in the general process of reintegration into the main stream of society. The stigma
attached to the illness, the negative attitude of the family and the community at large
only serve to compound the problems.
The relative isolation of psychiatry from other medical disciplines has also limited
its access to advances in disability work and research. Agreed concepts in the area
of disability are still lacking with unclear clarification of the relationship between
psychiatric illnesses on one hand and resultant or associated disabilities on the other.
This is because of the lack of a sharp differentiation between psychiatric symptoms,
especially the negative symptoms and the resultant disability.
Nevertheless, research in the last 5 years has clearly established:
1) Disability in chronic mental illness is a reality, as much as it is in physical
illnesses-and developmental defects.
UDR, January-June 1991
A New Perspective of Disability: Chronic Mental Illness
35
2) Disability caused by CMI is more often all encompassing, affecting the
individual’s personal, social and occupational functioning.
3) The extent of disability is related to the duration of illness and treatment, though
not always to the clinical state.
4) It is possible to identify a group of severely disabled individuals who will require
some kind of support for their entire lifetime and others for a shorter period.
New Initiatives for the CMI
Considered in the background of the information provided in terms of the extent
and gravity of the problem vis-a-vis the relative inaction in this field, the need to
develop initiatives for the CMI cannot be over-emphasised. These should broadly
encompass prevention, treatment and care, rehabilitation and increased community
participation.
Prevention
Since the exact causal mechanisms of the chronic mental illness, especially
schizophrenia have yet to be identified, primary prevention has a limited role. The
two main areas of work could be:
1) Increasing awareness about mental illness in general with the specific focus
on early signs and symptoms so that detection of the illness is not delayed for too
long. This would facilitate prompt treatment and would go a long way in
preventing/reducing disability. THIS SHOULD BE AN IMPORTANT. AREA OF
OPERATIONS—not merely the NGO’s dealing with mental health, but all others
working in primary care and general health.
2) Genetic counselling has a limited applicability in certain disorders with
discouragement of consanguineous marriages.
Care and Rehabilitation
While acute care for the mentally ill is provided by hospitals and private medical
facilities, it is aftercare or rehabilitation which is the sheet anchor of any strategy
aimed at reducing psychiatric disability. The clinical practice of this, just like its
counterpart in physical rehabilitation, is comprised of two intervention strategies:
1) Client skill development.
2) Environmental support development.
Psychiatric rehabilitation practice is guided by the basic philosophy of
rehabilitation: disabled persons need skills and environmental support to fulfil the
role demands of their living, learning, social .and working environments.
DDR, January-June 1991
36
R. Thara, M. Sarada Menon
Family support and intervention is a key element in this process. It is even more
relevant in India, where 90% of the patients continue to live with their families, which
have different kinds of stresses to cope with apart from the mentally ill individual.
Family interventions have generally been:
1) Educational—designed primarily to provide information.
2) Skill training—designed primarily to develop skills.
3)
Supportive—to enhance the family’s emotional capacity to cope with stress. “
Advocacy Groups
The most dramatic innovations in the role of the family in recent times has been
the development of advocacy and self-help groups. NAMI in the USA with more
than 80,000 members has become a powerful spokesman for the CMI. In India,
unfortunately, this is still very much in its infancy, although the need to strengthen
it is greater. One such group is ASHA working with the Schizophrenia Research
Foundation in Madras.
Public Education
While this is one of the key elements in any programme targetted at the
prevention/reduction of disability, its importance is increased manifold in the case
of chronic mental illness, where the exact causal factors have not yet been clearly
identified. Hence early detection becomes crucial to the prevention of chronicity and
disability.
Multi-media mass oriented programmes are the need of the hour and this again
is best handled by NGOs than the government. The stage has come to regard
psychiatric disability on par with other disabilities and initiate a concerted effort of
professionals, NGOs, Government agencies and the community. The barriers are not
architectural, but attitudinal and programmatic.
Employers, landlords, teachers, and neighbours possess the capacity to unleash
the talents of persons with psychiatric disabilities—if only they would unharness
themselves from their prejudices.
References
Jablensky A, Schwarz R, Tomov T (1980) WHO collaborative study on impairments and disabilities in
Schizophrenic patients: a preliminary communication—objectives and methods: Acta Psychiatrica
Scandinavian suppl., 285,62, 152-63.
Thata R, Rajkumar S, Valecha V (1988): Schedule for assessment of psychiatric disabilities—Modification
of the DAS-11, Indian Journal of Psychiatry, 30, 1, 47-54.
IJDR, January-June 1991
Indian Journal of Psychiatry, January 1988, 30(1), pp. 47-53
THE SCHEDULE FOR ASSESSMENT OF PSYCHIATRIC DISABILITY - A
MODIFICATION OF THE DAS - II
R. THARA1
S. RAJKUMAR2
V. VALECHA3
SUMMARY
Measurement of Disability is one of the off-shoot projects of the major multicentred study on ‘Factors Af
fecting Course and Outcome of Schizophrenia’ being held at Madras, Vellore and Lucknow. As part of this study,
modification of the Disability Assessment Schedule (II) was carried out at the Madras centre. Certain items of the
DAS were deleted and the rest were regrouped into 4 main areas of personal, social, occupational and global dis
ability. This modified instrument called the Schedule for Assessment of Psychiatric Disability (SAPD) was ad
ministered to 30 patients each of the 3 groups of psychoses, neurotics and diabetics. It was found that the SAPD
effectively discriminated the psychotic group from the other 2 groups. The authors recommend this instrument
for measurement of disability in an outpatient psychiatric population.
Introduction
Disability may be defined as distur
bances in the performance of social roles
that would normally be expected of an in
dividual in his habitual milieu, arising in
association with a diagnosable mental dis
order (Jablensky, Schwarz and Tomov
1980). As an essential ingredient of any
chronic mental disorder disability has lent
itself to measurement, although several at
tempts at developing instruments to mea
sure disability have not met with any great
degree of international agreement (Wing
1961, Cheadle and Morgan 1972, Morgan
and Cheadle 1974, Owens and Johnson
1980).
In an attempt to evolve a conceptually
satisfactory instrument which could be
used in culturally different settings, the
W.H.O. developed the Disability Assess
ment Schedule (D.A.S.). This has gone
1. Senior Research Officer
2. Add!. Prof, of Psychiatry and
Principal Investigator
3. Assistant Research Officer
through 3 revisions and the D.A.S. Ill is
currently in use.
In the ongoing ICMR project on ‘Fac
tors Affecting Course and Outcome of
Schizophrenia’, measurement of Disabil
ity is one of the offshoot projects at Madras
and Vellore centres. During the course of
this project, our experience with DAS II at
the Madras centre has revealed that it is
not entirely culture free and required cer
tain modifications. The outcome of this ef
fort was the modified instrument
‘Schedule for Assessment of Psychiatric
Disability’ (SAPD).
Why Disability?
Psychiatric Disability has emerged to
be an increasingly important area of re
search because of its role:(i) in understanding the nature of the ill
ness, especially its chronicity.
ICMR Project on Factors Affecting Course and Outcome of
Schizophrenia, Dept, of Psychiatry, Madras Medical College.
Madras-3.
48
THE SCHEDULE FOR ASSESSMENT OF PSYCHIATRIC DISABILITY
(ii) in planning intervention programme
for the chronically mentally ill.
Disability Assessment was recom
mended as priority area by the National
Advisory Committee on Mental Health
(1980). The WHO realising the impor
tance of disability assessment initiated a
multicentred study on assessment and re
duction of disability in 1976.
Need to modify DAS
The DAS used in the WHO mul
ticentred study on ‘Assessment and Re
duction of Disability’ initiated in 1976 was
designed specially for the assessment of
the patient’s behaviour and social func
tioning in his particular social and cultural
context.
It consists of 5 main parts on Overall
Behaviour, Social Role Performance, Pa
tient in hospital, Modifying factors and
Global evaluation. Part III was not used in
this study, as the sample consisted of out
patients only. On administering DAS II to
25 Out Patients at Department of
Psychiatry, Government General Hospi
tal, we found that most of Sec. IV on mod
ifying factors revealed very little useful in
formation. The concept of a patient’s
“asset” or “liability” being different from
what is perceived in the west, scoring on
items such as average assets, hobbies or ar
tistic activities was very difficult. The
scores on most of these items were as low
as 0/55 to 2/55.
The section on Home atmosphere
(4.3) though dealing with an important as
pect of expressed emotions does not con
tribute to the measurement of disability
and is not related to the rest of the schedule
by any particular set of classificatory ideas
or rules. Hence it was deleted.
The other item of DAS which elicited
a minimal positive response was the one on
Hetrosexual relationship (Section 2.5)
probably because they are not really
applicable to the existing socio-cultural
norms in India.
Therefore, before deleting these
items from the DAS, we thought it neces
sary to compare the scores of the schizop
hrenics on these sections with 2 other sam
ples: a group of neurotics and diabetics.
We chose diabeties because of its chronic
nature requiring prolonged, if not life
long, treatment, likely to cause disability
in several
spheres of functioning
(Murawski 1971).
Pilot Phase: 25 neurotics and 25
diabetics fulfilling the following criteria
were chosen.
The former were selected from out
patients attending the Dept, of Psychiatry,
Govt. General Hospital, Madras and the
latter from the Dept, of Diabetes &
Metabolism of the same hospital.
Group
Inclusion Criteria
Psychotics : Duration of illness; 2 years
fulfilling ICD (9) Criteria 295
&296.
Neurotics : Satisfying ICD (9) Criteria
(300). Minimum duration of
illness 6 months.
Diabetics : Currently diabetics, on treat
ment minimum duration of
illness 6 months. No overly
ing emotional or psychologi
cal problems.
Results
It was found that in all the three
groups, the mean scores on on sections
2.5,4.1,4.2, and 4.4 were rather low. Be
sides these items failed to discriminate
psychotics from neurotics and diabetics
(Table-1)
Further changes were required in the
R.THARAETAL.
Parti
Overall Behaviour 0 1 2 3 4 5 9
1.1.
1.2
1.3
1.5
Self Care
Spare time activity
Speed of performance
Interest and Information
Emergency Situation
Part II
Social Role
2.1
2.2
2.3
2.4
2.5
2.6
House-hold Activities
Communication
Social Contact Friction
Marital - Affective
Marital - Sexual
Parental Role
Partill
Occupational
3.1
3.2
3.3
Performance
No. of days of working
Occupational Interests
Part IV
Overall Disability
Psychotic ** Neurotic
**
(N = 25)
(N = 25)
Mean ± SD Mean ± SD
**
Diabetic
(N = 25)
Mean ±SD
0.04 ± 0.20
0.04 ±0.20
0.0 ±0.0
0.0 ±0.0
0.08 ± 0.27
0.08 ±0.27
0.04 ±0.20
0.0 ±0.0
0.04 ±0.19
0.08 ±0.27
0.04 ±0.20
0.0 ±0.0
** Not Significant.
form of regrouping of the items in order to
produce more workable results.
We divided the entire schedule under
4 main areas.
1.
Social Role Disability was sub divided
into A & B, section B covering marital
functioning. This had to be done since
this was not applicable to all patients
(60% of the sample).
3.
Part III is on Occupational Disability.
This is the same as in DAS II.
4.
Part IV is on overall disability - This
would be the subjective assessment of
the global disability.
Final study
Group
4.1
4.2
4.4
2.5
2.
0 - no disability; 1 - mild; 2 - moder
ate; 3 - severe. This modified instrument
consisting of 3 sections and a rating of
global disability is called the ‘Schedule for
Assessment of Psychiatric Disability’
(SAPD).
Table 1
Item
No.
49
These 2 items were hence included in
this section.
SAPD - FOR OUTPATIENTS
Personal Disability : We felt that ‘In
terests and Information’ and ‘Patient in
Emergency Situation’ are more indica
tive of personal than social disability
under which the DAS II had grouped it.
The SAPD was now administered to
90 patients, each of the three groups of
Schizophrenics, Neurotics and Diabetics
consisting of 30. The patients were
selected using the same diagnostic criteria.
Using Chi-Square (X2) analysis, it was
found that these 3 groups were essentially
similar as far as age, sex distribution and
duration of illness (Table-2).
Disability was assessed by interview
ing both the key informant and the pa
tients. The mean disability score for each
of the individual items was calculated,
unpaired ‘t’ - test was employed to study
the significance of the difference bet
ween the mean scores of disability in the
individual areas, as well as that of global
disability.
Inter-rater reliability exercises were
done for every 3rd case i.e., for a total of
30 cases. The inter-rater reliability at
Madras was 0.92 (kappa index of agree
ment).
THE SCHEDULE FOR ASSESSMENT OF PSYCHIATRIC DISABILITY
50
Table 2
Variable
Sex
Psychotic Group
(N = 30)
M + S.D.
Neurotic Group
(N = 30)
M±S.D.
male
32.94 ±10.69
29.43 +10.97
33.84 ±13.00
Female
31.31 ± 9.77
31.06 ± 10.05
34.73 ± ±7.53
< 30years
30-45 years
> 45 years
23.14 ± 4.21
37.54 ± 3.84
51.67 ± 6.02
20.43+ 3.62
37.57 ± 5.10
48.5 + 1.5
22.1 + 4.53
36.56 ± 4.21
54.75 ± 5.26
NS
0.75 ± 0.25
3.68 ± 0.98
9.57 ± 4.76
0.92 ± 0.34
3.25+ 1.09
10.38+ 4.50
1.17+ 0.33
3.47 ± 1.19
9.63 ± 4.02
NS
Diabetic Group
(N = 30)
M + S.D.
Statistical
findings
NS
Age
Duration of
illness
<2 years
2-5 years
> 5 years
Table 3
Psychotic Group (P)
Item
No.
1.1
1.2
1.3
1.4
1.5
2.2
2.3
2.4
2.5
2.6
3.2
3-3
4
Neurotic Group (N)
Diabetic Group (D)
‘t’ - test Values
ni
Mean ± Sd
"2
Mean ± SD
"3
Mean ± SD
PVSN
PVSA
NVSA
30
30
30
30
30
30
30
30
15
14
14
25
25
28
30
0.60 ±0.95
1.87 ±1.52
1.50 ±1.36
1.53 ±1.65
2.30 ± 2.07
1.47 ±1.67
1.60 ± 1.40
1.03 ±1.35
1.07 ±1.57
1.14 ±1.60
0.93 ± 1.15
1.76 ±1.80
2.24 ±1.99
1.75 ± 1.95
1.80 ±1.01
30
30
30
30
30
29
30
30
18
16
18
29
28
29
30
0.23 ± 0.50
0.40 ±0.71
0.76 ±0.90
0.43 ± 0.76
0.67 ±0.91
0.31±0.70
0.40 ± 0.85
0.20 ± 0.60
0.50 ± 0.90
0.75 ± 1.30
0.28 ±0.65
0.55 ±0.72
0.57 ± 1.08
0.52 ±0.81
0.87 ±0.56
30
30
30
30
29
30
30
30
17
0.07 ±0.25
0.30 ± 0.46
1.06 ±0.23
0.23 ±0.50
0.21 ±0.41
0.27 ±0.57
0.30 ±0.53
0.10 ±0.30
0.12 ±0.32
0.36 ± 0.48
0.12 ±0.32
0.58 ±0.84
0.69 ±1.17
0.17 ±0.46
0.70 ±0.78
1.67N.S.
6.88PC.01
2.64 P<.01
3.25 P<.01
3.89 P<.01
3.40PC.01
3.95 P<.01
2.88PC.01
1.26 N.S.
0.71 N.S
1.94N.S
3.26PC.01
3.78PC.01
2.89PC.01
4.34 PC. 01
2.92 Pc.01
5.32 Pc.01
1.74 N.S.
4.06PC.01
5.26PC.01
3.66 PC.01
4.67 Pc.01
3.62 PC.01
2.36PC.05
1.50 N.S
2.66 Pc.01
2.97PC.01
3.34 PC.01
4.08PC.01
4.63 PC.01
1.62 N.S.
0.64N.S.
2.06PC.05
1.19N.S.
2.45 PC.05
0.24N.S.
0.54 N.S.
O.SON.S.
1.61 N.S
0.91N.S
0.87 N.S
0.12N.S
0.39 N.S
1.95N.S
0.93 N.S
17
26
26
29
30
Results
The age and sex distribution of the pa
tients in the 3 groups was not significantly
different from each other. The duration of
illness which varied from 1 to 8 years was
also similar in the 3 groups (Table 2).
Table - 3 shows the mean scores ± S.D of
the three groups of patients on each of the
items of the SAPD. The psychotics have
mean scores ranging from 0.6 to 2.3 with
the lowest score being on self care (1.1)
and marital role functioning (2.4 - 2.6).
The highest disability scores are seen in the
areas of occupational functioning (3.1 to
3.3) and some items of personal disability
(1.2 & 1.5) which are greater than that of
other 2 groups (significant at 0.01 level).
It is clear from the table that both
R. THARA ET AL.
Table 4
Mean Disability score and one way Anova
Psychotic Group Neurotic Group Diabetic Group
(PG)
(NG)
(DG)
M±S.D.
M±S.D.
M±S.D.
Between
Groups
Within
Groups
F Ratio
Significant
Personal Disability
Score in all groups
(N = 30)
1.50 ±1.20
0.49 ±0.49
0.29 ±0.29
2
87
21.09
P<0.001
Social Role Score
in all groups
(N = 30)
1.36 ±1.28
0.44 + 0.79
0.24 ±0.36
2
87
13.05
P<0.001
Occupational disa
bility Score in all
groups (N = 30)
1.78 ±1.81
0.55 ±0.63
0.51 ±0.66
2
84
10.55
P<0.001
Overall Disability
score in all groups
(N = 30)
1.80 ±1.01
0.87 ± 0.56
0.70 ±0.78
2
87'
15.66
P<0.001
Table 5
Disability Scores (Mean)
Psychotic Neurotic Diabetic
Personal Disability
Social Role
Occupational Role
Critical Difference
1.77
0.52
0.55
0.60
2Se2
Critical Difference (C.D) = I -----
in the standard error of the difference bet
ween any two group means.
neurotics and Diabetics have low scores on
all items. There is no significant difference
between the scores of these 2 groups ex
ception 2 items (1.3 & 1.5). Table 4 shows
the results of the Analysis of variance
Technique (One-way classification) using
F-test. This was done for each of the 3 area
of disability as well as overall Disability.
One can readily appreciate the fact that
psychotics have significantly higher scores
than Neurotics and Diabetics in all the 4
areas (P C.001). This table also shows the
overall mean and SD scores of the 4 areas
of Disability while Table-3 indicates
scores on individual items. The highest
mean disability score is in global disability
followed by occupational disability (1.8 &
1.78 respectively).
Table - 5 has the mean disability scores ar
ranged in decreasing order of magnitude.
The difference between the scores of
psychotics and neurotics is statistically sig
nificant since it is greater than the critical
differences. The difference between
Neurotics and Diabetics is however less
than the critical difference. This clearly in
dicates that the SAPD effectively discrimi
nates between Disability in psychotics
from that of neurotics and Diabetics.
Discussion
The distribution of scores of disability
in the 3 groups show that Schizophrenics
have significantly greater disability scores
52
THE SCHEDULE FOR ASSESSMENT OF PSYCHIATRIC DISABILITY
than neurotics and diabetics in all areas ex
cept marital role functioning. It can there
fore be concluded that the SAPD is able to
effectively discriminate schizophrenic dis
ability from others (criterion validity).
However concurrent validity has not
been studied as the SAPD was not com
pared with other standardised instruments
measuring disability. This was not done
because of the paucity of conceptually
satisfactory tools to measure disability in
several areas. The existing rating
schedules used to describe social disability
or maladjustment lack a conceptual
framework by which disabilities can be
classified (Cooper 1980). Besides the
SAPD is only a modification of the parent
schedule DAS and not a totally new one.
It can be seen that disability among
the neurotics is similar to that in diabetics.
This finding has interesting connotations
as to the nature of Diabetics Mellitus itself,
its status as a somato psychic disorder
(Treuting 1967). It will be worthwhile to
carry out a more intensive study of disabil
ity in the various sub groups of neuroses
which has not been done in this study.
The reliability of the instrument is
also high and we felt it appropriate to re
commend the use of this schedule as a
reasonably valid and reliable instrument
for measuring disability in outpatient
schizophrenic population. There are how
ever certain limitations in this instrument.
As also in the DAS, the assessment of oc
cupational functioning needs to be dif
ferentiated between housewives, unmar
ried girls and those not pursuing a regular
job from those holding a regular job with a
constant income.
The SAPD can be used only as an in
strument to measure disability and will not
contribute towards the study of factors af
fecting it, such as expressed emotions etc.
These factors however could encompass
the entire gamut of clinical, personal and
socio demographic data and hence cannot
be incorporated in the assessment
schedule. In fact, this paper is the first of a
series of reports of a study of disability and
factors affecting it being conducted as an
offshoot of the ongoing ICMR project at
Madras, Vellore and Lucknow. The ensu
ing paper will deal with other aspects of
Disability.
Acknowledgements
The authors are grateful to the ICMR
for permission to publish this paper and
acknowledge the help rendered by Mr.
K.J. Raman, Statistician, ICMR Func
tional Psychosis Project, Department of
Psychiatry, Madras Medical College.
References
COOPER, J. (1980) The description and classifiestion of social disability by means of taxonomic
hierarchy. Acta Psychiatrica Scandinavica - sup
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DE JONG A, GIEL R, SLOOF C.J. & WIERSMA
D (1985) Social disability and outcome in
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Psychiatry, 147,631-636.
HALL J. (1979) Assessment Procedures used in
studies on long stay patients. British Journal of
Psychiatry 135, 330-335.
JABLENSKY, A. SCHWARZ, R. & TOMOV, T.
(1980) WHO collaborative study on Impairments
and Disabilities in Schizophrenic patients. A pre
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methods. Acta Psychiatrica Scandinavica Supple
ment 285,62.
MANJU ARORA & V.K. VARMA (1980) A
psychoticism Scale in Hindi-I construction and
initial tryout. Indian Journal of Psychiatry 22,
225-229.
MANJU ARORA & V.K. VARMA (1980) A
psychoticism scale in Hindi-II StandardisationIndian Journal of Psychiatry 22,230-235.
MORGAN, R. & CHEADLE, J. (1974) A scale of
disability and prognosis in long term mental ill
ness. British Journal of Psychiatry 125,475—478.
MURAWSKI B.J.. CHAZAN B.I, BALDIMOS,
MC, RYAN J.B. (1971) Personality patterns in
patients with Diabetes Mellitus of long duration.
R. THARAETAL.
In psychosomatic Medicine Current Journal arti
cles compiled by J.E. Jefferson Medical Exami
nation publishing Inc. 169-173.
OWENS, D.G.C. & JOHNSTONE E.C. (1980) The
Disabilities of Chronic Schizophrenia, their na
ture and the factors contributing to their develop
ment. British Journal ofPsychiatry 136,384-395.
TREUTING T.F. (1962) The role of emotional
factors in the etiology and course of Diabetes
Mellitus, Journal of Medical Science 244, 93110.
WING J.K. (1961) A simple and Reliable sub-clas
sification of chronic schizophrenia, Journal of
Mental Science 107, 862-879.
World
Health
Foram
Leon Eisenberg
Preventing mental, neurological and
psychosocial disorders
Printed from World Health Forum. Vol. 8, 1987 with the support from WHO Country Funds,
MNH/O01 1988-89.
Prevention
Leon Eisenberg
Preventing mental, neurological
and psychosocial disorders
Mental, neurological and psychosocial disorders constitute an enormous
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.
gs
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
'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.
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 11). 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.
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
0
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 pregnancy 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 workers 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
p-
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.
0
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
A development, and given the high mortality
7 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.
Immunization. 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.
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
6
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 arid
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.
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
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
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.
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
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
1.
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).
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.
BEHAVING IN A STRANGE MANNER
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Printed at Suresh Graphics
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(O'
COMMUNITY
MENTAL HEALTH
NEWS
For Private Circulation only
ISSUE NO. 9
OCT-DEC 1987
NIMHANS Designated
WHO Collaborative Centre
National Institute of Mental Health
and Neuro Sciences (NIMHANS) Ban
galore, has been collaborating with
World Health Organisation (WHO) in
a number of research projects, fellow
ships and training programmes. The
faculty members of NIMHANS have
also been assisting the WHO as short
term consultants and members of the
Mental Health Expert Advisory Panel.
INDO-US SYMPOSIUM (Oct - 27-30, 1987) Dr. Frank Sullivan, leader of US team
addressing the inaugural session. Others in the picture are (L to R) Dr. G. N. N. Reddy,
Mr. Gautam Basu and Mr. S. 5. Dhanoa. (Bottom) A view of the gathering.
In this issue
Indo-US Symposium on Community
Mental Health - Report (Page 2-8)
REACHING
THE
UNREACHED
From December 2,1986, NIMHANS
has been designated as WHO Collab
orating Centre for Research and
Training in Mental Health for four
years. The activities of the centre
would include: i) Psychosocial factors
in the promotion of health and
human development (early child
hood stimulation, adolescent prob
lem behaviour and its prevention,
indicators of mental health, psycho
social problems in PHC), ii) Preven
tion and control of alcohol and drug
abuse (career studies, health damage,
biological risk factors and outcome
studies), Hi) Prevention and treatment
of mental disorders (disease markers,
prevention programmes, disability
interventions, indicators of quality of
psychiatric care and training
materials).
Dr. G. N. N. Reddy, Director, NIM
HANS, is the Head of the Centre.
ICMR Centre for Advanced Research on
Community Mental Health
NIMHANS, Bangalore.
INDO-US SYMPOSIUM ON COMMUNITY MENTAL HEALTH
EDITORIAL
»■■■■
________ __ _______ ._________ -—---------
Indo-US Symposium on
Inauguration
’TF’ he Indo-US Symposium on Community Mental Health is the
i fourth in the series of symposia organised at NIMHANS, Bangalore as part
£<5n n developing mental health
U care, community mental health
of the NIMHANS-ADAMHA Collaborative Agreement. The earlier sym
posia focused on ‘Schizophrenia ', ‘Affective Disorders’ and Alcohol and
programmes ought to be given high
priority” Mr. S. S. Dhanoa, Secretary,
Ministry of Health and Family Wel
fare, New Delhi said while inaugurat
ing the Indo US Symposium on
Community Mental Health. Decen
tralised health care was one of the
answers to the massive health care j
problems in the country and the com- 1
Drug Abuse’.
The topic of community mental health is most appropriate for the
Symposium as currently there is a serious effort all over the world to
understand the community care of the mentally ill persons. The issue has
raised many questions about the need, the scope and limitations. As a
topic for exchange between India and USA it is important. India is enter
ing into the second decade of community mental health programmes
while USA has over four decades of experience of organising community
mental health programmes.
The Symposium was organised around six central themes, namely:
munity had a major role to play in this
he added. The Union Government
was in the process of setting up a
National Mental Health Advisory
Group to coordinate the mental
health programme in India. NIM
HANS and the Central Institute of Psy
chiatry, Ranchi will be the'focal point’
for implementation of NMHP for
which Rs. 10 million has been allotted
in the Seventh Plan.
1. Mental health planning and policy development,
2. Integration of mental health with primary health care,
3. Para-professionals and non-professionals in mental health care,
4. Family and social support systems,
5. Alternative patterns of care for the mentally ill, and
6. Mental health care of special groups.
Each of the sessions began with a key paper from an Indian and an
American professional. This was followed by responses of 2-3 profession
als as discussants. Discussion involving the members of the audience, the
key presenters and discussants followed. Each session was of two hours
duration. The special aspect of the Symposium was that the key papers and
discussants responses were available to the registered participants about
two weeks prior to the Symposium. This arrangement facilitated time for
discussion and active contributions from the participants. In fact, the
discussion following each session highlighted the controversies and areas
for future work.
The participants of the Symposium included 15 US delegates, 16 Indian
speakers, 50 registered delegates from different parts of India,and over70
faculty staff of the NIMHANS, Bangalore. In addition, the post-graduates
of NIMHANS were participants.
As part of the Symposium field visits were organised to the primary
health care facilities, schools, child care centres, half-way-home and
home care programme to provide opportunity for outstation delegates to
experience the community care programmes in India.
The proceedings of the Symposium would be published as a mono
graph (expected by Dec. 1988) which would include the key papers,
discussants responses, the discussion of each session, summing up com
ments; and a brief account of the community mental health care in India
and USA.
The current issue of CMH News brings together the highlights of the
symposium. It is hoped that the issues identified and discussed would
receive the efforts of the professionals, planners, and the people in the
years to come.
Dr. R. SRINIVASA MURTHY
Editor.
COMMUNITY MENTAL HEALTH NEWS
ISSUE No 9
OCT-DEC 1987.
Mr. Gautam Basu, Secretary, Minis
try of Health and Family Welfare, Kar
nataka State suggested changes in the
medical curriculam with accent on
mental health in the frame work of
public health. Citing the success of [
NIMHANS’ programmes in Gulbargaf
and Mysore divisions, he said the State
had a great responsibility in commun
ity health programmes.
i
Dr. Frank J. Sullivan, leader of the
US team said the human resources
development attempted by NIM
HANS, involving professionals and
non-professionals in the care of the
mentally ill, particularly in the villages
is very important innovations. Later,
he released the book on Affective Dis
orders which is the proceedings of
Second Indo-US Symposium 1985.
Dr. G. N. Narayana Reddy, Director,
NIMHANS, welcomed the gathering
and Dr. S. M. Channabasavanna,
Medical Superintendent, NIMHANS,
•
COMMUNITY
3 MENTAL HEAL™
NEWS
In this issue
Mental Health Act-1987 ★ Training for Medical
and Psychiatric Social Work Teachers * Fea
tures of Mental Disorders ★ Research Issues in
Psychiatric Epidemiology in India * Training for
Mothers of MR Children.
REACHING
THE
UNREACHED
For Private Circulation only
ISSUE NO. 8
JULY-SEPT 1987.
ICMR Centre for Advanced Research on
Community Mental Health
NIMHANS, Bangalore.
MENTAL HEALTH ACT 1987
Mental Health Act 1987
he mental health professionals
of India have been actively
working towards the amend
ment of the Indian Lunacy Act 1912
since 1948. As early as 1960, a revised
draft mental health bill was prepared
and considered by the First Workshop
of Superintendents of Mental Hospi
tals held at Agra. A draft bill was intro
duced for the first time in Lok Sobha in
1978. Thus the Mental Health Act 1987
has become a reality after nearly four
decades of efforts.
T
Salient features of the Mental Health
Act, 1987 are:
The terms like lunacy’ ‘insanity’
‘asylum’ have been replaced by
mental disorder, mentally ill person
and psychiatric hospital.
I
The Act defines a mentally ill per
son as a person who is in need of
treatment by reason of any mental dis
order other than mental retardation.
2
The Central Government shall
establish an Authority for mental
health. The Authority shall be
incharge of regulation, development,
direction and coordination with
respect to mental health services
under the central government and
supervise the psychiatric hospitals and
psychiatric nursing homes and other
mental health services under the con
trol of the central government. Men
tal Health Services include in addition
to psychiatric hospitals and psychiatric
nursing homes, observation wards,
day care centres, inpatient treatment
in general hospitals, ambulatory treat
ment facilities and other facilities,
convalescent homes and half-way
homes for mentally ill persons.
3
No person can establish or main* tain a psychiatric hospital or psy
chiatric nursing home unless with a
valid licence. The psychiatric hospital
or psychiatric nursing home will be
under the charge of a medical officer
who is a psychiatrist. The licensing
authority can revoke the licence if the
facility is not maintained in accor-
2
dance with the provisions of the Act
(Sections 6, 8,11).
In every psychiatric hospital or
psychiatric nursing home, provi
sion shall be made for such facilitiesas
may be prescribed for the treatment
of every mentally ill person, whose
condition does not warrant this
admission as an inpatient or who, for
the time being, is not undergoing
treatment as inpatient (Section 14).
5
The Mental Health Act 1987
received the assent of the President
on 22nd May 1987. It consolidates
and amends the law relating to the
treatment and care of the mentally ill
persons, to make better provision
with respect to their property and
affairs and for matters connected
therewith and incidental thereto.
application by the magistrate will be
held in camera (section 20, 21, 22).
Police Officers can take into
protection any person found
wandering at large and found to be
mentily ill, either unable to take care
of himself or there is reason to believe
to be dangerous by reason of mental
illness. Such persons, should be pro
duced before the nearest Magistrate
within 24 hours for reception orders
9
(section 22).
O
IV
Every officer in charge of a
police station, or a private per
son, who has reason to believe that
any person is mentally ill and not
under proper care and control, or is
ill-treated or neglected by any relativ^
or other person can report the same to
the magistrate (section 25).
The state government or the
central
government
shall
appoint for every psychiatric hospital
not less than five visitors, of whom at
least one shall be a medical officer,
preferably a psychiatrist and two
social workers. Not less than three vis
itors will visit at least once a month
and make a joint inspection of every
part of the facility. (Sections 37, 38).
"j| "1
I I
Any person (except minors) who
considers himself to be a mentally
ill person and desires to be admitted
to any treatment facility may.request
the medical officer in charge for being
admitted as a voluntary patient (Sec
tion 15). Voluntary patients should be
discharged with 24 hours of the
The medical officer in charge
receipt of request, except when such
0
may grant leave of absence to
discharge is not in the interest of the
the mentally ill for a maximum period
patient, can within 72 hours, consti
of sixty days (Section 45).
tute a Board consisting of two medical
officers and seek its opinion whether *i°l O Sections 50-73 relate to judicial
U
inquisition regarding alleged
the voluntary patient needs further
treatment. On the recommendation mentally ill person possessing prop
of the board patient can be continued erty, custody of his person and man
for treatment for a period of upto 90 agement of his property.
days at a time (section 18).
Where a mentally ill person is
Any mentally ill person unable to
“ « not represented by a legal prac
express his willingness for admis titioner in any proceeding under this
sion as a voluntary patient, can be Act before a District Court or a magis
admitted on application by a relative trate and he has not sufficient means
or a freind, if the medical officer in to engage a legal practitioner, the
charge is satisfied. This admission can court can assign a legal practitioner to
be upto a period of 90 days (section
represent him at the expense of the
19).
State (section 91).
6
'll
"I
7
Admission by reception order
*11 C The Indian Lunacy Act 1912
issued by magistrate. Such request
3
and the Lunacy Act 1977 are
by a relative will need two medical
repealed.
certificates. Any consideration of the
Summary by R. SRINIVASA MURTHY.
8
COMMUNITY MENTAL HEALTH NEWS, ISSUE NO 8, JULY-SEPT. 1987
TRAINING FOR MEDICAL AND PSYCHIATRIC EPIDEMIOLOGY IN INDIA
Training for Medical and Psychiatric
Social Work Teachers
he first Training Programme in
Community
Mental
Health
for Medical and Psychiatric
Social Work Teachers was held at
NIMHANS, Bangalore from 6 to 10
July, 1987.
T
Community Mental Health, in
social work parlance, is application of
methods of social work especially,
group work, community organi
sation, social action and social work
research for the promotion of mental
health, early diagnosis and treatment
of mental ailments and rehabilitation
of mentally ill and handicapped in the
community.
Considering the relevance and
importance of incorporation of com
munity mental health in social work
curriculum, the experts who partici
pated in the National Seminar on Psy
chiatric Social Workers role in
implementation of National Mental
Health Programme for India, held at
NIMHANS, Bangalore, on 27th and
28th March, 1986, made the recom
mendation that Medical and Psychiat
RECOMMENDATIONS
The recommendations made by the par
ticipants of the training are as follows:
1.
As far as possible, the contents of the
field work practice in social work need to be
enriched with community oriented health
programmes in general and mental health
programmes in particular.
2.
All the teachers dealing with medical and
psychiatric social work should have the
opportunity to get an exposure to the mod
ern trends in community mental health.
3.
Trainees in social work should be placed
in agencies extending community health
and mental health services.
4.
Trainees in social work should be guided
to undertake simple and suitable service
oriented research projects as part of their
training.
ric Social Work Teachers need to be
provided an in-service training pro
gramme in community mental health.
The main objectives of the in
service training programme were:
i)
to provide background to the historical pers
pectives of community oriented mental health
programme.
ii)
to highlight on the National policies on
health, mental health and allied community
programmes.
iii)
to focus on issues like community participa
tion, collaboration with other sectors like edu
cation and social welfare, and
iv)
to evolve practical means of incorporating
the community orientation in the medical and
Psychiatric Social Work Training.
Based on these aims and objectives,
the contents of the training pro
gramme focused on developments in
institutional and non-institutional
modalities of treatment, psychiatric
social work in community mental
health, student enrichment pro
gramme, village leaders’ orientation
and
involvement,
training
and
research programmes in community
6.
Collaboration between NIMHANS and
Schools of social work in India need to be
strengthened in such a way that it leads to
achievement of the objectives of the
National Mental Health Programme.
7.
Schools of social work should think of
updating their syllabi based on the modern
trends in mental health care in community
settings.
8.
Information pertaining to the persons/
trainers/policy makers/ administrators/being oriented in mental health care could be
passed on to the participants, so that they
could initiate collaborative efforts in the
respective places.
9.
New ideas and research reports should
be regularly made available to the teachers
so that they could update their knowledge
on community mental health.
5.
Teachers in social work need to be pro 10.
Review workshops should be organised
vided with opportunities for improving
periodically to assess the activities being
their knowledge and updating their profes
carried out as a result of the training in
sional skills by centres like NIMHANS.
community mental health.
COMMUNITY MENTAL HEALTH NEWS, ISSUE NO 8, JULY-SEPT. 1987
PARTICIPANTS
In the July '87 Programme, 16 Medical
and Psychiatric Social Work Teachers from
different schools of social work partici
pated. They are: Mrs. Aruna Khasgiwala
(M.S. University of Baroda, Baroda), Dr.
Ahmad Saghir Inam Shastri, (Kashi Vidyapith, Varanasi), Mrs. Anila Cangrade,
(Indore School of social work. Indore). Ms.
Cecilia Thangarajan (Stella Maris College,
Madras), Mr. Joseph Injodey (Rajagiri Col
lege of social Sciences, Kalamassery),
Mrs. Katy Y. Gandeira (Tata Institute of
Social Sciences, Bombay), Mr. M. Kannan,
(Madurai Institute of Social Work, Madu
rai) , Mr. Mosala Sunil Kumar (National Insti
tute of Social Work and Social Sciences,
Bhubaneswar),
Dr. M. M. Mukherjee
(Visva-Bharati, Sriniketan), Dr. (Mrs.) Promila Maitra (M.S.University of Baroda, Bar
oda), Dr. TBBSV Ramanaiah (Chatrapati
Shahu Central Institute of Business Educa
tion and Research, Kolhapur), Mrs. Sulakshana Malhotra, (Tripude College of Social
Work, Nagpur),Ms. RekhaTaunk, (Institute
of Social Work, Nagpur), Mr. A. Relton
(Bishop Heber College, Tiruchirapalli), Mr.
K. Shanmugavelayutham (Loyola College,
Madras), and Dr. P.D. Misra (Lucknow Uni
versity, Lucknow).
mental health, and other specific pro
grammes like psycho-social compo
nents of Bellary District Mental Health
Programme. Efforts were also made to
minimise the lectures and maximize
the participatory learning. Follow up
action was much emphasised in the
programme.
To enable the participants to incor
porate the elements of community
mental health in their classroom
teaching as well as field work training
programmes each one of them was
given 35 documents related to Medi
cal and Psychiatric Social Work issues
in practice of community mental
health.
On the last day of the programme,
the participants were divided into 3
groups, to intensively discuss on social
work aspects of field work practice,
teaching curriculum, research activi
ties and projects and develop
recommendations.
Dr. R. PARTHASARATHY
Asst. Professor
Dept, of Psychiatric Social Work
NIMHANS, BANGALORE - 29.
3
FEATURES OF MENTAL DISORDERS
DEVELOPMENT OF MENTAL HEALTH EDUCATION MATERIALS
Features of Mental Disorders
he ICMR Centre for Advanced
Research
on
Community
Mental Health has outlined the
development of appropriate public
mental health education materials as
one of its aims (ICMR-CAR-CMH,
1984). There is an urgent need in mak
ing available suitable public educa
tion materials, as seen from the
implementation of National Mental
Health Programme (DGHS, 1982), at
various centres in different states. As a
first step, among the various mental
health education aids, the centre took
up the development of the Flip chart
on Features of mental disorders for
the following reasons: (i)To facilitate
the health workers enquiry at field
level regarding the identification of
mentally ill cases, (ii) To provide a vis
ual presentation of different features
of mental illness for the lay public and,
To
(iii)
assist the health workers
enquiry to be systematic in using the
method given in the manual of Mental
Health for Multi-purpose Workers.
(CMH News, Issue 1, p. 6)
T
Strategies in development
The above described cards (See
Box) were sketched out in Indian ink
on demy size ivory art board and was
field tested. The objective was to
understand how the rural public
visualise them. The field testing was
carried out in Solur and Anekal PHC
areas of Bangalore District. Two
groups of respondents were consi
dered as subjects for the first and
second field tests. Group 1, consisted
of 35 community health guides, and
group 2, consisted of 35 resident trai
nees of Gruhini programme in a
Christian Hospital training centre. The
method of field test adopted was the
group approach, wherein, the cards
were shown to the respondents for a
minimum of 30 seconds to a maximum
of 60 seconds each. After this the
respondents were requested to des
cribe the content of the picture in
writing in a given response sheet.
4
Based on the content analysis of the
responses on black and white line
drawings from group 1, the material
was coloured and was presented to
group 2. Completion of the second
Department personnel and two
members of the Scientific Advisory
Committee of the ICMR Centre for
Advanced Research on Community
Mental Health, who are pioneers in
health education (Dr. V. Ramakrishna
and Dr. L. Ramachandran). All the
technical flaws and suggestions
pointed out by them were corrected
DESCRIPTION OF THE MATERIAL
Aim
:
To provide a visual comprehension of features of mental disorders.
Manual of Mental Health for Multi-purpose Workers - page 50.
Reference
Media
:
Format
:
Audio-visual
Flip-book - demy one-fourth size.
Target group
Rural, illiterate, Indian population. The maximum number addressed
with the aid would be 5-10 at a time.
Users
Health workers, block health educators and other health personnel
who have received basic mental health training.
Line and shade composition in multicolours.
Nature of visual
material
Number of cards
:
Eleven
CONTENTS OF THE MATERIAL (CARDS): (See cover page of this Issue)
1. Who talk nonsense and act in the strange manner and considered abnormal?
2. Who have become unusually cheerful, crack jokes and say that they are very wealthy, and
superior to others when it is really not so?
3. Who claim to hear voices or see things others cannot hear or see?
4. Who are very suspicious and claim that some people are frying to harm them?
5. Who talk about suicide or has made an attempt at suicide?
6. Who get possessed by God or spirit or who is said to be the victim of black magic or evil
power?
7. Who has become very quiet and does not talk or mix with people?
8. Who suffers from fits or loss of consciousness and fall down?
9. Who have become very sad lately, and cry without reason?
10. Who are dull, not mentally grown up like others of their age and slow since birth?
11. A collage of all the above said ten cards.
field test brought out the limitations
of the group interview procedure.
Hence, for further field testing it was
decided to adopt an indepth indivi
dual interview method. Further revi
sion of the charts were made based on
the responses of Group 2 and was
presented to 20 respondents of a third
group in a village in Anekal PHC area.
An indepth interview method was
adopted during this field test. Among
these twenty, only fifteen respond
ents agreed to the request.
Following the field test activity, the
field tested material along with the
responses and the script was pres
ented to the State Health Education
COMMUNITY MENTAL HEALTH NEWS, ISSUE NO 8, JULY-SEPT. 1987
and incorporated.
The revised material alongwith
script was given to six health workers
who were asked to demonstrate the
aid to the general public in the field
area. Following the exercise a selected
range of audience were interviewed
and it was found to be useful in terms
of the main idea being communicated
and comprehended. The animators
opinion on this exercise was also
obtained. They too felt it is practical to
communicate the mental health infor
mation through thisaid which is infor
mative and well done.
Following
the
above
activities,
FEATURES OF MENTAL DISORDERS
COMMUNITY MENTAL HEALTH NEWS, ISSUE NO 8, JULY-SEPT. 1987
5
RESEARCH ISSUES IN PSYCHIATRIC EPIDEMIOLOGY IN INDIA
6 COMMUNITY MENTAL HEALTH NEWS, ISSUE NO 8, JULY-SEPT. 1987
RESEARCH ISSUES IN PSYCHIATRIC EPIDEMIOLOGY IN INDIA
COMMUNITY MENTAL HEALTH NEWS, ISSUE NO 8, JULY-SEPT. 1987
TRAINING FOR MOTHERS OF MR CHILDREN
reported justifies future work in this
area. These studies can result in
understanding the nature and course
of mental disorders in the country.
The group recommends initiation of
studies, in this area with special
emphasis on (1) community studies,
2) studies starting with fresh cases,
3) assessment using standardised
tools, 4) using clear categories of
patients. These studies should be both
in urban and rural areas. The above
efforts requires tool development to
assess outcome, disability, impact on
the family, methods to combine mul
tiple data for outcome assessment.
These studies should be more and
more effective with longer period of
follow up.
Delivery of services and evolu-
I D tion forms an important need
reports from
NEW DELHI
Training for
Mothers of MR
Children
ost of the mothers learn
skills of child rearing from
the older women in their
families. These skills are generally
applicable to children with normal
intelligence. When a mentally
retarded child is born in the family,
these age old skills do not work effec
tively. As, a mentally retarded child
either fails to develop the skills so
essential to everyday life or takes a
much longer time to acquire skills
than a normal child. With special
methods of training mentally retarded
children can be trained effectively.
These special methods of training are
based on the principles of behaviour
modification.
M
in view of the National Mental Health
Programme. Only preliminary efforts
have been made in this direction. The
areas that should be focused in future
research are: (i) selection of priorities
(ii) identification of indicators of men
tal health care (iii) record system
(iv)
monitoring mechanisms, and Role of Parents
(v)
role of different levels of person Parents are becoming more active
nel in mental health care.
and assuming more active roles in the
*1The group reviewed the ethical
I O aspects of epidemiological
work and evaluation studies and
recommends that all such studies
should have an essential service com
ponent built into the project during
and after the project period.
■*1
The group reviewing the 3
decades of research in psychi
atric epidemiology in India, recog
nised the key role of ICMR in this
research effort. The group recom
mends that there should be con
tinued support for future work from
ICMR and other funding agencies like
NIPCCD, NCERT, ICSSR, DST etc. as
part of their research plans.
I/
Q
IO
«-1
The group considers the current workshop- as being useful
and recommends that a review work
shop be planned in 5 years.
8
teaching of their retarded children.
Due to lack of resources in the form of
trained professionals, parents and
others concerned with the child, need
to be adequately trained. Training
retarded children usually requires a
long period of time and must essen
tially be carried out in the child's natu
ral and everyday environment i.e. at
home. Parents being the most signifi
cant people in the child's life and a
potent source of reinforcement to a
child, hence by training, they can
become better equipped to deal with
present and future problems.
For these reasons an ICMR funded
project was started by Dr. M. Mehta at
the Department of Psychiatry, AllMS,
New Delhi to provide training for
mothers of mentally retarded child
ren, to become behaviour modifiers
of their own children. A second
objective of the project was to evalu
COMMUNITY MENTAL HEALTH NEWS, ISSUE NO 8, JULY-SEPT. 1987
ate variables which have a bearing on
the outcome of training programmes.
Training programme
Mothers were trained in specific
techniques of Behaviour modifica
tion. Three broad categories of behav
iour are mainly dealt with: 1. Self help
activities, 2. Preacademic skills and
3. Control of problem behaviour. The
total training programme consisted of
6-8 sessions initially and later 4-5 ses
sions in the follow-up phase. Each ses
sion was of 1 hour duration. The
experience has shown the importance
of training parents and the vital role
played by them in the total case. &
DR. (Mrs) M. MEHTA
Asst. Prof. Clinical Psychology
Dept, of Psychiatry
All India Institute of Medical Sciences
NEW DELHI - 110 029.
COMMUNITY MENTAL HEALTH NEWS
Issue No. 8, July-Sept 1987
The Community Mental Health News is
published by the ICMR centre for advanced
research on community mental health), to
keep the professionals, planners, adminis
trators and the interested public informed
about the development of community
mental health care; programme.
Copies of Community Mental Health
News are mailed free on request by inter
ested professionals and institutions.
We are interested in exchanging a few
copies of this journal, on reciprocal basis,
with other medico-health publications. We
would like to obtain information on projects/research findings/field work reports
relating community mental health pro
grammes in our country.
Letters, comments and communications
should be addressed to: The Editor, Com
munity Mental Health News, ICMR Centre
for Advanced Research on Community
Mental Health, NIMHANS, Bangalore 560 029, (India).
Editor
Dr. R. Srinivasa Murthy
Editorial Committee
Dr. Mohan K. Isaac. • C. R.Chandrashekar.
• Dr. R.Parthasarathy. •Dr. T.G.Sriram
• Dr. K. Sekar. •Mr. Mahendra Sharma.
• Mrs. Ahalya Raguram • Mr. Chandra Sekhar Rao. ®Mr. Nagarajaiah.
Asst. Editor
Mr. Soman Ponnempalath.
Phototypeset & Printed at SUDHINDRA, Bangalore-3.
COMiWMOT
P > MENTAL HEALTH
NEWS
l-_ -...... .........
MENTAL HEALTH
Organised and planned mental
health care activities are vital for
obviating the ill-effects of major socio
economic changes. A beginning in this
direction is proposed in the Seventh
Plan by according priority to streng
thening the existing psychiatry depart
ments, promotion of community
psychiatry by provision of drugs and
services through the primary health
care system and organisation of train
ing programmes.
— Seventh Five Year Plan (1985-90) Vol-2
Chapter 11, p 268
NMHP REVIEWED
The National Mental Health Pro
gramme for India formulated in
1982 by the Government of India
was reviewed as part of the meet
ing of the Health Secretaries on
November 3, 1987 at Nirman Bhavan, New Delhi. Dr. G. N. Narayana
Reddy and Dr. R. Srinivasa Murthy
were invited for the meeting. Dr.
Reddy presented the NMHP and
the progress achieved in imple
menting the same in the last five
years. This is the first time that the
NMHP has been discussed at the
level of Health Secretaries subse
quent to recommendation (August
1982) by the Central Council of
Health and Family Welfare.
In this issue
Editorial: Public, Professionals, Planners, Press, Poli
ticians and Mental Health Care ★ National Policy on
Mental Handicap * National Seminar on Voluntary
Agencies and Mental Health Care * Films :Kasauti,
Forgotten Millions.
REACHING
THE
UNREACHED
ICMR Centre for Advanced Research on
Community Mental Health
N1MHANS, Bangalore.
THE FIVE Ps OF MENTAL HEALTH CARE
EDITORIAL
Public, Professionals, Planners, Press,
Politicians and Mental Health Care
he begninning years of the
current decade (1980’s) has seen
the emergence of a growing aware
ness among the public, press,
planners, politicians and Professionals
(5 Ps) of the needs of the much neglected groups of individuals in the
society. This is referring to the revolu
tion in mental health care in India.
T
I
j
;
I
MENTAL HEALTH AND MEDIA
:
In the last few years, parents and
i public have repeatedly brought to the
I general awareness of the needs of the
i mentally ill and mentally handicapped
I individuals. These have been both
I efforts to organise services (CMH
| News, Issue 3 & 4) and to draw atten
tion to the problems of the mentally ill
in the mental hospitals (CMH News,
Issue 6 & 7, p. 16). The most recent and
vivid attempt is the coverage of the
‘world of mentally ill' in the National
TV under the serial titled Kasauti. This
serial is significant as for the first time
some of the images which were
I ‘haunting and horrifying' were pres
ented on National TV in a detailed
manner.fSee p. 7)
SEMINAR ON MENTAL HANDICAP
One such effort by the voluntary
organisations to develop a policy for
the mentally handicapped - National
Seminar to frame a National Policy for
the Mentally Handicapped was held at
Hyderabad from February 3-6, 1987.
This seminar was coordinated by the
Thakur Hariprasad Institute of Reha
bilitation for the mentally handi
capped children, Hyderabad.
Renowned subject matter experts,
representatives of the planning com
mission, the Government of India, the
State Governments, and the voluntary
organisations participated in the pol
icy document development. The dis
cussion sessions considered the areas
of : (i) basic rights, social security, leg
islation and taxation, (ii) health, and
(iii) education and employment. The
recommendations proposed at the
2
seminar was developed into a policy
document.
The National Policy on Mental Han
dicap was released by Hon. Prime
Minister Sri. Rajiv Gandhi on 14 Janu
ary 1988. We in this issue carry a
condensed version of the full docu
ment (See p.3-5). It is gratifying to
hear that this policy is receiving sup
port from planners and politicians in
the form of specific administrative
action. One of the first results
expected is the formation of a
National Trust for the mentally
handicapped.
POLICY FRAMEWORK
CMH News has covered the
National Mental Health Programme
(CMH News Issue 1, p. 2) as well as the
Education and National Health Policy
(CMH News, Issue 2, p. 6). In a way,
the above four policy documents
along with the Mental Health Act,
1987 (CMH News, Issue 8, p. 2) pro
vide the broad framework for the
development of Mental Health pro
grammes in the coming years.
At the international level, World
Health Assembly (1987) concluded:
"Mental, neurological and psychosocial dis
orders constitute an enomous public health
burden for both developing and developed
nations. Review of the evidence demonstrates
that the implementation of a comprehensive
programme on prevention based methods cur
rently available could produce a substantial
reduction in the suffering of mentally ill, des
truction of the human potential and the eco-'
nomic loss they produce. Such a programme
would attack both the biological and the social
causes which underlie these disorders. For suc
cess, it requires a national commitment, coordi
nated action in many social sections and
coordination at an international level”.
RESPONSIBILITIES Of THE PROFESSIONALS
In the above remarkable develop
ments of the decade, the role played
by the public and press have been
very vital. It is creditable that the pub
lic concern has found a responsive
chord in the minds and actions of the
planners and politicians. The future
depends to a large extent on the Pro
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE No 10 ■ JAN-MAR 1988
fessionals. The professional groups
with interest in the broad area of men
tal health care, will have two major
responsibilities. Firstly, to recognise
the vital role played by the public,
press, planners and politicians and
actively work with them in developing
and implementing the policies.
Secondly, they have to provide the
technical know-how for the pro
gramme in terms of advances in men
tal health skills, methods to transfer
skills,mechanisms of evaluation and
support. Without these twin responsi
bilities by the professionals the best of
the policy documents would only
remain on paper. The mental health
and related professionals have a uni
que opportunity to shape events for
the future.
|
In this connection it is appropriate I
to refer to what Dr. Norman Sartorius,
Director, Division of Mental Health, I
WHO, Geneva, has to say:
"Righting the twentieth century is the best j
prescription of a better twenty-first century, i
There is so much to do that starting anywhere j
will be richly rewarding. The guarantors of I
improvment in the future are people: the fact I
that in many countries people have started to '
think about ways to make the mental health j
policies and programmes for the twenty - first j
century useful is an important first step; others j
are bound to follow. We should be happy that
there is so much that we can contribute to the
development of better programmes for tomor
row, but time is .short and we must start right
now’7.
Here lies the challenge and road
ahead to reach the unreached.
DA
R. SRINIVASA MURTHY/?
Editor
REFERENCES
National Policy on Mental Handicap, 1988.
National Mental Health Programme for
India, 1982.
3.
National Health Policy, 1982.
4.
National Policy on Education 1986.
5.
The Mental Health Act, 1987.
6.
WHO (1987) Prevention of mental, neuro
logical and psychosocial disorders,Geneva,
Switzerland.
7.
Eisenberg,L. (1987) Preventing mental,
neurological and Psychological Disorders,
World Health - Forum, Vol 8, 1987.
8.
Sartorius, N. Mental Health Policies and pro
grammes for the Twenty-first Century - A
personal View. Integr. Psychiatry, 5: 151158., 1987.
1.
2.
NATIONAL POLICY ON MENTAL HANDICAP
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE No 10 ■ JAN-MAR 1988
NATIONAL POLICY ON MENTAL HANDICAP
facilities for care, there are some
recent positive developments. At the
level of services development, the
starting of parent training pro
grammes at Delhi, Vellore, Chandi
garh and Bangalore and Self-help
Group movement in a number of cen
tres in the country can have major
impact. The Self-Help Group move
ment is an expression of the potential
for helping each other among families
with mentally handicapped individu
als. The initial results reported about
the integration of mental health care
with primary health care from differ
ent centres again offer the possibility
of the health sector playing an. impor
tant role. The District Rehabilitation
Centre (DRC) is another new pro
gramme which offers a decentralised
and deprofessionalised care for the
handicapped persons. Other innova
tions relate to integrated education of
the mentally retarded children and
foster-parent programme. All these
efforts point to a positive trend to
examine alternatives for the needs of
the country.
Need for National Policy
Mentally handicapped individuals
require the efforts of a number of dis
ciplines, namely, health, welfare, edu
cation, law, rehabilitation, nursing
along with efforts of voluntary agen
cies. The other aspect of mentally han
dicapped individuals is the need for
longitudinal, in most persons, life
long support of one form or the other.
These twin aspects of multi
disciplinary inputs and long-term care
call for well coordinated efforts. Such
a programme cannot occur without a
national policy.
The development of approaches for
the needs of the mentally handi
capped persons in the country has
shown a gradual and definite shift
towards the family as a unit. This
change in focus of care has been the
outcome of the difficulties in provid
ing continuous care in the institu
tional settings. The cost of
comprehensive care by professionals
is not only expensive but difficult to
DECLARATION ON THE RIGHTS OF MENTALLY RETARDED PERSONS
Resolution Adopted by the General Assembly of the United Nations (on the report of the Third
Committee [A/8588] 2856 (XXVI) 20 Dec. 1971.
1. The mentally retarded person has, to the maximum degree of feasibility, the same rights as
other human beings.
2. The mentaly retarded person has a right to proper medical care and physical therapy and to
such education, training, rehabilitation and guidance as will enable him to develop his ability
and maximum potential.
3. The mentally retarded person has a right to economic security and to a decent standard of I
living. He has a right to perform productive work or Io engage in any other meaningful
occupation to the fullest possible extent of his capabilities.
4. Whenever possible, the mentally retarded person should live with his own family or with I
foster parents and participate in different forms of community life. The family with which he
liv&s should receive assistance. If care in an institution becomes necessary, it should be
provided in surroundings and other circumstances as close as possible to those of normal life.
5. The mentally retarded person has a right to a qualified guardian when this is required to j
protect his personal well-being and interests.
6. The mentally retarded person has a right to protection from exploitation, abuse and degrad
ing treatment. If prosecuted for any offence, he shall have a right to due process of law with g
full recognition being given to his degree of mental responsibility.
"
Whenever mentally retarded persons are unable, because of the severity of their handicap, j
to exercise all their rights in a meaningful way or it should become necessary to restrict or ,
deny some or all of these rights, the procedure used for that restriction or denial of rights '
must contain proper legal safeguards against every form of abuse. This procedure must be
based on an evaluation of the social capability of the mentally retarded person by qualified I
experts and must be subject to periodic review and to the right of appeal to higher 1
authorities.
•
link it across all the developmental
stages. This would mean that the
needs of the family receive approp
riate attention from the point of iden
tification in terms of professional
expertise and social security. Expe
riences in India have demonstrated
the capacity of the family to form
primary care providers with approp
riate training, continuous professional
The aim of the medical services
needs to be chiefly preventive
although diagnostic and therapeu
tic services are essential for the
affected. Early and complete diag
nosis, not only of the defects and
disabilities, primary and secon
dary, but also of the capabilities
and aptitudes of the retarded child
should be the first priority. He
needs to be rehabilitated and con
verted into a useful, productive
citizen.
- Ms. SAROJ KHAPARDE
Union Minister of State for Health & Family
Welfare. (All India Seminaron National Pol
icy for Mentally Handicapped, Hyderabad,
Feb 3,1987)
4 COMMUNITY MENTAL HEALTH NEWS ■ ISSUE No 10 ■ JAN-MAR 1988
help and administrative supports.
Objectives
(1)
To evolve a policy concerning
health, education, social security and
legislative measures for improving the
quality of the life of the mentally han
dicapped persons in the country.
(2)
To ensure availability and acces
sibility of basic care for all the mentally
handicapped persons in the foreseeaM
ble future, and
(3)
To promote community partici
pation and stimulate efforts towards
self-help in the families of the men
tally handicapped individuals.
Strategies for action
Recent advances have provided
some insights into the causes of men
tal handicap and many of them are
preventable. In India, there is an
urgent need to improves pre-natal
and post - natal care, to prevent men
tal handicap.
Early identification: The damage to
the brain and the delayed develop-
NATIONAL POLICY ON MENTAL HANDICAP
FAMILY AS THE UNIT
It has been internationally emphasised that the organisation of services for
the mentally handicapped citizens should have the family as the focus. This
would mean that: (i) family should be the unit receiving care, (ii) regardless
of the type of services proposed, parents should not be penalised economi
cally and socially for keeping their child at home, and (iii) the social costs of
mental handicap should form the basis of planning of services on how to deal
with the problem and not any other consideration.
These principles enunciated in early 1950’s have a special relevance to the
country due to the family structure, geographical distribution and the cur
rent economic and social development.
— From National Policy on Mental Handicap.
ment is best recognised at the earliest
time possible. There is sufficient expe
rience to show the value of stimula
tion programmes begun early in life. It
lipas been now recognised that home
fare is the most appropriate method
of maximising the capacities of the
child. Against this background, it is
recognised that the different catego
ries of health personnel like commun
ity health volunteers, Bala Sevikas,
MPWs, health supervisors, medical
officers and pediatricians can be
oriented to intensify their efforts
towards prevention, early identificat
ion and guidance for home-care.
Care including rehabilitation: The
approach to provide services to all the
mentally handicapped persons would
bringforth the needs for rehabilitation
programmes beyond those provided
by home training, special schools and
vocational training. Specific efforts
^re to be made for rehabilitation at the
district level, along the lines of DRC
with active community participation.
National Trust: The care of the per
sons with mental handicap requires to
be organised with a national perspec
tive to achieve social security and
bring together mechanisms to ensure
quality of life. This would require the
formation of a National Trust for the
welfare of mentally handicapped as a
means to provide social security. The
objectives of the Naional Trust will be
to provide guardianship, foster care,
mobilisation of resources to streng
then the family and the community.
there is need to start special school
units at the district level all over the
country. In order to provide services
for individuals with multiple handi
caps, those with severe retardation,
school units should also have limited
residential facilities. There is need for
providing wider opportunities by
encouraging voluntary agencies in
terms of aid, land etc. to start special
schools for the mentally handicapped
individuals. Priority should be given to
States and Union Territories where
such facilities are at present limited or
not existing. Steps should be initiated
to improve the standards of all train
ing schools. As an immediate mea
sure, there is need to provide
short-term courses for all those work
ing in special schools, welfare person
nel, untrained teachers and teachers
of normal schools.
Pilot programmes: In the last 40
years of planning of services for the
The new Twenty-point pro
gramme (1986) includes the needs
of the handicapped citizens as part
of the health programme (point 8)
as follows: ‘Pay special attention to
programmes for the rehabilitation
of the handicapped’. Thus, the
government is already committed
to provide services for the mentally
handicapped individuals and a
comprehenive policy can emerge
against the above existing policies
and programmes.
From National Policy on Mental Handicap.
Special school units: As a first step,
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE No 10 ■ JAN-MAR 1988
mentally handicapped persons, the
focus has been on special schools,
special institutions for residential care
resulting in a very limited coverage of
mentally handicapped persons. In line
with the current health and welfare
policies of the government to provide
services with universal coverage and
accessibility as focus, it is necessary
that pilot programmes be initiated.
These pilot programmes should
examine the feasibility as well as the
operational details.
Community Participation: The
scope for community participation is
significant in thisarea.Activitiesof the
voluntary agencies, individuals and
groups can lead to prevention of men
tal handicap. They also have an important role in development of
community based programmes, sup
porting self-help groups, organising
mobile services and to act as a pres
sure group to bring about policy and
programme changes. Community
participation should not only be sup
ported but encouraged to form the
backbone of the services develop
ment.
A National information and docu
mentation centre should be estab
lished at the central and lateral state
levels. There is need for research to be
an important part of the development
of the care programme. The following
areas should receive urgent atten
tion: (i) Impact of mentally handi
capped member on the family, (ii)
Effectiveness of preventive measures
to decrease mental handicap, (iii) Im
pact of public education and aware
ness activities, (iv) Comparative
evaluation of different models of care
(v) The effect of school integration on
handicapped children, (vi) Genetics
of mentally handicapped, especially
community studies in consanguinous
marriages, and (vii) Utility of Yoga for
mentally handicapped persons.
Summarised from Report on National Policy on
Mental Handicap, Thakur Hariprasad Institute
of Rehabilitation for the Mentally Handicapped
Children, Vivekananda Nager, Hyderabad 500 660.
NATIONAL SEMINAR ON VOLUNTARY AGENCIES
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE No 10 ■ JAN-MAR 1988
FILMS ON MENTAL HEALTH
FILMS ON MENTAL HEALTH
KASAUT1
”T he'world of the mentally ill'and
u
'the different images of mental
health’ were the subject matter of two
of the episodes of Kasauti serial aired
by the National TV in January 1988.
Mr. Ramesh Sharma, director of the
film said, "Basically, Kasauti was try
ing to focus on marginalised people,
people who did not normally come
under the scrutiny of everyday life,
whose plight was real, and whose
problems should be given a larger
voice. In identifying areas, we felt that
mental health was one area that peo
ple had so many misconceptions
■bout, there were so many stigmas att
ached to it, that it was almost like put
ting these people away from society.
Everyone treats mental health patients
the way they treat lepers, people who
should be in a separate colony. Invari
ably what has happened is that
because of the stigma attached to
mental health, in Ranchi, for example
most of the patients come from the
lower middle class and a rural back
ground. There is almost an attitude of
treating them as the scum of the earth,
locking them up and forgetting them.
We thought that we should research
and investigate and find out what
AGENCIES REPRESENTED IN THE SEMINAR
B. St. Joseph’s Bala Sadanam, -Trichur 2. Dr.
Durgabai Deshmukh School and Training
Centre for Mentally Retarded, Madras.
3. Samadhan, New Delhi. 4. Nandavan,
School for Mentally Retarded Children,
Nagpur. 5. Vikas M.M. Farms, Bangalore.
6. Medico-Pastoral Association, Banga
lore. 7. T. T.
Ranganathan
Clinical
Research Foundation, Madras. 8. Sneha,
Madras. 9. Chetna, Lucknow. 10. Federa
tion for the welfare of the mentally
retarded. New Delhi. 11. Asssciation for the
Mentally Handicapped, Bangalore.
12. Snehasadan, Bombay. 13. Indira Mem
orial Institute for Effective Thinking and
Human Relations Society, Guntur. 14. Fam
ily Service Centre, Bombay. 15. Rotary-Save
the Children Fund, Visakhapatnam.
16. Kiriya Pushpa Family Helper Project,
Mysore. 17. Vivekananda Girijana Kalyana
actually was the state of mental health
in India"1.
The two episodes focused on:
(i) the limited mental health care in
India, (ii) the poor conditions of the
mental hospitals, (iii) the problems of
chronic inmates of the mental hospi
tals, (iv) poor community acceptence
of the recovered mentally ill, (v) the
types of abuses that can occur in the
institutions, (vi) the limitations of the
legal provisions, (vii) the help seeking
by the emotionally disturbed from tra
ditional healers, the temples of heal
ing etc., (viii) the role of Ayurvedic
system of cure, and (ix) the inade
quate undergraduate medical educa
tion in mental health.
Part of the programme looks at the
alternative approaches that are being
developed. The most important of
these are: (i) the active involvement
of the family as a support system,
(ii) integration of mental health care
as part of primary health care in order
to provide services in a decentralised,
deprofessionalised-manner to destig
matise and demystify mental health
care. The ongoing work in the Solur
PHC of the ICMR Centre for
Advanced Research on Community
Mental Health was used as an example
in the second episode, and (iii) devel
opment of active, rehabilitative efforts
Kendra, Mysore. 18. Young Women Chris
tian Association, Coimbatore. 19. Enedsa,
Mysore. 20. Janatha Kendra, Mangalore.
21. Elmhrist Institute of Community Studies,
Santiniketan. 22. Nehru Institute of Youth
Affairs, Bhubaneswar. 23. Young Women
Christian Asssciation, Madras. 24. Directo
rate of Health & Family Welfare, Madras.
25. Indian Institute of Youth Welfare, Nag
pur. 26. Youth for Unity and Voluntary
Action, 8, Bombay. 27. Don Bosco lllam,
Madras. 28. Abhaya, Trivandrum. 29. Sanjivini Society for Mental Health, New Delhi.
30. Manovikas Kendra, Bangalore. 31. Atma
Shakti Vidyalaya, Bangalore. 32. Fraternal
Life Service Home, Pondicherry.
33. Clarke’s School for Mentally Retarded,
Madras. 34. Concern (India), Madras.
35. Punjab Association, Madras. 36. Schi
zophrenia Research Foundation (SCARF)
Madras. 37. National Institute of mental
health & Neuro Sciences, Bangalore.
e
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE No 10 ■ JAN-MAR 1988
THE KYOTO PRINCIPLES
*
87
The participants at the International forum
believed that, in the absence of a clear set of
international standards for the protection of the
mentally ill, it would be useful to define a set of
basic principles. These were accepted unanim
ously by all at the forum and were signed on
their behalf by the panellists. They are:
1.
Mentally ill persons should receive humane,
dignified, and professional treatment.
2.
Mentally ill persons should not be discrimi
nated against by. reason of their mental
illness.
3.
Voluntary admission should be encouraged
whenever hospital treatment is necessary.
4.
There should be an impartial and informal
hearing before an independent tribunal to
decide, within a reasonable time of admis
sion, whether an involuntary patient needs
continued hospital care.
■5. Hospital patients should enjoy as free an
environment as possible, and should be able
to communicate with other persons.
*
• Recommendations of the International Forum
on Mental Health Law Reform, Organised
jointly by the Japanese Society of Psychiatry and
Neurology and the International Academy of
Psychiatry and Law, Kyoto, January 1987 (From
Lancet March 21,1987 p. 676-677).
at all levels especially in mental hospi
tals with public involvement and
voluntary organisations.
In many ways; as the commentary
notes, the world-of mentally ill reflects
the complexity of the large society
with many pluses and minuses. The
tearrj itself found, "In many ways, the
making of this programme was an eyeopener because although we had
known and heard about the callous
state of affairs in our mental health
asylums, we were shocked beyond
words to see that it was even worse
than what we thought it was. In spite
of the fact that over the years there
have been a lot of medical advances,
and the categories in mental health
have been so well defined, you find
that antiquated ideas of a mental
health patient as a chronic looney, as
someone to be locked away, still pre
vail. We found that in the bleak scena
rio that we were travelling through,
there were a lot of people with a lot of
courage, a lot of conviction, and a lot
FILMS ON MENTAL HEALTH
8 COMMUNITY MENTAL HEALTH NEWS ■ ISSUE No 10 ■ JAN-MAR 1988
Phototypeset & Printed at SUDHINDRA, Bangalore-3.
COMMUNITY
For Private Circulation only
MENTAL HEALTH
NEWS
ISSUE Nos. 11 & 12
APRIL-SEPT 1988
EDITORIAL
District Mental
Health Programme
uring the last ten years the develop
ment of models for mental health care
have gradually become more and more
sophisticated in terms of methodology. The
initial studies related to small groups of 30
to 40 thousand population. These studies
illustrated the feasibility of integrating mental
health care with general health services with
adequate support and supervision from the
professionals. But critical examination of
these experiences by experts showed that
models with these ranges of population
would be too limited for wider application
and the inputs from mental health profes
sionals were excessive.
Against this background the starting of
District Mental Health Programme at Bellary
is a major development in the mental health
planning in our country. Currently, we not
only have plans for an average size district
of over 1.5 million population but also have
the details of the type service, level of care
and the mechanisms for monitoring the pro
gramme.
D
This issue of Community Mental Health
News brings together the evolution, strategy
of action and results of the first three years
of the Programme for wider circulation
among the mental health professionals and
planners.
- Dr. R. SRINIVASA MURTHY
(Editor)
In this issue
District Mental Health
Programme at Bellary
Top left: A sign board of the newly started psychiatric clinic at Hospet Gen. Hospital. Right: A
female health worker visits a patient's home. Below: Dr. Venkatesh Murthy, Med. Officer of Karur
PHU, Slruguppa, Interviewing a patient and her family members.
REACHING
THE
UNREACHED
ICMR Centre for Advanced Research on
Community Mental Health
NIMHANS, Bangalore.
DISTRICT MENTAL HEALTH PROGRAMME AT BELLARY
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE Nos. 11 & 12 ■ APRIL-SEPT. 1988
DISTRICT MENTAL HEALTH PROGRAMME AT BELLARY
periences, simple manuals of instructions
and short-term training programmes for
medical officers and multipurpose workers
of PHCs were developed (CMH News
Issue No. 1). Pilot training programmes
were carried out and evaluated at Primary
Health Centres at Malur and Anekal (Kolar
and Bangalore Districts, Karnataka State).
These pilot programmes helped the unit
to crystallize the educational objectives for
the mental health training of PHC person
nel and meaningfully revise and rewrite
the manuals of instructions in basic men
tal health care.
Dr. H.L. Thimpie Gowda, Minister for H & FW, inaugurating DMHP at Bellary on 20 July 1985.
Others in the Picture are Mr. M. Ramappa, MLA, Bellary and Dr. V.G. Shetty, DHO Bellary.
Right: Dr. J.L. Javare Gowda, DHS, speaking on the occasion.
health care services, was thought of as
a feasible and appropriate approach. The
growing consensus amongst experts in the
field — national and international — is ,
‘decentralisation and integration of mental
health services with the general health ser
vices by training the existing general
health care personnel to provide basic
mental health care’.
4L
An expert committee of the WHO on
‘Organisation of Mental Health Service in
Developing Countries’ which met in 1974
(WHO 1975) urged the member states to
recognise mental disorders as a problem
of high priority for the individual, for the
community and for national development
and made several important recommen
dations. The committee recommended
that: “Countries should, in the first
instance earry out one or more pilot
programmes to test the practicability of
including basic mental health care in
an already established programme of
health care in a defined rural or urban
population”. It further recommended that
“training programmes, including a simple
manual for the training of health workers
should be devised and evaluated”.
During 1975-76, major community.
mental health care experiments were
launched at Bangalore and Chandigarh
to test the feasibility of shifting the care of
the mentally ill from the ‘hospital’ to the
‘community’ and from the ‘mental health
specialist’ to the ‘primary care physician’.
Community Mental Health Unit
at NIMHANS
The Department of Psychiatry at
National Institute of Mental Health and
Neuro Sciences (NIMHANS) focused its
attention on extending mental health ser
vices into the community as early as
1975. A specially designated and staffed
‘Community Psychiatry Unit’ was estab
lished. The main aim of the Unit was to
extend mental health services by inte
grating it with the existing system of
primary health care. For this, the
primary health care staff had to be train
ed in basic mental health care. More
specifically, the task of the unit was to
develop, carry out and evaluate suitable
short-term training programmes in basic
mental health care for different categories
of health care personnel, so that after
training, these personnel could provide
mental health care in their respective
areas of work.
A rural community mental health and
training centre was established at
Sakalawara (Anekal Taluk) near
Bangalore in 1976. Initially a service pro
gramme was developed and feasibility
exercises were carried out in the villages
around Sakalawara. Based on these ex
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE Nos. 11 & 12 ■ APRIL-SEPT. 1988
Since 1982, every month, regular
training programmes for medical officers
and health workers, working in various
PHCs and/or PHUs of Gulbarga and
Mysore divisions (Karnataka state) and
deputed by the Department of health and
family welfare are held at the rural men
tal health centre at Sakalawara. These are
held in small batches of 5-15 persons and
are residential. The health workers’ train
ing is for a period of 6 days while the
medical officers’ training is for 12 working
days. The training is routinely evaluated
by pre and post-training assessments. So
far, more than 400 medical officers and
600 health workers have participated in
this training.
The regular monthly training program
mes and their evaluation facilitated fre
quent reviews and whenever necessary,
revisions of the ‘training package’, name
ly, education objectives, methodology of
training, time allotment for various ac
tivities, manuals of instructions, tools of
pre and post-training assessments and
simple records for mental health care at
PHCs. After several revisions, the rewrit
ten ‘Manual of Mental Health for Multi
purpose Workers’ and ‘Manual of Mental
Health for Medical Officers’ are currently
available in printed form for wider use
(CMHNews, Issue No. 1). Similarly, the
instruments for evaluation of the training
also have been standardized.
Evaluation of work carried out
by trained PHC personnel
While it is acceptable that the mental
health training can be evaluated in a
limited way by pre and post-training
DISTRICT MENTAL HEALTH PROGRAMME AT BELLARY
3. NMHP envisages implementation of the programme atleast in one district
of every state in the country, within a specific period of time.
namely, Bangalore, Calcutta, Baroda and
Patiala. Few other experiments from cen
tres like Vellore, Lucknow, Jaipur and
Hyderabad also added to the growing
evidence for community based mental
health care by general health staff. By
then, the ‘National Mental Health Pro
gramme’ (NMHP - 1982) for India was
also approved by the Central Council of
Health and family welfare for countrywide
implementation (CMH News, Issue
4. All health care and welfare programmes are implemented and monitored
No. 1).
Need for Developing a District Model for delivery
of Mental Health Care
1. Earlier efforts to integrate mental health with PHC involved only popula
tion of 40,000 to 60,000 and personnel of one PHC
2. Field level evaluation of trained PHC personnel highlighted the need for
developing a district model.
at a district level.
assessments which would give an indica
tion of the knowledge gained by the
trainees, the ultimate criteria for evalua
tion will have to be the ability of the
primary health care team to recognize and
manage the mentally ill in their PHCs thus
bring down the overall neuropsychiatric
morbidity. In a few ‘micro level’ pilot
research projects carried out in either in
part of or a whole PHC involving a limited
number of personnel, it had already been
shown that mental health care can be pro
vided at the PHC level by trained PHC
personnel.
Following the training, when a follow
up visit was made the doctors and health
workers in the centres visited had under
taken mental health care activities to vary
ing extent. Some of the centres and
personnel had done excellent work while
others had done very limited amount of
work.
There appeared to be problems
because of the small number of health
workers trained from each PHC. Popula
tion coverage wise, they accounted only
for a small percentage of the total popula
tion of the PHC. In some PHCs the train
ed doctors talked to all the health workers
to identify, refer and follow-up cases and
impart mental health education. Many of
the cases presently being managed by the
doctors, were identified by themselves
from their daily clinics.
None of the health care personnel
interviewed felt that their work load had
increased because of this programme,
while many feared that as the number of
cases identified and managed increases,
the work load too might increase. It was
noticed that the work of the health per
sonnel could have been better if several
of their following administrative and
supervisory needs were fulfilled: (i) pro
vision of minimum number of essential
psychotropic and antiepileptic drugs on a
regualr basis, (ii) provision of simple recor
ding and reporting method, (iii) involve
ment of all the health care personnel, of
the PHC/district belonging to various
categories, (iv) regular supervision and
monitoring of the programme at all levels,
namely, PHC, district, division etc.,
(v) availability of specialist referral
facilities, (vi) provision of material for
public mental health education, (vii) faci
lities for continued learning of trained per
sonnel (refresher courses), and (viii) to
improve public understanding and accep
tance of PHC as places of treating men
tally ill and epileptics. The field.level
evaluation of trained PHC personnel
highlighted the need for planning men
tal health care at a district level.
Genesis of the Bellary District
Mental Health Programme
By 1983-84 in addition to the ongoing
work of the community mental health unit
at NIMHANS, few other projects had
practically demonstrated that primary
health care system can provide mental
health care at the community level.
Notable amongst these are the “Strategies
for Extending Mental Health Care” a
WHO multicentre collaborative study with
a collaborating centre at Chandigarh and
the ICMR-DST (Indian Council of Medical
Research - Dept, of Science and Tech
nology) ‘Severe Mental Morbidity Project’
carried out at 4 centres in the country,
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE Nos. 11 & 12 ■ APRIL-SEPT. 1988
A result of these developments was the
increasing realization that further work
was needed to consolidate the gains and
achievements of the previous few years.
The existing know-how of integrating
mental health with primary health care
had to be operationalized and applied to
larger areas and target populations. The
already proven methods of-training, the
PHC personnel, manuals, curricula, train
ing aids of different types and methods of
evaluation had to be applied in a wider
setting. The district level psychiatric
facilities of referral and consultation by the
PHC Teams had to be developed. Above
all, the National Mental Health Pro
gramme, already approved for implemen
tation, envisaged the operationalization of
the programme ‘in at least one district in
every State and Union Territory, and in
at least */2 of all the districts in some States
within five years’. It is proposed by the
NMHP that specialized psychiatric services
be made available at the district level. It
would be the responsibility of specialist
health personnel at the district level to
provide training and supervision to the
workers at the primary health centre level.
So, it was in the light of all these specific
issues and as the next logical step in the
implementation of the National Mental
Health Programme that the ‘district men
tal health programme’ was developed by
the community mental health unit of
NIMHANS.
During the field level evaluation visits
in 1983 to several peripheral health care
institutions by a team of the community
mental health unit of NIMHANS, head
ed by Director and Senior Officers of
Department of Health and Family
Welfare, Karnataka, many health workers
reported that, while they had identified
DISTRICT MENTAL HEALTH PROGRAMME AT BELLARY
and referred many cases of mental ill
nesses and epilepsy, most of them had
not actually come to the PHCs and PHUs
for assessment and initiation of treatment.
Since the number of neuropsychiatric
patients seeking treatment at the
peripheral health institutions were low,
many PHC doctors including their super
visory officers like the District Health
Officer (DHO) had doubts about the
actual prevalence of these disorders in the
rural community. Therefore, aimed at
demonstrating to the rural public that
mental illness and epilepsy could be
assessed and managed at health institu
tions close to their villages by trained
health personnel and demonstrate to the
medical officers and their administrators
like the DHO that large number of per
sons suffer from these conditions in their
own PHCs, mental health camps were
conducted in one of the districts of
Gulbarga division, Bellary.
Information about these camps were
given to the public by the health workers
and these mental health camps were
actually organized and conducted by
trained PHC staff with the assistance of
resource persons from NIMHANS. Such
camps were held at Siruguppa, Hadagally,
Harappanahally (Taluk Hq. towns) and
Bellary from 18.09.1983 to 01.10.1983
and large number of mentally ill and
epileptics (ranging from 135 to 300 at
each centre) were examined and treat
ment initiated. They were advised to visit
jj PHCs/PHUs where trained personnel
worked, close to their villages for follow
up. This opportunity was also utilized for
public education by group meetings and
exhibitions on mental health. A major out
come of these camps was the sensitization
and increased'awareness of health officials
particularly the DHO (Dr. K.B. Makapur)
of Bellary District regarding the need for
organizing mental health services in the
periphery — both at the district head
quarters and the peripheral health in
stitutions.
Following the above experience,
District Mental Health Programme
(DMHP) was developed over a period of
several months during 1984-85. The
decision to take up Bellary as the district
for developing implementing and evalu-
HEALTH CARE FACILITIES
IN BELLARY DISTRICT
Medical College
1
Primary Health Centres
23
Primary Health Units
28
General Hospitals (Taluk)
7
Govt. Allopathic Dispensaries
18
Urban Family Welfare Centres
6
National Leprosy Control Centres :
4
No. of Medical Officers
77
No. of Health Workers
(Male - 268; Female - 353).
: 621
ating DMHP emerged following the
evaluation of April 1983 and the mental
health camps in several places in the
district in Sept-Oct. 1983. Following a
series of meetings of NIMHANS team
with the district health office team and the
Deputy Commissioner of Bellary, it was
decided that the DMHP be taken up as
a joint project of Dept, of Health and
Family Welfare, (Govt, of Karnataka)
District Administration, Bellary and
NIMHANS. At a meeting, held at Bellary
in May 1985 attended by Dr. G.N.
Narayana Reddy, Director NIMHANS,
Dr. C.Prasanna Kumar, Joint Director
(Health Programmes & Planning), Direc
torate of Health and Family Welfare,
Govt, of Karnataka and Mr. Sudhir
Kumar, Deputy Commissioner, Bellary
and their respective teams, the joint pro
ject was formalized.
It was agreed that NIMHANS will con
tinue to offer technical inputs in terms of
training, monitoring and evaluation of the
programme, the district administration will
ensure the funding for adequate and
regular supply of drug requirements
(estimated expenditure Rs. 50,000/- per
year) and printing of records for health
personnel and the Directorate of Health
and Family Welfare services will imple
ment the programme through its existing
infrastructure and personnel. In addition
the directorate also agreed to spare the
services of one of its medical officers
(Assistant Surgeon) with experience of
programme administration to oversee the
DMHP at the district level (Programme
Officer) and meet his transport needs
(Vehicle, driver and POL) to tour the
district regularly.
The DMHP was formally inaugurated
at Bellary by the then Health Minister of
Karnataka Dr. H.L. Thimme Gowda on
20th July 1985. The inaugural function
was attended, in addition to a large
number of the general public, by members
of the legislative assembly from the
District, Mr. B.Shivarama Reddy, Mr.
M.Ramappa and Mr. C.M. Revana Siddaiah, Dr. J.L. Javare Gowda, Director
of Health Services, Dr. G.N. Narayana
Reddy and Mr. Sudhir Kumar.
Aims and objectives of the DMHP
The general aim of the District Mental
Health Programme is to extend mental
Advantages of planning mental health care at
a district level
1. The district is an independent administrative unit with district commissioner
as the head.
2. DHO, has powers of planning activities in the district.
3. Monitoring of programmes occur at the district level.
4. Inter-sectoral coordination is possible at the district level.
5. Mobilisation of additional resources is possible.
6. All existing staff can be best utilised by involving the total district for care
programme.
7. A district, not a PHC, is the planning and implementation unit for most
other health and welfare programmes.
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE Nos. 11 & 12 ■ APRIL-SEPT. 1988
DISTRICT MENTAL HEALTH PROGRAMME AT BELLARY
the district are not trained within a
reasonable period of time. Deputation of
large numbers of these personnel to
Bangalore can cause disruption of their
routine ongoing work. The 2-week train
ing module has no planned facility for
1)
To develop and implement a decen
refresher inputs to the trainees to clarify
tralized training programme in men
their doubts which arise after their using
tai health for all categories of health
the knowledge gained through the initial
personnel, appropriate to their levels
training. Continuous ‘on-the-job’ inputs
of functioning with least disruption to
though of short duration can be very
the ongoing general health care ac
beneficial to trained personnel. Therefore,
tivities.
a ‘decentralized training’ strategy was
2)
To provide a minimum range ofdeveloped.
essential drugs for treatment of
The training was to be carried out for
severely mentally ill persons at all
different categories of personnel separate
peripheral health care institutions.
ly and wherever the numbers were high,
3)
To develop a system of simple recorin batches of manageable numbers. The
ding and reporting of care by health broad approach of training was to impart
care personnel.
to the trainees not only new knowledge
about mental illnesses but also the ability
4)
To monitor the effect of the service
to identify and manage all the mentally ill
programme in terms of treatment
in their community . The educational ob
utilization and outcome with treat
jectives of the training were to teach the
ment.
personnel to carry out various tasks
5)
To develop mechanisms of com already identified. The training was to be
munity participation in the mental decentralized and carried out at the district
health care programme through headquarters and taluk headquarters
planned activities.
towns. It was to be divided into 3 different
sessions of 1 to 3, each held at intervals
6)
To study the cost-effectiveness of the
of few months. This would enable the
programme.
trainees to bring back difficulties in im
Towards achieving these objectives the plementation of the programme, so that
DMHP has several components, namely, they could be discussed and clarified.
(i) Training of personnel, (ii) Provision of Manuals of instructions (for doctors and
Drugs, (iii) Simple recording system,
health workers) already developed for this
(iv) District level programme officer & his purpose, would be made use of for the
team (v) District Mental Health Clinic, training.
(vi) Review cum training as part of visits
to die periphery, (vii) Weekly mental health
Thus, the training for PHC personnel
clinics in the periphery, (viii) Monthly at a district level was as follows:
reporting, monitoring and feedback,
(ix) Community participation, and a) Medical officers: Total trianing days
- 9, in 3 sessions of 3 + 3 + 3 days
(x) Field Training for MH professionals.
with an interval between sessions of not
less than 3 months, and in batches of
Training of Health Personnel
not more than 25.
Services for the mentally ill can become
b) Multipurpose workers: Total
an integral part of the general health ser
training days 4 - in 3 sessions of 1 +
vices, only if all categories of personnel
2+1 day with an interval between
are trained to carry out routinely, the
sessions of not less than 3 months.
mental health care tasks assigned to them.
One batch could consist of all the
It would not be possible to effectively
health workers in a PHC and venue of
and meaningfully launch a mental health
the training may preferably be the PHC
programme, if most- of the personnel in
itself.
health services to the severely mentally ill
persons in the district through the existing
health care personnel and institutions.
The more specific objectives of the Pro
gramme are:-
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE Nos. 11 & 12 ■ APRIL-SEPT. 1988
c) Health supervisors (health inspec
tors and lady health visitors): Total
training days - 4, in 2 sessions of 2 +
2 days with an interval period between
sessions of not less than 3 months. The
training can be either at district head
quarters or one or two taluk head
quarters. In addition, the supervisors
would be expected to attend the train
ing for multipurpose workers.
d) Community health volunteers:
Two days of training preferably during
their initial 3 months training period.
The CHVs should be called for a 2 day
training at the PHC level to be carried
out by trained medical officers, and
health supervisors.
e) Block health educators: The
block health educators of each PHC
(generally, one in each PHC) could
join the programme of health super
visors i.e., 4 days in 2 sessions of 2 +
2 days.
In addition to the above mentioned for
mal training for larger groups of person
nel, informal ‘on the job’ training inputs
will continue for personnel of PHC by a
district mental health team visiting PHCs
regularly once in two or three months,
preferably on a fixed day of the week
which could be designated as the weekly
‘Mental Health clinic’ day when most of
the old and new patients of the PHU/
PHC could visit the centre for their follow
up consultation.
While training in mental health for
medical officers, multipurpose workers
and other functionaries is important for
identification and management of the
needy population, the programme would
be successful only if it is regularly super
vised and monitored at the district and
sub-divisional levels by the DHO and
ADHOs. Therefore, even the supervisory
officers at the district level were ap
propriately oriented and sensitized to the
mental health needs of the population.
Training for Medical Officers
The total number of medical officers
practising the allopathic system, working
in various health institutions of the district
and coming under the administrative con-
DISTRICT MENTAL HEALTH PROGRAMME AT BELLARY
trol of district health officer in Bellary in
1984-85 is around 75. The doctors were
trained in 3 batches for 3 consecutive days
at Bellary. The training was earned out by
a faculty of two psychiatrists from the com
munity mental health unit, NIMHANS.
The primary objective of the training
was to sufficiently sensitize the medical of
ficers to mental health problems in the
community and demystify the manage
ment of common psychiatric problems.
They were told about the extent of men
tal health problems in the community,
need and strategy of integrating mental
health with primary health care and their
role in its implementation. Of the three
training days available, the first day’s mor
ning was spent for these topics. In addi
tion, a pre-training assessment of their
present mental health knowledge was also
carried out during the 1st day morning.
They were shown short video recorded
interviews of the patients suffering from
different psychiatric conditions and were
asked the diagnosis, management and
prognosis.
During the afternoon session of the first
day, the basis of normal human behaviour
was discussed, reviewing the structure
and functions of the brain and the factors
contributing to the understanding of
behaviour — biological, psychological and
sociocultural. In the light of this understan
ding of norma! human behaviour, the
various abnormalities that can take place
to produce mental illnesses of different
types, were then discussed. The various
features, types, causes and treatment of
mental disorders in general was also
covered.
The whole of second day was utilised
for teaching ‘psychosis’. After discussing
their (the trainees) general reactions to a
severely mentally ill patient, the approach
Top: Dr. Sekar Seshadri, Lecturer in
Psychiatry, NIMHANS, reviewing the diag
noses of a patient at Mariammanahally PHC.
Dr. Krishna Murthy, MOH, is also seen.
Middle: Dr. Muralidhar, Former Programme
Officer, DMHP, examining a patient at
District Clinic at Bellary.
Below: Three Lady Medical Officers taking
the history of a patient during a training ses
sion at Bellary.
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE Nos. 11 & 12 ■ APRIL-SEPT. 1988
DISTRICT MENTAL HEALTH PROGRAMME AT BELLARY
to a psychotic patient — history taking
and examination — was discussed, fol
lowed by clinical features, types and prac
tical management of psychosis. The
emphasis was mainly on giving the doc
tors to diagnose and satisfactorily manage
psychotic conditions, and hence the prac
tical work of interviewing and diagnosing
as many actual cases as possible was given
the maximum priority in the allotment of
training of the second day. Carefully
prepared video recordings of interviews
with psychosis patients highlighting the
symptomatology, and clinical presenta
tions were also demonstrated and
discussed.
On third day, the morning session was
spent for discussion on epilepsy. The doc
tors’ basic pre-training knowledge regar
ding epilepsy seemed to be much better
than their knowledge of mental illness and
hence there were large number of ques
tions, doubts and clarifications. Although
neurosis, mental retardation and other
childhood problems are to be covered in
detail during the second phase of train
ing, are also briefly touched upon. The
afternoon is mainly made use of for
discussion on the problems which are like
ly to come up in the implementation of
the mental health care programme all
over the district. There is no post-training
assessment. The doctors were assured
about the availability of drugs at the PHCs
and PHUs.
Following the initial training, all the
medical officers were to identify and
manage cases from their clinics as well as
cases referred by the health workers from
the community. They were also required
to maintain simple records, follow-up the
cases regularly and refer cases which they
could not manage to the District head
quarters. Essential drugs were made avail
able at all peripheral institutions. The
progress of the mental health care pro
gramme was reviewed every month dur
ing the monthly conference of medical
officers.
The second phase of the training was
carried out after a few months. This
3-days training begin with an assessment
of the doctors’ knowledge of mental
health care. The assessment was carried
out to ascertain how much of mental
health care knowledge the doctors had
retained, after the initial phase of training
and accordingly develop the curriculum
and methodology for the second phase
of training. The doctors had difficulty in
differentiating schizophrenia, reactive
psychosis and depression. While they
knew the common drugs and their
dosage, they were unsure of dosages and
duration of treatment for specific con
ditions.
To facilitate development of diagnostic
and management skills, most of the time
during the 3 days was used for practical
demonstration of cases and discussion of
cases worked up by each of the trainees.
Emphasis is also laid on nonpharmacological management of non-psychotic
psychiatric disorders.
Provision of Drugs
Earlier efforts at integrating mental
health with primary health care had
shown that availability of five basic
psychotropic drugs (Tab. Chlorpromazine
50 mg./lOO mg., Tab. Imipramine
25 mg., Tab. Trihexyphenidyl 2 mg. Inj.
Fluphenazine and Tab. and Tab. Pheno
barbitone 60 mg.) at the primary health
centre/unit was very essential for the suc
cessful implementation of the programme
following the training of the health care
personnel. All these drugs are routinely
not available in the PHCs and these drugs
are generally not included in the supplies
to the periphery from the state level
general medical stores. Therefore specific
efforts were made to generate the
necessary funds to supply minimum
amounts of essential drugs during the first
one or two years of the programme to
every peripheral health care institution, in
Bellary district.
This crucial assistance for the starting
of the district programme — initially
Rs. 20,000 and later Rs. 50,000 annually
came from the district administration from
the district development funds, and was
sanctioned in 1984-85 by the then
Deputy Commissioner of Bellary district
Shri Sudhir Kumar. The availability of
these funds helped in the launching of the
programme all over the district. Subse-
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE Nos. 11 & 12 ■ APRIL-SEPT. 1988
Community
Awareness
and
Participation
Activities
or any effective community oriented
programme we need to look into the 4
Ps: Political or Planners’ commitment, Pro
fessional commitment, Progress in the
mental health know-how, and Participation
of the community (Srinivasa Murthy, 1985).
Community participation, according to
N1PCCD Manual (1984) is a coglomeration
of activities which enable the community to:
(a) be aware of its needs and problems,
(b) enrich the knowledge about services and
facilities in operation, (c) get conviction
about the efficacy and usefulness of those
services, (d) develop an understanding
about its participation and contribution, and
(e) involve consciously and actively in the
implementation of new strategies for
practice.
F
Considering its value and importance, all
efforts have been taken from the very incep
tion of Bellary District Mental Health Pro
gramme to ensure community awareness
and strengthen its participation in a wide
range of activities related to mental health
care.
Mental Health Camps: The mental health
camps organised at Siruguppa, Hadagally,
Harappanahally and Bellary in the year
1983 had sown the seeds of public
awareness about mental health problems
and services. Large numbers of mentally ill,
ranging from 135 to 300 were examined
and teatment initiated. The overall effect of
these camps was the increased awareness
of the public about mental health problems
in their community, and the facilities for
treatment available near their homes. It also
sensitized the health officials regarding the
need for organising mental health services
beyond the District Headquarters setting.
District Mental Health Committee: A
District Mental Health Committee was
formed as part of the District Health and
Family Welfare Committee. This committee
headed by the Deputy Commissioner
having the representatives from different
departments like Education, Social Welfare
and Development enhanced the process of
DISTRICT MENTAL HEALTH PROGRAMME AT BELLARY
communication and interaction between
health and other departments which in turn
represents the intersectoral cooperation at
higher levels of administration.
Orientation to Media Personnel: It is
important that personnel involved with mass
media activities — Newspapers, magazines,
A.I.R., News agencies, State and Central
wings of Publicity are oriented towards the
facts of mental health problems as well as
newly introduced services in the district.
Accordingly, one day programme was
organised for the representatives of the mass
media personnel, they were adequately
helped to incorporate the mental health
matters into their day-to-day media ac
tivities. As a result of such efforts, the mass
media personnel gained scientific awareness
about mental health problems and transmit
Contact with Voluntary Agencies: In order
to enlist the. support from the Voluntary
agencies for mental health programmes,
professionals’ participation in the meetings
of Rotary Club, Lions Club, Croftons
(Ladies) Club, Youth Clubs, Mahila Mandais and other allied agencies was proved
to be fruitful. Initially, these collaborative
activities with voluntary agencies would
seem to be challenging, but in due course
of time with the continuous and consistent
efforts of the professionals, they became
rewarding and enriching experience.
Orientation to Zilla Parishad Members:
Initial efforts were taken to discuss with the
Chief Secretary and the Deputy Commis
sioner and later with the President of Bellary
Zilla Parishad regarding the issues related to
mental health services in the district. Their
Booklets: Specific booklets both in Kannada
(6,000 copies) and in English (1,000 copies)
on District Mental Health Programme were
printed for the communication to the Youth
Clubs, voluntary agency members, staff of
Welfare institutions, teachers, Mandal and
Zilla Parishad members, MLAs, and MPs
and others interested in the programme.
This method helped them to understand the
details of the programme and the scope of
their participation.
Films: The District Health Education Wing
continued to screen NIMHANS’ films on
mental health in the villages along with other
films on family planning, health activities
etc. It has been observed that the movies
on ‘Child and its mind’ and ‘Towards Light’
became popular among the rural folks in the
district. The villagers started realising the
value of modern treatment for mental
ailments and their increased convictions led
to increased utilisation of the services.
Cinema Slides: Cinema slides were pre
pared with the help of local agencies like
Lions Club, Rotary Clubs and Union Bank
of India. These were shown in the theatres
to create awareness about the features of
mental illnesses, mental retardation and
Epilepsy and the available services in the
Government Hospitals, PHCs and PHUs.
Educating the Educators: Considering the
fact that not less than 40 percent of the
beneficiaries of the mental health services
offered by the PHC system being children
and adolescents, the discussion was later
focussed on the modalities of the involve
ment of th eight Assistant Educational
Officers and of the District. Documents like
Dr. R. Parthasarathy, Asst. Prof, of PSW, NIMHANS, demonstrating symptoms of a patient to
a group of HWs at Hollalu.
ted the same to the public through their
respective media.
Interaction with Social Welfare Person
nel: Social welfare personnel like super
intendents, teachers, case workers,
supervisors, wardens and others working in
the Remand Home, Junior/Senior Certified
schools, and other institutions were met and
group discussions were held. During such
sessions, the focus was made on issues
related to mental health risks of delinquents,
orphans, deserted individuals, destitute
women and physically handicapped. Later,
the welfare personnel were met periodically
to strengthen the impact of orientation pro
grammes conducted initially.
positive responses and support, in fact gave
a fillip to the programme. Subsequently, a
brief orientation programme was arranged
to other members of the Zilla Parishad. The
details pertaining to the beneficiaries, the
nature of help, the importance of public
involvement and related issues were briefed
to the august gathering of the MLAs, MPs,
Zilla Parishad members, VIPs of the Bellary
District, Mass Media personnel and the
public in the monthly meeting of the Zilla
Parishad. As a result of such interactions,
the Zilla Parishad members felt that these
orientation programmes need to be held at
Mandal Panchayat level so that local
involvement could be intensified.
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE Nos. 11 & 12 ■ APR1L-SEPT. 1988
Mental Health perspectiues of the new
system, Mental Health problems of stu
dents, play activities: pathways to an inte
grated personality, Learning Difficulties:
Causes Remedies and How to get along
with people were sent to them. They served
as background material for discussions and
interactions resulting in the active collabora
tion with Schools and teachers in Bellary
District.
Satisfied Consumers: Effors have been
made to offer systematic education to the
family members of the patients. The patients
who dropped out were followed-up. Home
visits were made, reminder letters were writ
ten emphasising the regular follow-up. This
was given much emphasis and importance
with the understanding that the satisfied
beneficiary would be the best agent of
education and community participation.
Dr. R. PARTHASARATHY
Asst. Professior of Psychiatnc Social Work,
NIMHANS, Bangalore
DISTRICT MENTAL HEALTH PROGRAMME AT BELLARY
quently during the first annual review,
Essential Drugs for
when the programme was reviewed by
Primary Health Institutions
the Director of Health Services along with
the Deputy Commissioner of Bellary and
Tab. Chlorpromazine
50 mg.
Director of NIMHANS, it was decided that
Tab. Imipramine
25 mg.
for the routine running of the programme,
Tab. Phenobarbitone
60 mg.
part of the drugs would be supplied from
2 mg.
Tab, Trichexyphenidyl
the General Medical Stores and the re
Inj. Fluphenazine
25 mg.
maining could be purchased locally by the
District Health Officer from the discre,tionary funds available to him for pur Records of Research Team
The research team will keep a record
chase of drugs. Currently, all the essential
of all the cases registered in every
psychotropic drugs are made available in
peripheral
institution of the district, at the
every peripheral health care institution of
Bellary district. The amount of drugs district head-quarters. This will be essen
tially
an
extract
of the case cards main
available in each institution is related to
the number of cases being managed and tained by the medical officers in various
.
institutions.
These
will be obtained during
the indenting and regular supply of drugs
all over the district is monitored by the regular visits to the periphery by the
research
team
after
scrutiny and review
programme officer.
with the medical officer and his staff at
each
of
the
institution.
The research team
Recording and Reporting System
A simple recording and reporting will also keep a note of the overall quality
of
mental
health
care
delivered
in each of
system is designed to be maintained at
the institutions with special mention of any
various levels.
lacunae observed.
Health worker’s records
Records of DHO and DHS
Patient identification cards: As
Monthly statistics of all types of case
soon as the health worker identifies a pa
identification,
case holding and case cure,
tient with psychiatric illness, he issues a
drug consumption, and list of mentally
card to the patient or to the family
disabled
people
who are certified for
members which has to be presented to the
dispensation of social benefits etc. is main
doctor in the hospital.
tained properly at the DHO and DHS
Record book: A record book is main
level.
tained by the health workers. This record
Programme Officer and the District
consists of minimum details of the patients
and their symptoms on one side and col Team
umns to record the follow-up details on
The various national health care pro
the other side of the sheet. This record is
grammes like Family Welfare Programme,
checked by the supervisory staff at regular National Malaria Eradication Programme,
intervals regarding completion and ap
(NMEP) Tuberculosis Control Pro
propriateness of the information.
gramme, Leprosy Control Programme
Doctor’s records
Four different proformas are designed
for the dpctors to collect information
about patients with psychoses, neuroses,
mental retardation and epilepsy. The
follow-up details are recorded in the
cards.
A separate monthly report form was to
be filled up by the doctor in which he gives
minimum details of the new cases iden
tified in that month, the drug position and
the number of drop-outs etc.
10
etc., are monitored and supported at the
district headquarters level by programme
officers who work under the DHO. These
personnel are often medical officers who
have several years of service and admini
strative experience or those who have
specialised in this area. During the initial
planning of the DMHP, it was agreed by
the Directorate of Health and Family
Welfare that a programme officer for the
DMHP would be appointed from ‘leave
cum deputation reserve’ pool. Hence one
of the assistant surgeons with many years
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE Nos. 11 & 12 ■ APRIL-SEPT. 1988
of experience in various capacities in the
district and with interest in mental health
was appointed as the programme officer.
He was deputed to NIMHANS for a
6-week training to gain proficiency in
clinical psychiatry and thus be able to
monitor and supervise the other PHC
doctors and health workers. During this
period, he worked like a resident both in
outpatient and inpatient settings and par
ticipated in all the teaching programmes
at NIMHANS. Following the successful
completion of the training he returned to
Bellary to run a regular mental health
clinic at the district health and family
welfare office campus (District TB Cen
tre) in addition to organising the DMHP.
The office of DMHP was also opened
at the District TB centre, Bellary. In addi
tion, a health assistant (MPW) was also
deputed to assist the work of the pro
gramme officer.
One of the assistant surgeons of the
district (Medical Officer of PHC.Ittigi) got
interested in psychiatry after attending the
initial pilot decentralised training in mental
health held in Bellary. He pursued this
interest to seek admission for a two year
post-graduate diploma in psychiatry at
NIMHANS and later successfully com
pleted the course (1984-86) and returned
to Bellary. He assisted the DMHP as a
trained psychiatrist at the district head
quarters and later took over as pro
gramme officer, when the services of the
first programme officer was withdrawn.
The programme officer is assisted by
district level research team consisting of
3 assistant research officers — one each in
psychology, Social Work and statistics.
This team is appointed by NIMHANS and
funded by NIMHANS research grants. Al
though DMHP was formally inaugurated
in 1985, the first staff joined in September
1986, and full team of 3 persons was
available only from October 1988. The
team assists the programme officer in run
ning the district clinic, monitoring the pro
gramme by regular field visits, routine
data collection from the periphery and its
analysis. The psychologists, in addition,
certifies the mentally retarded individuals
and assist in their management and the
DISTRICT MENTAL HEALTH PROGRAMME AT BELLARY
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE Nos. 11 & 12 ■ APRIL-SEPT. 1988
DISTRICT MENTAL HEALTH PROGRAMME AT BELLARY
Training for Mental Health
Personnel
NIMHANS has a 4-week ‘Training of
Trainers of PHC personnel in Mental
Health Care’ programme for mental
health professionals desirous of initiating
community based programmes. These
programmes are conducted a few times
a year and many mental health profes
sionals from different parts of the country
as well as other developing countries
attend the programmes. Field visits to
Bellary and some of the health institutions
in the district lasting 3-4 days, and discus
sions with various persons connected with
the programme like PHC personnel, the
DC, DHO and programme officer have
now become an integral component of
the ‘Training of Trainers’ programme.
This visit has been rated as one of the
‘most useful’ activities of the programme
by many participants. Many such visits
were carried out several times during the
last 3 years. The participants of these pro
grammes include senior professionals like
superintendents.of mental hospitals, pro
fessors and assistant professors of
psychiatry. During the past three years,
participants have come from almost all the
states and union territories of the country
as well as from other developing countries
in the region like Bangladesh. These visits
have been found to be very useful by the
‘ participants as they acquire a first hand
experiential understanding of the DMHP
as the field level realities and constraints.
Popular
Bellary
3,85,714
Sandur
1,26,658
Slruguppa
1,48,929
Rate per 10,000 population
Cases detected
1985 861987-88
1986-87
1985-86
1986-87
1,545
2,257
19.10
40.05
154
277
429
12.15
21.86
33.87
225
357
499
15.10
23.97
33.50
737
1987-88
58.51
98,814
173
220
280
17.50
22.26
Harapanahalli
1,57,627
333
494
716
21.12
31.33
45.42
Kudligi
1,65,679
331
438
601
19.97
26.43
36.27
H.B. Halil
Hospet
613
11.86
20.06
90,600
262
325
457
28.91
35.87
50.44
14,03,311
2,487
4,116
5,852
17.72
29.33
41.70
2,29,290
Hadahalli
28.33
272
460
26.73
TABLE - 2 : Talukwise detection of cases from 1983 to July 1988
Taluk
Doctor
in position
_ ..
Epilepsy
Psychosis
M.R.
Neurosis
Total
%
Bellary
13
886
664
201
506
2,257
38.56
Sandur
4
322
48
17
42
429
Slruguppa
9
301
119
15
64
499
8.52
Hospet
12
463
100
26
24
613
10.47
H.B. Halil
6
229
34
12
05
280
4.78
Kudligi
11
496
71
21
17
605
10.33
Harapanahalli
12
547
85
63
21
716
12.23
Hadahalli
10_________280
81
28
64_______ 453
Total
77
3,524
1,202
383
743
5,852
7.33
7.74
100
TABLE - 3 : Mode of referral of cases
Model of referral
Epilepsy
%
Psychosis
M.R.
Neurosis
%___________ %__________ %
Results and discussion
MPW & other health staff
454
(12.88)
145
(12.06)
96
(25.06)
63
(8.47)
Table 1 to 8 and the bar diagrams
show certain aspects of the Bellary District
Mental Health Programme particularly the
utilisation pattern and outcome of treat
ment in an illustrative manner.
Doctors (Govt., G.P., Dist. Hosp.)
306
(8.68)
267
(22.21).
13
(3.39)
225
(30.26)
Other patients
240
(6.81)
124
(10.32)
36
(9.39)
74
(9.95)
Identified in the clinic
178
(5.05)
58
(4.82)
10
(2.61)
34
(4.57)
1,220
(34.62)
Others (Camp, village leaders)
284
(23.62)
85
(22.19)
191
(25.70)
144
(4.08)
No clear Information about referral
147
(12.22)
106
(27.67)
99
(13.22)
982
(27.86)
177
(14.72)
37
(9.66)
57
(7 67)
383
(100)
743
(100)
The data presented in these Tables
refer to the period from the beginning of
the programme till 31st July 1988. It
specifically refers to 5852 cases identified
and registered at the district clinic as well
as all the peripheral health care institutions
of the district, and reviewed by the district
team.
The number of all categories of patients
being identified managed has been cdn-
12
TABLE - 1 : Talukwise total case detection f>er 10,000 population (Bellary District)
Taluk
COMMUNITY MENTAL HEALTH NEWS
Self (Patient or his family)
Total
3,524
1.202
(100)
(100)
figures tn paranthesis show percentage
ISSUE Nos. 11 & 12 ■ APRIL-SEPT. 1988
DISTRICT MENTAL HEALTH PROGRAMME AT BELLARY
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE Nos. 11 & 12 ■ APRIL-SEPT. 1988
DISTRICT MENTAL HEALTH PROGRAMME AT BELLARY
TABLE - 7 : Comparison between various types of institutions 1983 to July 1988 (PSYCHOSES)
Total
Dist.
clinic
No. of
G.Hs.
PHCs
No. of
No. of
cases
PHU +
GGAD
No. of
cases
Total number of cases
632
(52.58)
180
(14.97)
284
(23.62)
106
(8.82)
1,202
(100)
Regular and maintaining improvement
338
(53.48)
71
(39.44)
65
(22.89)
33
(31.13)
507
(42.18)
Stopped drug on advice
64
(10.12)
17 •
(9.44)
18
(6.34)
19
(17.92)
118
(9.82)
Irregular and dropout
216
(34.18)
90
(50.10)
194
(68.30)
54
(50.94)
554
(46.09)
Cases with duration of illness less than 1 week
38
(6.01)
15
(8.33)
16
(5.63)
15
(14.15)
84
(6.99)
Drug used CPZ + THP
212
(33.54)
70
(38.89)
38
(13.38)
26
(24.53)
346
(28.78)
Drug used CPZ + FPZ + TPH
266
(42.08)
33
(18.33)
30
(10.56)
28
(26.41)
357
(29.70)
No. of
TABLE - 8 : Comparison between various types of institutions 1983 to July 1988 (EPILEPSY)
Clinic
(N-l)
Cases
G.Hs
(N-7)
Cases
PHCs
(N —23)
Cases
PHU & GAD
(N-27)
Cases
Total
(N-58)
Cases
Total No. of cases
609
(17.28)
957
(27.15)
1,509
(42.82)
449
(12.74)
3,524
(100)
Regular cases
*
400
(21.06/
65.68)
' 458
(24.11/
47.85)
781
(41.12/
51.76)
.260
(13.69/
57.90)
1,899
(100/
53.88)
Irregular cases
200
(12.58)
490
(30.82)
717
(45.09)
183
(11.51)
1,590
(100)
Regular - controlled
334
(54.84)
399
(41.69)
223
(49.66)
1,630
(46.25)
Uncontrolled cases
66
(10.84)
59
(6.16)
674
(44.66)
107'
(7.09)
37
(8.24)
269
(7.63)
Drugs used - phenobarb only
337
(55.34)
907
(94.77)
1,455
(96.42)
420
(93.54)
3,119
(88.50)
Drugs used - phenobarb + DPH
147
(24.13)
34
(3.55)
35
(2.32)
24
(5.34)
237
(6.72)
Fit free - 1 yr.
131
(21.51)
201
(21.00)
316
(20.94)
101
(22.49)
749
(21.25)
Controlled within 6 months
183
(54.79)
268
(67)16)
431
(63.95)
130
(58.29)
1012
(62.08)
* % of regular cases within the district and % of regular within institutions.
the psychotics and 53 percent of the
epileptics have been utilizing the services
quite regularly and have reported
improvement and reduction or disap
pearance of initial symptoms.
The decentralised training strategy in
phases, adopted for the DMHP is a feasi
ble method for training large number of
primary health care personnel within a
resonable period of time and without ma
14
jor disruption in their routine work. The
training, in phases, allows the trainee doc
tors and health workers to bring back their
practical experiences, doubts and diffi
culties for discussion during a formal train
ing session. The continued ‘on-the-job
training’ carried out during the field visits
by the district team and/or NIMHANS
team, was found to be invaluable. The
frequent mobility of health personnel
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE Nos. 11 & 12 ■ APRIL-SEPT. 1988
within the district and out of the district
due to transfers, leaves, proceedings for
post-graduation, promotions etc., posed
a problem as the new staff had to quickly
be given the mental health training.
The recording and reporting system for
the DMHP were designed based on the
previous experiences of the investigators
as well as the patterns of certain other
national programmes. Though simple,
these are found to be complicated and dif
ficult to handle four separate case cards
for four separate diagnosis. The record
keeping by the health workers and their
supervisors was found to be not satisfac
tory. The monthly reporting form too re
quires several modifications. The quality
of the case records varied from institution
to institution and according to the
diagnosis. Epilepsy records tended to
have more information at most of the cen
tres. The personal details of the patient
along with diagnosis and drugs prescribed
were available in most records. All details
of clinical condition and follow-up details
were lacking in many centres.
During the field visits the district team,
‘on the job training’ was given by examin
ing difficult cases and discussing them with
the health personnel. Doubts about
management, filling-up of case'records
and monthly return forms etc., were also
classified. While all institutions had neuro
psychiatric cases registered, the numbers
varied widely from about 20 to more than
200. From the records, discussions with
the doctors and examining some of the
cases on treatment, the broad diagnostic
categorisation and lines of management
followed by the trained doctors in regard
to typical cases appeared to be adequate.
But most of the doctors had problem
cases of various types. In some, the pro
blems arose because adequate doses of
medications were not started eg., in
managing acute psychotics (manics) to
control their excitement, or in certain
epileptics who needed higher doses or
combinations of anti-epileptics to reach a
fit free status. In others, the difficulty was
in determining the types of fit especially
when cases were typical, eg., combination
of genuine epilepsy with hysterical attacks,
and convulsions other than grandmal. In
few cases, doctors had difficulty in suc
DISTRICT MENTAL HEALTH PROGRAMME AT BELLARY
cessfully managing side-effects of pheno
thiazines. This was complicated on rare
occasions by patients developing uncom
mon side-effects like tardive dyskinesia,
rabbit syndrome etc. Several doctors had
successfully managed status epilepsy.
In one centre, the medical officer mar
shalled support from the local communi
ty and started rehabilitation of two
mentally retarded at his own primary
health unit. In many institutions, the team
came across patients who had improved
considerably or recovered as a result of
the treatment.
One general difficulty expressed by all
the doctors was that, while their health
wokers know about one or more cases in
their respective catchment areas, they
were unable to successfully persuade
them to come to the PHCs. Of the
registered cases, about 30 - 40 percent
were reportedly irregular and health
workers were unable to carry out any
follow-up with these patients. The
dropouts were more with psychosis
patients. Lot of patients went to the PHCs
because they had seen other patients
improving. It was not possible for the
review team to interview many health
workers other than the headquarters
workers during these periods. From dis
cussions with doctors, it was apparent that
the identification, referral, follow-up role
given to the health worker was not very
effective in most PHCs. Many patients
mentioned that they were sent to the
PHC/PHU by the health worker of their
area. It would be necessary to, attend
monthly meetings of PHCs to see all the
health workes together to review the pro
gramme.
All institutions visited had designated
a certain day of the week for the mental
health clinic. In many institutions, boards
displayed the day and time of mental
health clinics. While patients were seen on
all days, the effort was to see old patients
coming for follow-up on a particular day
and time.
The review visits to the peripheral insti
tutions highlighted the need for such visits
by the District team/NIMHANS team on
a regular basis to monitor the programme.
These can contribute.to the development
of confidence and skills of doctors and act
as the much needed ‘continued on the job
training’. The visits will ensure better
quality recording which is essential for
satisfactory monitoring. The most striking
point was the steady increase in the
numbers of cases on treatment, the
quality of care, the availability of records
and a format for reporting of the work to
the district headquarters.
Future of the DMHP
The DMHP has completed three years
and is presently in its fourth year of imple
mentation. Till the launching of this pro
The range of drugs available at the
institutions depended on the numbers and
types of cases on treatment. Phenobar
bitone and chlorpromazine were available
at all the institutions. Antidepressants-and
depot phenothiazines were not available
at some of the institutions in the district.
gramme, the experience available in the
country as well as elsewhere, of inte
grating mental health with primary health
care, was only from a limited population
and health personnel involving either part
of or, a whole PHC. But the DMHP
involving a population of 1.5 million and
hundreds of health personnel has substan
tially increased the mental health profes
sionals’ understanding of the general
health care services and operational and
managerial problems of implementing a
new health programme.
The visit by mental health professionals
from other states to Bellary district, has
facilitated their starting similar program
mes in their respective states. Currently,
a programme similar to the Bellary DMHP
is being implemented at Nagpur District
in Maharashtra.
It has also been a unique example of
collaboration between a district level
administrative set up, the state depart
ment of health and family welfare and a
national institute to develop, implement
and evaluate a health service programme.
The district health personnel under the
PERSONS INVOLVED IN DMHP AT BELLARY
(Present & past)
DIRECTORATE OF HEALTH AND FAMILY
WELFARE, GOVERNMENT OF KARNATAKA
Present:
1.
Dr. J.L. Javare Gowda, Director of H & FW
Services.
2.
Dr. C. Prasanna Kumar, Jt. Director & State
level programme officer for Mental Health.
3.
Dr. C.R. Krishna Murthy, Divisional Jt. Direc
tor, Gulbagra
4 Dr. T. Nizamuddln, District Health & FW Of
ficer, Bellary.
5. Dr. Karur Badri Vishal, Programme Officer,
DMHP, Bellary.
Past
1.
Dr. A, Narayana Rao, Director of H & FW Ser
vices'(Retd). ,
2? Dr. K.B Makapur, Jt. Director (Formerly DHO,
Bellary).
3. Dr. V.G. Shetty, DHO, Chitradurga (Former
ly DHO, Bellary).
4.
Dr. N. Muralidhar. Asst. Surgeon, (Formerly
Programme officer, DMHP).
ZILLA PARISHAD, DISTRICT
ADMINISTRATION, BELLARY
Present
1.
Mr. Bhavi Bettappa, President, ZP.
2.
Mr. Nattakattappa, Vice President, ZP.
3.
Mr. B. Lakshminarayan Shetty", Chairman,
Health Committee, ZP.
4.
Mr. S. A. Patil, IAS, thief Secretary. ZP.
Past
1.
Mr. Sudhir Kumar. IAS, Deputy Secretary,
Ministry of Eco Affairs, Govt, ol India (Formerly
Dy. -Commissioner)
2.
Mr. C.S. Surajana. IAS, Formerly Chief
Secretary. ZP, Belleary.
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE Nos. 11 & 12 ■ APRIL-SEPT. 1988
NIMHANS
Present
1.
Dr. G.N. Narayana Reddy, Director,
2.
Dr. S.M. Channabasavanna, Dean & Prof, of
Psychiatry,
3.
Dr. R. Srinivasa Murthy, Prof. & Head, Deptt.
Of Psychiatry,
4. Dr. G.G. Prabhu, Prof. & Head. Deptt. of
Clinical Psychology,
5.
Dr. LA. Sheriff, Prof. & Head, Deptt. of
Psychiatric Social Work,
6.
Mrs. Reddamma Raju, Assoc. Prof. & Head,
Deptt. of Nursing,
" Dr. Mohan K. Isaac, Assoc. Prof, of Psychiatry
7.
(Co-ordinator, DMHP, Bellary),
8.
Dr. C.R. Chandrashekhar, Asst. Prof, of
Psychiatry.
9.
Dr. R. Parthasarathy, Asst. Prof, of PSW,
10.
Mrs. Ahalya Raghuram, Lecturer in Clinical
Psychology,
11.
Dr. T.G. Sriram. Lecturer in Psychiatry,
12.
Mr. Mohan Krishna, Tutor in Psychiatric
Nursing.
Past
1. Mr. Nagarajaiah, Tutor in Psychiatric Nursing
2.
Ms Nomitha Varma, Formerly Lecturer in
Clinical Psychology,
3.
Dr. Shekhar Seshadri, Lecturer In Psychiatry.
RESEARCH STAFF AT BELLARY
1. Mr. Arun Naik, ARO Social Work,
2. Ms. Smitha Sanju, ARO Clinical Psychology,
3.
Mr. Jayasimha. Statistical Assistant.
ADDRESS: Programme Officer, District Mental
Health Programme, DHO’s Office, Bellary,
KARNATAKA.
15
DISTRICT MENTAL HEALTH PROGRAMME AT BELLARY
reaching the health care institutions as well
as the time taken from the onset of the
illness till consultation at any of the
centres.
Conclusion
A patient under medication (Left) doing his routine office work in a government office, Bellary
□
supervision of the NIMHANS team of
investigators have been carrying out the
training, monitoring and field level evalua
tion of the programme. In addition, a
district mental health clinic is also being
run at the district headquarters. The data
generated so far gives certain indications
of the nature of utilization, extent of
coverage and the outcome of interven
tion. While this kind of data will continue
to be generated during the fourth year of
DMHP, it is proposed that various other
aspects of the programme also be studied.
Till July 1988, there are more than
1200 psychotics, 3525 epileptics, 750
neurotics and 380 mentally retarded who
are registered and on management at dif
ferent institutions in the district. It is pro
posed to assess the quality of care being
offered to these persons through the
DMHP by examining a random number
of psychotics/epileptics in detail. This
detailed assessment would be carried out
by consultants of NIMHANS, who are not
associated with DMHP.
Amongst the registered patients, only
about 40-50 percent come regularly for
follow-up as advised by the medical
officers/health workers. It is proposed to
carry out a comparison of those persons
who are regular to follow-up with those
who are irregular and to study factors in
fluencing regularity of follow-up. Similar
ly, there are noticeable differences in the
performance and quality of work of health
personnel. Comparing good perfomers
versus poor performers amongst these
personnel is likely to give insights about
16
The NMHP envisages operationalisa
tion of the programme at least in one
district of every state in the country within
reasonable period of time. Bellary District
Mental Health Programme is likely to
develop the necessary operational exper
tise for organising mental health care
through the existing PHC set up at a
district level and thus usher wider im
plementation of NMHP all over the
country.
Dr. MOHAN K ISAAC,
Assoc. Professor of Psychiatry,
NIMHANS. Bangalore 560 029
(Coordinator, District Mental Health Programme,
Bellary)
COMMUNITY MENTAL HEALTH NEWS
Issue Nos. 11 & 12, April-Sept. 1988
The Community Mental Health News is
published by the ICMR Centre for Advanced
Research on Community Mental Health, to keep
the professionals, planners, administrators and
the interested public informed about the
development of community mental health care
programmes.
Copies of Community Mental Health News
are mailed free on request by interested profes
sionals and institutions.
TOTAL CASES IDENTIFIED (YEAR-WISE)
overall performance of primary health
care personnel in health care program
mes. The already achieved care identifica
tion and registration rate (of about 4 per
1000) in the district is lower than what can
be expected (about 15 to 20 per 1000)
based on published psychiatric epidemio
logical data. It would mean that there are
still large numbers of persons with psycho
sis, mental retardation and epilepsy in the
district, who are not yet identified.
It is proposed to survey certain areas
of the district and identify and assess such
persons who have so far not made use of
the existing mental health facilities. It is
also proposed to study the ‘pathways’
which mentally ill patients take before
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE Nos. 11 & 12 ■ APRIL-SEPT. 1988
We are interested in exchanging a few copies
of this journal, on reciprocal basis, with other
medico-health publications. We would like to
obfaln information on projects/research findings/field work reports relating community men
tal health programmes in our country.
Letters, comments and communications
should be addressed to: The Editor, Com
munity Mental Health News. ICMR Centre for
Advanced Research on Community Mental
Health, NIMHANS, Bangalore - 560 029,
(India).
Editor
Dr. R. Srinivasa Murthy
Editorial Committee
Dr. Mohan K. Isaac • Dr. C.R. Chandrashekar.
• Dr. R. Parthasarathy • Dr. T.G. Sriram.
• Dr. K. Sekar • Mr. Mahendra Sharma.
• Mrs. Ahalya Raghuram • Mr. Chandra
Sekhar Rao • Mr. Mohan Krishna.
Asst. Editor
Mr. Soman Ponnempalath.
Printed at Precision Fototype Services. B’lore.
VAW
COMMUNITY
MENTAL HEALTH
32emVZm HE‘lrH
NEWS
V Matn, , 8(ock
Aoramangala
Dangalorc-560034 ___________
For Private Circulation only
ISSUE Nos. 11 & 12
APRIL-SEPT 1988
EDITORIAL
District Mental
Health Programme
uring the last ten years the develop
ment of models for mental health care
have gradually become more and more
sophisticated in terms of methodology. The
I initial studies related to small groups of 30
to 40 thousand population. These studies
illustrated the feasibility of integrating mental
health care with general health services with
adequate support and supervision from the
professionals. But critical examination of
these experiences by experts showed that
models with these ranges of population
would be too limited for wider application
and the inputs from mental health profes
sionals were excessive.
Against this background the starting of
District Mental Health Programme at Bellary
is a major development in the mental health
planning in our country. Currently, we not
only have plans for an average size district
of over 1.5 million population but also have
the details of the type service, level of care
and the mechanisms for monitoring the pro
gramme.
D
This issue of Community Mental Health
News brings together the evolution, strategy
of action and results of the first three years
of the Programme for wider circulation
among the mental health professionals and
planners.
- Dr. R. SRINIVASA MURTHY
(Editor)
In this issue
District Mental Health
Programme at Bellary
Top left: A sign board of the newly started psychiatric clinic at Hospet Gen. Hospital. Right: A
female health worker visits a patient’s home. Below: Dr. Venkatesh Murthy, Med. Officer of Karur
PHU, Slruguppa. interviewing a patient and her family members.
REACHING
THE
UNREACHED
ICMR Centre for Advanced Research on
Community Mental Health
NIMHANS, Bangalore.
DISTRICT MENTAL HEALTH PROGRAMME AT BELLARY
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE Nos. 11 & 12 ■ APRIL-SEPT. 1988
DISTRICT MENTAL HEALTH PROGRAMME AT BELLARY
periences, simple manuals of instructions
and short-term training programmes for
medical officers and multipurpose workers
of PHCs were developed (CMH News
Issue No. 1). Pilot training programmes
were carried out and evaluated at Primary
Health Centres at Malur and Anekal (Kolar
and Bangalore Districts, Karnataka State).
These pilot programmes helped the unit
to crystallize the educational objectives for
the mental health training of PHC person
nel and meaningfully revise and rewrite
the manuals of instructions in basic men
tal health care.
Dr. H.L. Thimme Gowda, Minister for H & FW, inaugurating DMHP at Bellary on 20 July 1985.
Others in the Picture are Mr. M. Ramappa, MLA, Bellary and Dr. V.G. Shetty, DHO Bellary.
Right: Dr. J.L. Javare Gowda, DHS, speaking on the occasion.
health care services, was thought of as
a feasible and appropriate approach. The
growing consensus amongst experts in the
field — national and international — is ,
‘decentralisation and integration of mental
health services with the general health ser
vices by training the existing general
health care personnel to provide basic
mental health care’.
An expert committee of the WHO on
‘Organisation of Mental Health Service in
Developing Countries’ which met in 1974
(WHO 1975) urged the member states to
recognise mental disorders as a problem
of high priority for the individual, for the
community and for national development
and made several important recommen
dations. The committee recommended
that: “Countries should, in the first
instance carry out one or more pilot
programmes to test the practicability of
including basic mental health care in
an already established programme of
health care in a defined rural or urban
population”. It further recommended that
“training programmes, including a simple
manual for the training of health workers
should be devised and evaluated”.
During 1975-76, major community.
mental health care experiments were
launched at Bangalore and Chandigarh
to test the feasibility of shifting the care of
the mentally ill from the ‘hospital’ to the
‘community’ and from the ‘mental health
specialist’ to the ‘primary care physician’.
Community Mental Health Unit
at NIMHANS
The Department of Psychiatry at
National Institute of Mental Health and
Neuro Sciences (NIMHANS) focused its
attention on extending mental health ser
vices into the community as early as
1975. A specially designated and staffed
‘Community Psychiatry Unit’ was estab
lished. The main aim of the Unit was to
extend mental health services by inte
grating it with the existing system of
primary health care. For this, the
primary health care staff had to be train
ed in basic mental health care. More
specifically, the task of the unit was to
develop, carry out and evaluate suitable
short-term training programmes in basic
mental health care for different categories
of health care personnel, so that after
training, these personnel could provide
mental health care in their respective
areas of work.
A rural community mental health and
training centre was established at
Sakalawara (Anekal Taluk) near
Bangalore in 1976. Initially a service pro
gramme was developed and feasibility
exercises were carried out in the villages
around Sakalawara. Based on these ex
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE Nos. 11 & 12 ■ APRIL-SEPT. 1988
Since 1982, every month, regular
training programmes for medical officers
and health workers, working in various
PHCs and/or PHUs of Gulbarga and
Mysore divisions (Karnataka state) and
deputed by the Department of health and
family welfare are held at the rural men
tal health centre at Sakalawara. These are
held in small batches of 5-15 persons and
are residential. The health workers’ train
ing is for a period of 6 days while the
medical officers’ training is for 12 working
days. The training is routinely evaluated
by pre and post-training assessments. So
far, more than 400 medical officers and
600 health workers have participated in
this training.
The regular monthly training program
mes and their evaluation facilitated fre
quent reviews and whenever necessary,
revisions of the ‘training package’, name
ly, education objectives, methodology of
training, time allotment for various ac
tivities, manuals of instructions, tools of
pre and post-training assessments and
simple records for mental health care at
PHCs. After several revisions, the rewrit
ten ‘Manual of Mental Health for Multi
purpose Workers’ and ‘Manual of Mental
Health for Medical Officers’ are currently
available in printed form for wider use
(CMHNews, Issue No. 1). Similarly, the
instruments for evaluation of the training
also have been standardized.
Evaluation of work carried out
by trained PHC personnel
While it is acceptable that the mental
health training can be evaluated in a
limited way by pre and post-training
DISTRICT MENTAL HEALTH PROGRAMME AT BELLARY
Need for Developing a District Model for delivery
of Mental Health Care
1. Earlier efforts to integrate mental health with PHC involved only popula
tion of 40,000 to 60,000 and personnel of one PHC
2. Field level evaluation of trained PHC personnel highlighted the need for
developing a district model.
3. NMHP envisages implementation of the programme atleast in one district
of every state in the country, within a specific period of time.
4. All health care and welfare programmes are implemented and monitored
at a district level.
assessments which would give an indica
tion of the knowledge gained by' the
trainees, the ultimate criteria for evalua
tion will have to be the ability of the
primary health care team to recognize and
manage the mentally ill in their PHCs thus
bring down the overall neuropsychiatric
morbidity. In a few ‘micro level’ pilot
research projects carried out in either in
part of or a whole PHC involving a limited
number of personnel, it had already been
shown that mental health care can be pro.vided at the PHC level by trained PHC
personnel.
Following the training, when a follow
up visit was made the doctors and health
workers in the centres visited had under
taken mental health care activities to vary
ing extent. Some of the centres and
personnel had done excellent work while
others had done very limited amount of
work.
There appeared to be problems
because of the small number of health
workers trained from each PHC. Popula
tion coverage wise, they accounted only
for a small percentage of the total popula
tion of the PHC. In some PHCs the train
ed doctors talked to all the health workers
to identify, refer and follow-up cases and
impart mental health education. Many of
the cases presently being managed by the
doctors, were identified by themselves
from their daily clinics.
None of the health care personnel
interviewed felt that their work load had
increased because of this programme,
while many feared that as the number of
cases identified and managed increases,
the work load too might increase. It was
noticed that the work of the health per
sonnel could have been better if several
of their following administrative and
supervisory needs were fulfilled: (i) pro
vision of minimum number of essential
psychotropic and antiepileptic drugs on a
regualr basis, (ii) provision of simple recor
ding and reporting method, (iii) involve
ment of all the health care personnel, of
the PHC/district belonging to various
categories, (iv) regular supervision and
monitoring of the programme at all levels,
namely, PHC, district, division etc.,
(v) availability of specialist referral
facilities, (vi) provision of material for
public mental health education, (vii) faci
lities for continued learning of trained per
sonnel (refresher courses), and (viii) to
improve public understanding and accep
tance of PHC as places of treating men
tally ill and epileptics. The field.level
evaluation of trained PHC personnel
highlighted the need for planning men
tal health care at a district level.
Genesis of the Bellary District
Mental Health Programme
By 1983-84 in addition to the ongoing
work of the community mental health unit
at NIMHANS, few other projects had
practically demonstrated that primary
health care system can provide mental
health care at the community level.
Notable amongst these are the “Strategies
for Extending Mental Health Care” a
WHO multicentre collaborative study with
a collaborating centre at Chandigarh and
the ICMR-DST (Indian Council of Medical
Research - Dept, of Science and Tech
nology) ‘Severe Mental Morbidity Project’
carried out at 4 centres in the country,
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE Nos. 11 & 12 ■ APRIL-SEPT. 1988
namely, Bangalore, Calcutta, Baroda and
Patiala. Few other experiments from cen
tres like Vellore, Lucknow, Jaipur and
Hyderabad also added to the growing
evidence for community based mental
health care by general health staff. By
then, the ‘National Mental Health Pro
gramme’ (NMHP — 1982) for India was
also approved by the Central Council of
Health and family welfare for countrywide
implementation (CMH News, Issue
No. 1).
A result of these developments was the
increasing realization that further work
was needed to consolidate the gains and
achievements of the previous few years.
The existing know-how of integrating
mental health with primary health care .
had to be operationalized and applied to ()
larger areas and target populations. The
already proven methods of training, the
PHC personnel, manuals, curricula, train
ing aids of different types and methods of
evaluation had to be applied in a wider
setting. The district level psychiatric
facilities of referral and consultation by the
PHC Teams had to be developed. Above
all, the National Mental Health Pro
gramme, already approved for implemen
tation, envisaged the operationalization of
the programme ‘in at least one district in
every State and Union Territory, and in
at least */2 of all the districts in some States
within five years’. It is proposed by the
NMHP that specialized psychiatric services
be made available at the district level. It
would be the responsibility of specialist ,
health personnel at the district level to v
provide training and supervision to the
workers at the primary health centre level.
So, it was in the light of all these specific
issues and as the next logical step in the
implementation of the National Mental
Health Programme that the ‘district men
tal health programme’ was developed by
the community mental health unit of
NIMHANS.
During the field level evaluation visits
in 1983 to several peripheral health care
institutions by a team of the community
mental health unit of NIMHANS, head
ed by Director and Senior Officers of
Department of Health and Family
Welfare, Karnataka, many health workers
reported that, while they had identified
DISTRICT MENTAL HEALTH PROGRAMME AT BELLARY
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE Nos. 11 & 12 ■ APRIL-SEPT. 1988
**'’9*'ore-560034 -
5
DISTRICT MENTAL HEALTH PROGRAMME AT BELLARY
the district are not trained within a c) Health supervisors (health inspec
tors and lady health visitors): Total
reasonable period of time. Deputation of
training days - 4, in 2 sessions of 2 +
large numbers of these personnel to
2 days with an interval period between
Bangalore can cause disruption of their
sessions of not less than 3 months. The
routine ongoing work. The 2-week train
training can be either at district head
ing module has no planned facility for
1)
To develop and implement a decen
quarters or one or two taluk head
refresher inputs to the trainees to clarify
tralized training programme in men
quarters. In addition, the supervisors
their doubts which arise after their using
tai health for all categories of health
would
be expected to attend the train
the knowledge gained through the initial
personnel, appropriate to their levels
ing for multipurpose workers.
training.
Continuous
‘
on-the-job
’
inputs
of functioning with least disruption to
the ongoing general health care ac though of short duration can be very d) Community health volunteers:
beneficial to trained personnel. Therefore,
tivities.
Two days of training preferably during
a ‘decentralized training’ strategy was
their initial 3 months training period.
2)
To provide a minimum range ofdeveloped.
The CHVs should be called for a 2 day
essential drugs for treatment of
The training was to be carried out lor
training at the PHC level to be carried
severely mentally ill persons at all
out by trained medical officers, and
peripheral health care institutions. different categories of personnel separate
ly and wherever the numbers were high,
health supervisors.
3)
To develop a system of simple recorin batches of manageable numbers. The
e) Block health educators: The
ding and reporting of care by health broad approach of training was to impart
block health educators of each PHC
care personnel.
to the trainees not only new knowledge
(generally, one in each PHC) could
4)
To monitor the effect of the serviceabout mental illnesses but also the ability
join the programme of health super
programme in terms of treatment to identify and manage all the mentally ill
visors i.e., 4 days in 2 sessions of 2 +
utilization and outcome with treat in their community. The educational ob
2 days.
jectives of the training were to teach the
ment.
personnel to carry out various tasks
In addition to the above mentioned for
5)
To develop mechanisms of comalready identified. The training was to be
munity participation in the mental decentralized and carried out at the district mal training for larger groups of person
health care programme through headquarters and taluk headquarters nel, informal ‘on the job’ training inputs
planned activities.
towns. It was to be divided into 3 different will continue for personnel of PHC by a
district mental health team visiting PHCs
6)
To study the cost-effectiveness of thesessions of 1 to 3, each held at intervals
of few months. This would enable the regularly once in two or three months,
programme.
trainees to bring back difficulties in im preferably on a fixed day of the week
Towards achieving these objectives the plementation of the programme, so that which could be designated as the weekly
DMHP has several components, namely, they could be discussed and clarified. ‘Mental Health clinic’ day when most of
(i) Training of personnel, (ii) Provision of Manuals of instructions (for doctors and the old and new patients of the PHU/
Drugs, (iii) Simple recording system,
health workers) already developed for this PHC could visit the centre for their follow
(iv) District level programme officer & his purpose, would be made use of for the up consultation.
team (v) District Mental Health Clinic, training.
While training in mental health for .
(vi) Review cum training as part of visits
medical officers, multipurpose workers '
to the periphery, (vii) Weekly mental health
Thus, the training for PHC personnel and other functionaries is important for
clinics in the periphery, (viii) Monthly
at a district level was as follows:
identification and management of the
reporting, monitoring and feedback,
needy population, the programme would
(ix) Community participation, and a) Medical officers: Total trianing days
- 9, in 3 sessions of 3 + 3 + 3 days be successful only if it is regularly super
(x) Field Training for MH professionals.
with an interval between sessions of not vised and monitored at the district and
less than 3 months, and in batches of sub-divisional levels by the DHO and
Training of Health Personnel
ADHOs. Therefore, even the supervisory
not more than 25.
officers at the district level were ap
Services for the mentally ill can become
b) Multipurpose workers: Total propriately oriented and sensitized to the
an integral part of the general health ser
training days 4 - in 3 sessions of 1 +
mental health needs of the population.
vices, only if all categories of personnel
2+1 day with an interval between
are trained to carry out routinely, the
sessions of not less than 3 months.
mental health care tasks assigned to them.
Training for Medical Officers
One batch could consist of all the
The total number of medical officers
It would not be possible to effectively
health workers in a PHC and venue of
practising the allopathic system, working
and meaningfully launch a mental health
the training may preferably be the PHC
in
various
health institutions of the district
programme, if most-of the personnel in
itself.
and coming under the administrative con-
health services to the severely mentally ill
persons in the district through the existing
health care personnel and institutions.
The more specific objectives of the Pro
gramme are:-
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE Nos. 11 & 12
APRIL-SEPT. 1988
DISTRICT MENTAL HEALTH PROGRAMME AT BELLARY
trol of district health officer in Bellary in
1984-85 is around 75. The doctors were
trained in 3 batches for 3 consecutive days
at Bellary. The training was carried out by
a faculty of two psychiatrists from the com
munity mental health unit, NIMHANS.
The primary objective of the training
was to sufficiently sensitize the medical of
ficers to mental health problems in the
community and demystify the manage
ment of common psychiatric problems.
They were told about the extent of men
tal health problems in the community,
need and strategy of integrating mental
health with primary health care and their
role in its implementation. Of the three
training days available, the first day’s mork ning was spent for these topics. In addi'tion, a pre-training assessment of their
present mental health knowledge was also
carried out during the 1st day morning.
They were shown short video recorded
interviews of the patients suffering from
different psychiatric conditions and were
asked the diagnosis, management and
prognosis.
During the afternoon session of the first
day, the basis of normal human behaviour
was discussed, reviewing the structure
and functions of the brain and the factors
contributing to the understanding of
behaviour — biological, psychological and
sociocultural. In the light of this understan
ding of normal human behaviour, the
various abnormalities that can take place
to produce mental illnesses of different
h types, were then discussed. The various
" features, types, causes and treatment of
mental disorders in general was also
covered.
The whole of second day was utilised
for teaching ‘psychosis’. After discussing
their (the trainees) general reactions to a
severely mentally ill patient, the approach
Top: Dr. Sekar Seshadri, Lecturer in
Psychiatry, NIMHANS, reviewing the diag
noses of a patient at Mariammanahally PHC.
Dr. Krishna Murthy, MOH, is also seen.
Middle: Dr. Muralidhar, Former Programme
Officer, DMHP, examining a patient at
District Clinic at Bellary.
Below: Three Lady Medical Officers taking
the history of a patient during a training ses
sion at Bellary.
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE Nos. 11 & 12 ■ APRIL-SEPT. 1988
DISTRICT MENTAL HEALTH PROGRAMME AT BELLARY
to a psychotic patient — history taking
and examination — was discussed, fol
lowed by clinical features, types and prac
tical management of psychosis. The
emphasis was mainly on giving the doc
tors to diagnose and satisfactorily manage
psychotic conditions, and hence the prac
tical work of interviewing and diagnosing
as many actual cases as possible was given
the maximum priority in the allotment of
training of the second day. Carefully
prepared video recordings of interviews
with psychosis patients highlighting the
symptomatology, and clinical presenta
tions were also demonstrated and
discussed.
On third day, the morning session was
spent for discussion on epilepsy. The doc
tors’ basic pre-training knowledge regar
ding epilepsy seemed to be much better
than their knowledge of mental illness and
hence there were large number of ques
tions, doubts and clarifications. Although
neurosis, mental retardation and other
childhood problems are to be covered in
detail during the second phase of train
ing, are also briefly touched upon. The
afternoon is mainly made use of for
discussion on the problems which are like
ly to come up in the implementation of
the mental health care programme all
over the district. There is no post-training
assessment. The doctors were assured
about the availability of drugs at the PHCs
and PHUs.
Following the initial training, all the
medical officers were to identify and
manage cases from their clinics as well as
cases referred by the health workers from
the community. They were also required
to maintain simple records, follow-up the
cases regularly and refer cases which they
could not manage to the District head
quarters. Essential drugs were made avail
able at all peripheral institutions. The
progress of the mental health care pro
gramme was reviewed every month dur
ing the monthly conference of medical
officers.
The second phase of the training was
carried out after a few months. This
3-days training begin with an assessment
of the doctors’ knowledge of mental
health care. The assessment was carried
8
out to ascertain how much of mental
health care knowledge the doctors had
retained, after the initial phase of training
and accordingly develop the curriculum
and methodology for the second phase
of training. The doctors had difficulty in
differentiating schizophrenia, reactive
psychosis and depression. While they
knew the common drugs and their
dosage, they were unsure of dosages and
duration of treatment for specific con
ditions.
To facilitate development of diagnostic
and management skills, most of the time
during the 3 days was used for practical
demonstration of cases and discussion of
cases worked up by each of the trainees.
Emphasis is also laid on nonpharmacological management of non-psychotic
psychiatric disorders.
Provision of Drugs
Earlier efforts at integrating mental
health with primary health care had
shown that availability of five basic
psychotropic drugs (Tab. Chlorpromazine
50 mg./lOO mg., Tab. Imipramine
25 mg., Tab. Trihexyphenidyl 2 mg. Inj.
Fluphenazine and Tab. and Tab. Pheno
barbitone 60 mg.) at the primary health
centre/unit was very essential for the suc
cessful implementation of the programme
following the training of the health care
personnel. All these drugs are routinely
not available in the PHCs and these drugs
are generally not included in the supplies
to the periphery from the state level
general medical stores. Therefore specific
efforts were made to generate the
necessary funds to supply minimum
amounts of essential drugs during the first
one or two years of the programme to
every peripheral health care institution, in
Bellary district.
This crucial assistance for the starting
of the district programme — initially
Rs. 20,000 and later Rs. 50,000 annually
came from the district administration from
the district development funds, and was
sanctioned in 1984-85 by the then
Deputy Commissioner of Bellary district
Shri Sudhir Kumar. The availability of
these funds helped in the launching of the
programme all over the district. Subse-
COMMUNITY MENTAL. HEALTId NEWS'* ISSUE Nos. 11 & 12 ■ APRIL-SEPT. 1988
Community
Awareness
and
Participation
Activities
or any effective community oriented
programme we need to look into the 4
Ps: Political or Planners’ commitment, Pro
fessional commitment, Progress in the
mental health know-how, and Participation
of the community (Srinivasa Murthy, 1985).
Community participation, according to
N1PCCD Manual (1984) is a coglomeration
of activities which enable the community to:
(a) be aware of its needs and problems,
(b) enrich the knowledge about services an''
facilities in operation, (c) get convictiol
about the efficacy and Usefulness of those
services, (d) develop an understanding
about its participation and contribution, and
(e) involve consciously and actively in the
implementation of new strategies for
practice.
F
Considering its value and importance, all
efforts have been taken from the very incep
tion of Bellary District Mental Health Pro
gramme to ensure community awareness
and strengthen its participation in a wide
range of activities related to mental health
care.
Mental Health Camps: The mental health
camps organised at Siruguppa, Hadagally,
Harappanahally and Bellary in the year
1983 had sown the seeds of public
awareness about mental health problem} '
and services. Large numbers of mentally iii,ranging from 135 to 300 were examined
and teatment initiated. The overall effect of
these camps was the increased awareness
of the public about mental health problems
in their community, and the facilities for I
treatment available near their homes. It also
sensitized the health officials regarding the *
need for organising mental health services
beyond the District Headquarters setting.
District Mental Health Committee: A
District Mental Health Committee was
formed as part of the District Health and
Family Welfare Committee. This committee
eaded by the Deputy Commissioner
having the representatives from different
departments like Education, Social Welfare
and Development enhanced the process of
DISTRICT MENTAL HEALTH PROGRAMME AT BELLARY
communication and interaction between
health and other departments which in turn
represents the intersectoral cooperation at
higher levels of administration.
Orientation to Media Personnel: It is
important that personnel involved with mass
media activities — Newspapers, magazines,
A.I.R., News agencies, State and Central
wings of Publicity are oriented towards the
facts of mental health problems as well as
newly introduced services in the district.
Accordingly, one day programme was
organised for the representatives of the mass
media personnel, they were adequately
helped to incorporate the mental health
matters into their day-to-day media ac
tivities. As a result of such efforts, the mass
media personnel gained scientific awareness
about mental health problems and transmit
Contact with Voluntary Agencies: In order
to enlist the. support from the Voluntary
agencies for mental health programmes,
professionals’ participation in the meetings
of Rotary Club, Lions Club, Croftons
(Ladies) Club, Youth Clubs, Mahila Mandais and other allied agencies was proved
to be fruitful. Initially, these collaborative
activities with voluntary agencies would
seem to be challenging, but in due course
of time with the continuous and consistent
efforts of the professionals, they became
rewarding and enriching experience.
Booklets: Specific booklets both in Kannada
(6,000 copies) and in English (1,000 copies)
on District Mental Health Programme were
printed for the communication to the Youth
Clubs, voluntary agency members, staff of
Welfare institutions, teachers, Mandal and
Zilla Parishad members, MLAs, and MPs
and others interested in the programme.
This method helped them to understand the
details of the programme and the scope of
their participation.
Films: The District Health Education Wing
continued to screen NIMHANS’ films on
mental health in the villages along with other
films on family planning, health activities
etc. It has been observed that the movies
on ‘Child and its mind’ and ‘Towards Light'
became popular among the rural folks in the
district. The villagers started realising the
value of modern treatment for mental
ailments and their increased convictions led
to increased utilisation of the services.
Orientation to Zilla Parishad Members:
Initial efforts were taken to discuss with the
Chief Secretary and the Deputy Commis
sioner and later with the President of Bellary
Zilla Parishad regarding the issues related to
mental health services in the district. Their
Cinema Slides: Cinema slides were pre
pared with the help of local agencies like
Lions Club, Rotary Clubs and Union Bank
of India. These were shown in the theatres
to create awareness about the features of
mental illnesses, mental retardation and
Epilepsy and the available services in the
Government Hospitals, PHCs and PHUs.
Dr R Parthasarathy, Asst. Prof, of PSW, NIMHANS, demonstrating symptoms of a patient to
a group of HWs at Hollalu.
ted the same to the public through their
respective media.
Interaction with Social Welfare Person
nel: Social welfare personnel like super
intendents, teachers, case workers,
supervisors, wardens and others working in
the Remand Home, Junior/Senior Certified
schools, and other institutions were met and
group discussions were held. During such
sessions, the focus was made on issues
related to mental health risks of delinquents,
orphans, deserted individuals, destitute
women and physically handicapped. Later,
the welfare personnel were met periodically
to strengthen the impact of orientation pro
grammes conducted initially.
positive responses and support, in fact gave
a fillip to the programme. Subsequently, a
brief orientation programme was arranged
to other members of the Zilla Parishad. The
details pertaining to the beneficiaries, the
nature of help, the importance of public
involvement and related issues were briefed
to the august gathering of the MLAs, MPs.
Zilla Parishad members, VIPs of the Bellary
District, Mass Media personnel and the
public in the monthly meeting of the Zilla
Parishad. As a result of such interactions,
the Zilla Parishad members felt that these
orientation programmes need to be held at
Mandal Panchayat level so that local
involvement could be intensified.
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE Nos. 11 & 12 ■ APRIL-SEPT. 1988
Educating the Educators: Considering the
fact that not less than 40 percent of the
beneficiaries of the mental health services
offered by the PHC system being children
and adolescents, the discussion was later
focussed on the modalities of the involve
ment of th eight Assistant Educational
Officers and of the District. Documents like
Mental Health perspectives of the new
system, Mental Health problems of stu
dents, play activities: pathways to an inte
grated personality. Learning Difficulties:
Causes Remedies and How to get along
with people were sent to them. They served
as background material for discussions and
interactions resulting in the active collabora
tion with Schools and teachers in Bellary
District.
Satisfied Consumers: Effors have been
made to offer systematic education to the
family members of the patients. The patients
who dropped out were followed-up. Home
visits were made, reminder letters were writ
ten emphasising the regular follow-up. This
was given much emphasis and importance
with the understanding that the satisfied
beneficiary would be the best agent of
education and community participation.
Dr. R. PARTHASARATHY
Asst. Professior of Psychiatric Social Work,
NIMHANS. Bangalore
community health CEO,
326. V Main, 1 Block
K»r»manga|a
8angalor»-560034
Ibrtla
DISTRICT MENTAL HEALTH PROGRAMME AT BELLARY
quently during the first annual review,
when the programme was reviewed by
the Director of Health Services along with
the Deputy Commissioner of Bellary and
Director of NIMHANS, it was decided that
for the routine running of the programme,
part of the drugs would be supplied from
the General Medical Stores and the re
maining could be purchased locally by the
District Health Officer from the discre.tionary funds available to him for pur
chase of drugs. Currently, all the essential
psychotropic drugs are made available in
every peripheral health care institution of
Bellary district. The amount of drugs
available in each institution is related to
the number of cases being managed and
the indenting and regular supply of drugs
all over the district is monitored by the
programme officer.
Recording and Reporting System
A simple recording and reporting
system is designed to be maintained at
various levels.
Essential Drugs for
Primary Health Institutions
Tab. Chlorpromazine
50 mg.
Tab. Imipramine
25 mg.
Tab. Phenobarbitone
Tab, Trichexyphenidyl
60 mg.
Inj. Fluphenazine
25 mg.
2 mg.
Records of Research Team
The research team will keep a record
of all the cases registered in every
peripheral institution of the district, at the
district head-quarters. This will be essen
tially an extract of the case cards main
tained by the medical officers in various
institutions. These will be obtained during
regular visits to the periphery by the
research team after scrutiny and review
with the medical officer and his staff at
each of the institution. The research team
will also keep a note of the overall quality
of mental health care delivered in each of
the institutions with special mention of any
lacunae observed.
soon as the health worker identifies a pa
tient with psychiatric illness, he issues a
card to the patient or to the family
members which has to be presented to the
doctor in the hospital.
Record book: A record book is main
tained by the health workers. This record
consists of minimum details of the patients
and their symptoms on one side and col
umns to record the follow-up details on
the other side of the sheet. This record is
checked by the supervisory staff at regular
intervals regarding completion and ap
propriateness of the information.
Doctor’s records
Four different proformas are designed
for the doctors to collect information
about patients with psychoses, neuroses,
mental retardation and epilepsy. The
follow-up details are recorded in the
cards.
A separate monthly report form was to
be filled up by the doctor in which he gives
minimum details of the new cases iden
tified in that month, the drug position and
the number of drop-outs etc.
10
The office of DMHP was also opened
at the District TB centre, Bellary. In addi
tion, a health assistant (MPW) was also
deputed to assist the work of the pro
gramme officer.
Programme Officer and the District
Team
One of the assistant surgeons of the
district (Medical Officer of PHC.Ittigi) got
interested in psychiatry after attending the
initial pilot decentralised training in mental
health held in Bellary. He pursued this
interest to seek admission for a two year
post-graduate diploma in psychiatry at
NIMHANS and later successfully com
pleted the course (1984-86) and returned
to Bellary. He assisted the DMHP as a
trained psychiatrist at the district head
quarters and later took over as pro
gramme officer, when the services of the
first programme officer was withdrawn.
The various national health care pro
grammes like Family Welfare Programme,
National Malaria Eradication Programme,
(NMEP) Tuberculosis Control Progfamme, Leprosy Control Programme
etc., are monitored and supported at the
district headquarters level by programme
officers who work under the DHO. These
personnel are often medical officers who
have several years of service and admini
strative experience or those who have
specialised in this area. During the initial
planning of the DMHP, it was agreed by
the Directorate of Health and Family
Welfare that a programme officer for the
DMHP would be appointed from ‘leave
cum deputation reserve’ pool. Hence one
of the assistant surgeons with many years
The programme officer is assisted by
district level research team consisting of
3 assistant research officers — one each in
psychology, Social Work and statistics.
This team is appointed by NIMHANS and
funded by NIMHANS research grants. Al
though DMHP was formally inaugurated
in 1985, the first staff joined in September
1986, and full team of 3 persons was
available only from October 1988. The
team assists the programme officer in run
ning the district clinic, monitoring the pro
gramme by regular field visits, routine
data collection from the periphery and its
analysis. The psychologists, in addition,
certifies the mentally retarded individuals
and assist in their management and the
Health worker’s records
Patient identification cards: As
of experience in various capacities in the
district and with interest in mental health
was appointed as the programme officer.
He was deputed to NIMHANS for a
6-week training to gain proficiency in
clinical psychiatry and thus be able to
monitor and supervise the other PHC
doctors and health workers. During this
period, he worked like a resident both in
outpatient and inpatient settings and par
ticipated in all the teaching programmes
at NIMHANS. Following the successful
completion of the training he returned to
Bellary to run a regular mental health
clinic at the district health and family
welfare office campus (District TB Cen
tre) in addition to organising the DMHP.
Records of DHO and DHS
Monthly statistics of all types of case
identification, case holding and case cure,
drug consumption, and list of mentally
disabled people who are certified for
dispensation of social benefits etc. is main
tained properly at the DHO and DHS
level.
,
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE Nos. 11 & 12 ■ APRIL-SEPT. 1988
!<D
€>
DISTRICT MENTAL HEALTH PROGRAMME AT BELLARY
to facilitate the team to tour the periphery
on the other days. This clinic caters largely
to people from Bellary and villages nearby
including, people from adjoining Andhra
Padesh. When patients belonging to other
PHCs register here, they are assessed and
referred to the trained medical officer
closest to their villages. The simple records
for psychosis, epilepsy, mental retardation
and neurosis are maintained for all
registered patients.
The efforts are going on to develop the
district mental health clinic as a model for
the peripheral institutions. It partly fulfills
the need for a referral centre at the district
headquarters for the peripheral doctors.
Field Visits by the District Team
Mr. Bhavi Bettappa, President ZP, Bellary speaking during the Second Annual Review Meeting
of DMHP at Bellary. Others in the picture are Dr. G.N.N. Reddy, Dr. Prasanna Kumar and
Mr. Nattakarlappa. Bottom: Annual Review Meeting in progress.
social worker initiates community par
ticipation activities in the district.
Reporting, Monitoring and
Feedback
Medical officers of all the peripheral in
stitutions are expected to send the mon
thly reporting forms giving the details
about the number of cases on hand, cases
newly identified during the month, and
cases attending follow-up during the
month. The monthly reporting form gives
various details of all the new cases iden
tified during the month (name, age, sex
etc.) and also details about the drugs posi
tion. The DMHP is reviewed along with
all other progammes during the monthly
meeting at the PHCs and also during the
monthly meeting of medical officers held
at the district headquarters by DHO. The
medical officers are given a feed back on
their work based on their monthly repor
ting forms. Monitoring and supervision
are also carried out by the programme of
ficer and his team by regular field visits to
the peripheral institutions.
District Mental Health Clinic
at Bellary
The programme officer and his team
run an outpatient mental health clinic at
Bellary. During the initial period (first one
and half year) this was a daily clinic, but
later it was reduced to three days a week
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE Nos. 11 & 12 ■ APRIL-SEPT. 1988
While the district clinic is an important
constitutent of the DMHP,-the success of
the district programme will be determined
by the work of peripheral institutions and
personnel working there. In addition to
monthly reporting of work by each centre
and the review at the monthly medical
officers meeting at the district level the
crucial factor which enhances the quality
of work at peripheral health care institu
tions is the regular field visits by the district
team, on many occasions, also accom
panied by persons from NIMHANS.
These visits facilitate cross checking the
diagnosis and management of a certain
number of cases on treatment at the
PHCs and PHUs, understanding the pro
blems which doctors and health workers
face in managing cases, maintaining
records etc., and assisting the health per
sonnel to promote comunity participation.
The lack of availability of an independent
vehicle for the DMHP during the initial
two years hampered to some extent,
achieving of the targets of field visits set
initially.
Community Participation in
DMHP
From the very inception of the DMHP,
it was recognised that community par-,
ticipation should be developed to form the
backbone of the programme. Various ac
tivities have been undertaken towards
achieving this during the past three years
and a summary report is given elsewhere
in this issue. (See p. 8 & 9)
DISTRICT MENTAL HEALTH PROGRAMME AT BELLARY
Training for Mental Health
Personnel
NIMHANS has a 4-week ‘Training of
Trainers of PHC personnel in Mental
Health Care' programme for mental
health professionals desirous of initiating
community based programmes. These
programmes are conducted a few times
a year and many mental health profes
sionals from different parts of the country
as well as other developing countries
attend the programmes. Field visits to
Bellary and some of the health institutions
in the district lasting 3-4 days, and discus
sions with various persons connected with
the programme like PHC personnel, the
DC, DHO and programme officer have
now become an integral component of
the ‘Training of Trainers' programme.
This visit has been rated as one of the
‘most useful’ activities of the programme
by many participants. Many such visits
were carried out several times during the
last 3 years. The participants of these pro
grammes include senior professionals like
superintendents.of mental hospitals, pro
fessors and assistant professors of
psychiatry. During the past three years,
participants have come from almost all the
states and union territories of the country
as well as from other developing countries
in the region like Bangladesh. These visits
have been found to be very useful by the
participants as they acquire a first hand
experiential understanding of the DMHP
as the field level realities and constraints.
TABLE - 1 : Talukwise total case
detection per 10,000 population (Bellary District)
Rate per 10,000 population
Cases detected
Taluk
Population
Bellary
3,85,714
1985-86
1986-87
1987-88
1985-845
1986-87
737
1,545
2,257
19.10
40.05
1,26,658
154
277
429
12.15
21.86
33.87
Siruguppa
1,48,929
225
357
499
15.10
23.97
33.50
22.26
173
220
280
17.50
1,57,627
333
494
716
21.12
31.33
45.42
Kudligi
1,65,679
331
438
601
19.97
26.43
36.27
Hospet
2.29,290
272
460
613
11.86
20.06
Hadahalli
90,600
262
325
457
28.91
35.87
50.44
4.116
5,852
17.72
29.33
41.70
2,487
14,03,311
26.73
TABLE - 2 : Talukwise detection of cases from 1983 to July 1988
Taluk
Doctor
in position
Epilepsy
Psychosis
M.R.
Neurosis
Total
%
Bellary
13
886
664
201
506
2,257
38.56
4
Sandur
322
48
17
42
429
Siruguppa
9
301
119
15
64
499
8.52
Hospet
12
463
100
26
24
613
10.47
7.33
H.B. Halil
6
229
34
12
05
280
Kudligi
11
496
71
21
17
605
10.33
Harapanahalli
12
547
85
63
21
716
12-23
Hadahalli
10
280
81
28
64
453
Total
77
3,524
1,202
383
743
5,852
4.78
7..T4
ISO!
i
TABLE - 3 : Mode of referral of cases
Psychosis
%
M.R.
%
Results and discussion
MPW & other health staff
454
(12.88)
145
(12.06)
96
(25.06)
Table 1 to 8 and the bar diagrams
show certain aspects of the Bellary District
Mental Health Programme particularly the
utilisation pattern and outcome of treat
ment in an illustrative manner.
Doctors (Govt., G.P., Dist. Hosp.)
306
(8.68)
267
(22.211
13
(3.39)
Other patients
240
(6.81)
124
(10.32)
36
(9.391
12
28.33
98,814
Harapanahalli
H.B. Halil
Epilepsy
%
The number of all categories of patients
being identified managed has been cOn-
58.51
Sandur
Model of referral
The data presented in these Tables
refer to the period from the beginning of
the programme till 31st July 1988. It
specifically refers to 5852 cases identified
and registered at the district clinic as well
as all the peripheral health care institutions
of the district, and reviewed by the district
team.
1987-88
•&.4T)
225
i(9.95)
Identified in the clinic
178
(5.05)
58
(4.82)
10
(2.61)
Self (Patient or his family)
<4.57)
1,220
(34.62)
284
(23.62)
85
(22.19)
Others (Camp, village leaders)
191
(25.70)
144
(4.08)
147
(12.22)
106
(27.67)
No clear information about referral
99
(13.22)
982
(27.86)
177
(14.72)
37
(9.66)
(7.67)
3,524
(100)
1,202
(100)
383
(100)
743
(100)
_ _________
Total
Figures In paranthesis show tpercentage
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE Nos. 11 & 12 ■ APRIL-SEPT. 1988
DISTRICT MENTAL HEALTH PROGRAMME AT BELLARY
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE Nos. 11 & 12 ■ APRIL-SEPT. 1988
13
DISTRICT MENTAL HEALTH PROGRAMME AT BELLARY
TABLE - 7 : Comparison between various types of Institutions 1983 to July 1988 (PSYCHOSES)
Dist.
clinic
No. of
cases
G.Hs.
PHCs
No. of
cases
Total number of cases
632
(52.58)
180
(14.97)
Regular and maintaining improvement
338
(53.48)
Stopped drug on advice
64
(10.12)
Irregular and dropout
No. of
cases
PHU +
GGAD
No. of
cases
No. of
cases
284
(23.62)
106
(8.82)
1,202
(100)
71
(39.44)
65
(22.89)
33
(31.13)
507
(42.18)
17
(9.44)
18
(6.34)
19
(17.92)
118
(9.82)
216
(34.18)
90
(50.10)
194
(68.30)
54
(50.94)
554
(46.09)
Cases with duration of Illness less than 1 week
38
(6.01)
15
(8.33)
16
(5.63)
15
(14.15)
84
(6.99)
Drug used CPZ + THP
212
(33.54)
70
(38.89)
38
(13.38)
26
(24.53)
346
(28.78)
Drug used CPZ + FPZ + TPH
266
(42.08)
33
(18.33)
30
(10.56)
28
(26.41)
357
(29.70)
Total
TABLE - 8 : Comparison between various types of Institutions 1983 to July 1988 (EPILEPSY)
Clinic
(N-l)
Cases
G.Hs
(N-7)
Cases
PHCs
(N-23)
Cases
PHU & GAD
(N-27)
Cases
Total
(N-58)
Cases
Total No. of cases
609
(17.28)
957
(27.15)
1,509
(42.82)
449
(12-74)
3,524
(100)
Regular cases
*
400
(21.06/
65.68)
458
(24.11/
47.85)
781
(41.12/
51.76)
260
(13.69/
57.90)
1,899
(100/
53.88)
Irregular cases
200
(12.58)
490
(30.82)
717
(45.09)
183
(11.51)
1,590
(100)
Regular - controlled
334
(54.84)
399
(41.69)
674 '
(44.66)
223
(49.66)
1,630
(46.25)
Uncontrolled cases
66
(10.84)
59
(6.16)
107
(7.09)
37
(8.24)
269
(7.63)
Drugs used - phenobarb only
337
(55.34)
907
(94.77)
1,455
(96.42)
420
(93.54)
3,119 ■
(88.50)
Drugs used - phenobarb + DPH
147
(24.13)
34
(3.55)
35
(2.32)
24
(5.34)
237
(6.72)
Fit free - 1 yr.
131
(21.51)
201
(21.00)
316
(20.94)
101
(22.49)
749
(21.25)
Controlled within 6 months
183
(54.79)
268
(67116).
431
. (63.95)
130
(58.29)
1012
(62.08)
* % of regular cases within the district and % of regular within institutions.
the psychotics and 53 percent of the
epileptics have been utilizing the services
quite regularly and have reported
improvement and reduction or disap
pearance of initial symptoms.
The decentralised training strategy in
phases, adopted for the DMHP is a feasi
ble method for training large number of
primary health care personnel within a
resonable period of time and without ma
14
COMMUNITY MENTAL HEALTH NEWS
jor disruption in their routine work. The
training, in phases, allows the trainee doc
tors and health workers to bring back their
practical experiences, doubts and diffi
culties for discussion during a formal train
ing session. The continued ‘on-the-job
training’ carried out during the field visits
by the district team and/or NIMHANS
team, was found to be invaluable. The
frequent mobility of health personnel
ISSUE Nos. 11 & 12 ■ APRIL-SEPT. 1988
within the district and out of the district
due to transfers, leaves, proceedings for
post-graduation, promotions etc., posed
a problem as the new staff had to quickly
be given the mental health training.
The recording and reporting system for
the DMHP were designed based on the
previous experiences of the investigators
as well as the patterns of certain other
national programmes. Though simple,
these are found to be complicated and dif
ficult to handle four separate case cards
for four separate diagnosis. The record
keeping by the health workers and their
supervisors was found to be not satisfac
tory. The monthly reporting form too re
quires several modifications. The quality
of the case records varied from institution
to institution and according to the
diagnosis. Epilepsy records tended to
have more information at most of the cen
tres. The personal details of the patient
along with diagnosis and drugs prescribed
were available in most records. All details
of clinical condition and follow-up details
were lacking in many centres.
During the field visits the district team,
‘on the job training’ was given by examin
ing difficult cases and discussing them with
the health personnel. Doubts about
management, filling-up of case records
and monthly return forms etc., were also
classified. While all institutions had neuro
psychiatric cases registered, the numbers
varied widely from about 20 to more than
200. From the records, discussions with
the doctors and examining some of the
cases on treatment, the broad diagnostic
categorisation and lines of management
followed by the trained doctors in regard
to typical cases appeared to be adequate.
But most of the doctors had problem
cases of various types. In some, the pro
blems arose because adequate doses of
medications were not started eg., in
managing acute psychotics (manics) to
control their excitement, or in certain
epileptics who needed higher doses or
combinations of anti-epileptics to reach a
fit free status. In others, the difficulty was
in determining the types of fit especially
when cases were typical, eg., combination
of genuine epilepsy with hysterical attacks,
and convulsions other than grandmal. In
few cases, doctors had difficulty in suc
DISTRICT MENTAL HEALTH PROGRAMME AT BELLARY
cessfully managing side-effects of pheno
thiazines. This was complicated on rare
occasions by patients developing uncom
mon side-effects like tardive dyskinesia,
rabbit syndrome etc. Several doctors had
successfully managed status epilepsy.
In one centre, the medical officer mar
shalled support from the local communi
ty and started rehabilitation of two
mentally retarded at his own primary
health unit. In many institutions, the team
came across patients who had improved
considerably or recovered as a result of
the treatment.
One general difficulty expressed by all
the doctors was that, while their health
wokers know about one or more cases in
their respective catchment areas, they
were unable to successfully persuade
them to come to the PHCs. Of the
registered cases, about 30 - 40 percent
were reportedly irregular and health
workers were unable to carry out any
follow-up with these patients. The
dropouts were more with psychosis
patients. Lot of patients went to the PHCs
because they had seen other patients
improving. It was not possible for the
review team to interview many health
workers other than the headquarters
workers during these periods. From dis
cussions with doctors, it was apparent that
the identification, referral, follow-up role
given to the health worker was not very
effective in most PHCs. Many patients
mentioned that they were sent to the
PHC/PHU by the health worker of their
area. It would be necessary toxattend
monthly meetings of PHCs to see all the
health workes together to review the pro
gramme.
All institutions visited had designated
a certain day of the week for the mental
health clinic. In many institutions, boards
displayed the day and time of mental
health clinics. While patients were seen on
all days, the effort was to see old patients
coming for follow-up on a particular day
and time.
The review visits to the peripheral insti
tutions highlighted the need for such visits
by the District team/NIMHANS team on
a regular basis to monitor the programme.
These can contribute to the development
of confidence and skills of doctors and act
as the much needed ‘continued on the job
training’. The visits will ensure better
quality recording which is essential for
satisfactory monitoring. The most striking
point was the steady increase in the
numbers of cases on treatment, the
quality of care, the availability of records
and a format for reporting of the work to
the district headquarters.
Future of the DMHP
The DMHP has completed three years
and is presently in its fourth year of imple
mentation. Till the launching of this pro
The range of drugs available at the
institutions depended on the numbers and
types of cases on treatment. Phenobar
bitone and chlorpromazine were available
at all the institutions. Antidepressants and
depot phenothiazines were not available
at some of the institutions in the district.
gramme, the experience available in the
country as well as elsewhere, of inte
grating mental health with primary health
care, was only from a limited population
and health personnel involving either part
of or a whole PHC. But the DMHP
involving a population of 1.5 million and
hundreds of health personnel has substan
tially increased the mental health profes
sionals’ understanding of the general
health care services and operational and
managerial problems of implementing a
new health programme.
The visit by mental health professionals
from other states to Bellary district has
facilitated their starting similar program
mes in their respective states. Currently,
a programme similar to the Bellary DMHP
is being implemented at Nagpur District
in Maharashtra.
It has also been a unique example of
collaboration between a district level
administrative set up, the state depart
ment of health and family welfare and a
national institute to develop, implement
and evaluate a health service programme.
The district health personnel under the
PERSONS INVOLVED IN DMHP AT BELLARY
(Present & past)
DIRECTORATE OF HEALTH AND FAMILY
WELFARE, GOVERNMENT OF KARNATAKA
Present:
1.
Dr. J.L. Javare Gowda, Director of H & FW
Services.
2.
Dr. C. Prasanna Kumar, Jt Director & State
level programme officer for Mental Health.
3.
Dr. C.R. Krishna Murthy, Divisional Jt. Direc
tor, Gulbagra
4.
Dr. T. Nizamuddin, District Health & FW Of
ficer, Bellary.
5.
Dr. Karur Badri Vishal, Programme Officer,
DMHP, Bellary.
Past
1.
Dr. A. Narayana Rao, Director of H & FW Ser
vices (Retd).
2? Dr. K B. Makapur, Jt. Director (Formerly DHO,
Bellary).
3. Dr. V.G. Shetty, DHO, Chitradurga (Former
ly DHO, Bellary).
4. Dr. N. Muralidhar, Asst Surgeon, (Formerly
Programme officer, DMHP).
Z1LLA PARISHAD, DISTRICT
ADMINISTRATION, BELLARY
Present
1.
Mr. Bhavi Bettappa, President, ZP.
2.
Mr. Nattakattappa, Vice President, ZP.
3.
Mr. B. Lakshminarayan Shetty. Chairman,
Health Committee, ZP.
4.
Mr. S. A. Patil, IAS, Chief Secretary, ZP.
Past
1.
Mr. Sudhir Kumar, IAS, Deputy Secretary,
Ministry of Eco. Affairs, Govt, of India (Formerly
Dy. Commissioner)
2.
Mr. C.S. Surajana, IAS, Formerly Chief
Secretary, ZP, Belleary.
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE Nos. 11.& 12 ■ APRIL-SEPT. 1988
NIMHANS
Present
1.
Dr. G.N. Narayana Reddy, Director,
2.
Dr. S.M. Channabasavanna, Dean & Prof, of
Psychiatry;
3.
Dr. R. Srinivasa Murthy, Prof. & Head, Deptt.
of Psychiatry,
4.
Dr. G.G. Prabhu, Prof. & Head, Deptt. of
Clinical Psychology,
5.
Dr. LA. Sheriff, Prof & Head, Deptt. of
Psychiatric Social Work,
6.
Mrs. Reddamma Raju, Assoc, fcrof. & Head,
Deptt. of Nursing,
7.
Dr. Mohan K Isaac, Assoc. Prof, of Psychiatry
(Co-ordinator, DMHP, Bellary),
8.
Dr C.R. Chandrashekhar, Asst. Prof, of
Psychiatry.
9.
Dr. R. Parthasarathy, Asst. Prof, of PSW,
10.
Mrs. Ahalya Raghuram, Lecturer in Clinical
Psychology,
11.
Dr. T.G. Sriram, Lecturer in Psychiatry,
12.
Mr. Mohan Krishna, Tutor in Psychiatric
Nursing.
Past
1. Mr. Nagarajaiah, Tutor in Psychiatric Nursing
2.
Ms. Nomitha Varma, Formerly Lecturer in
Clinical Psychology,
3.
Dr. Shekhar Seshadri, Lecturer in Psychiatry.
RESEARCH STAFF AT BELLARY
1. Mr. Arun Naik, ARO Social Work.
2. Ms. Smitha Sanju. ARO Clinical Psychology.
3.
Mr. Jayasimha, Statistical Assistant.
ADDRESS. Programme Officer, District Mental
Health Programme, DHO’s Office, Bellary,
KARNATAKA.
15
DISTRICT MENTAL HEALTH PROGRAMME AT BELLARY
16
COMMUNITY MENTAL HEALTH NEWS ■ ISSUE Nos. 11 & 12 ■ APRIL-SEPT. 1988
Printed at Precision Fototype Services, B’lore.
FionaTluss®
...... "■.............................rf,M
........................................................................................ ........ IIP . ...... >■!■■
k
A BI-MONTHLY BULLETIN ON PRIMARY HEALTH CARE IN COMMUNITY HEALTH
K°^n8S|a
Issue 18th June 1991
Bsnga/ofo.56003<.
India
PREVENTING PROBLEMS
OF THE MIND
Diseases of the mind, mental or emotional, are
serious problems to our communities. Probably
more work time is lost by mental problems than by
any other disease. About 29% of all people have
permanent mental handicaps and since they
should have all the rights and privileges that other
people enjoy, programmes of rehabilitation,
meaningful work and the security of an understand
ing and affectionate home should be provided for
them.
Another 89% of all people, at one time or the
other are not able to function fully for various
periods of time due to various degrees of serious
emotional anxiety.
Normal reactions to anxiety caused by stress or
threats to our well being are like those of “fight" or
“flight". These can be: rapid heart beat; rapid
breathing; trembling; tight muscles; perspiration;
feelings of weakness and nausea; diarrhoea; urin
ary frequency, dry mouth or feeling of sadness
(reactive depression). Those who are feeling sad
may try to commit suicide without really intending
to die. This is their silent cry for help. However, they
may die because their plans are accidently suc
cessful!
These being normal reactions, they are pre
vented by:
(1) Understanding the cause of threats.
Because people always feel the need for mean
ing and purpose fortheir lives in their relationships
with others, which gives a sense of personal worth,
any threat to these feelings, can cause anxiety
(disease).
There are many causes of anxiety. Some of these
causes are: loss of job opportunities; financial
losses; job transfers; sickness; unwanted pregnan
cy; the approaching delivery date; menopause
symptoms; an insult; separation or loss of family
members and friends or a divorce and many other
forms of threats that cause stress.
(2) Deciding proper ways to deal with them.
(3) Being involved productively in social and
community activities.
Beyond these relatively normal reactions to
anxiety there are neurotic reactions characterized
by a loss of emotional control. People with these
problems are usually still acceptable to society,
often trying to get sympathy or pity by exaggerating
their problems and demanding help in one way or
the other.
A BI-MONTHLY BULLETIN ON PRIMARY HEALTH CARE IN COMMUNITY HEALTH
___
Issue 18th June 1991
Signs of neurotic reactions are:
1.
Unexplainable and unusual temporary sensa
tions in different parts of the body which are
usually worse in tense circumstances.
2.
Abnormal fear of disease with complaints of
chest pain, awareness of the heart beating, or
headache without evident physical cause.
3.
Going from doctor to doctor because medicines
don’t really cure the problem.
4.
Excessive hand washing, fingernail biting,
nightmares, and difficulty in going to sleep.
5.
Sudden loss of a certain body function (voice,
use of arm or leg, sensations, even eyesight)
excessively deep sighing or severe vomiting
(these are called hysteria).
These problems can be cared for best by:
1.
Showing genuine personal concern and respect
for the patient and expecting respect in return.
2.
Encouraging talking about the patient's feelings
so that they begin to understand the reasons for
them.
3.
Giving a snack or warm drink to divert attention
from the patient’s sense of suffering.
4.
Giving relistic firm reassurance that, if the
patient is willing, the problem can be cared for
effectively.
5.
Helping the patient rediscover the joy of giving
as well as receiving.
Even small children have neurotic reactions such
as breath holding, finger sucking beyond infancy,
hair pulling, stammering, stuttering, finger nail
biting, abnormal eating patterns, stealing and
lying. These are mostly attention and comfort
seeking habits usually found in children wanting
and needing more love without over protection and
security without over-restriction.
Alcoholics and drug addicts are also neurotics
who have sought ways to escape from their feelings
with dependency developing drugs. They need
specialized help.
B Fiona -FIuse
There are other types of mental diseases requir
ing treatment by specialists. These are the psych
oses.
I .Schizophrenics who have signs such as:
1.
They are not easily accepted by society be
cause they make others feel uncomfortable.
2.
They do not realise that they have any problem
and therefore are difficult to help.
They don’t want sympathy or help.
4. They escape from the real world with its pro
blems into their own world, with which they often
interact (as when they walk around naked ortallw)
as if to some unseen person-hallucinations),
and feel that those who don’t understand them
are trying to harm or even kill them (delusions).
These patients can therefore be dangerous to
others. There are now very helpful medicines
given by specialists which may have to be taken
permanently to help schizophrenic people feel
more comfortable interacting with the real world
so that many of them can be rehabilitated to not
only care for themselves, but also perform pro
ductive tasks.
II. Physiologic Depression (morbid melancholy^
of which the symptoms often are: inability to sleep,
often waking up very early in the morning; constant
tiredness; lack of ability to concentrate; withdrawal
from other people and suicidal thoughts. This can
be very serious as 1/7 of all severely depressed
people actually commit suicide. As psychotics,
they also want to withdraw from this world.
The first step in caring for a depressed person is
to have a proper physical examination. The next
step is to have a fully qualified physician or
psychiatrist give proper medicine which may be
needed only temporarily. These medicines are
helpful in lightening the mood of the depressed
patient, often restoring them to useful activity.
Issue 18th June 1991
For both neurotic reactive depression or psycho
tic physiologic depression whether taking medi
cines or not, certain routines can be very helpful
such as:
1.
Do something constructive.
Write a daily plan from the time one gets out of
bed until it is time to sleep.
(List everything in manageable steps).
Don’t wait until you feel like doing something
to do it. ("Prime the pump”) by getting started
with even a small step).
2.
3.
•
4.
5.
6.
_
W
Lend a helping hand to someone. Think “since I
can do things I am not worthless” (human
contact itself helps in healing—creates incen
tives for volunteering).
Schedule enjoyment with friends; doing enjoyable and manageable projects; mastering a
new skill; dining out or going to cinemas;
smiling as much as possible because be
haviour shapes emotions; walking briskly; sit
ting upright (the actions that go with being
happy can make one feel happy).
Exercise regularly by walking, jogging, swim
ming, bicycling etc. (Exercise boosts self confi
dence and the increased energy output later
produces relaxation with reduced tension and
anxiety.
■Fiona ¥lusB
ssFional^lus Focus s.
How to keep your neighbourhood
clean
Action for the household to take
• Put all animal and human excreta into the latrine, and
teach children to use the latrine. If there is no latrine,
bury or burn excreta
• Keep the latrine clean at all times
• Put all food scraps into a special container which is
covered and kept out of reach of children and animals
• Food scraps can be fed to domestic animals
• If animals are kept, keep them penned or fenced in
• Put all garbage in a container in a safe place away
from children; keep it covered to keep out flies and
rats. When it is full, take it to a special pit or dump,
where it can be composted buried or burnt.
• If the community does not have a communal pit, dig
a pit for the family, away from the water source, and
fence it off. Each time rubbish is put in the pit, cover
it with a layer of earth
• Fill in holes in the floor, in the street, and close to
the home
• Dig drains to cary away water
• Keep the area around the home clean and free from
garbage
• Make a special area where the family can bathe
Brighten the environment with bright lights and
furnishings.
Read helpful books about depression.
Sometimes in addition to medicines, a
machine giving electro convulsive therapy
(E.C.T.) is useful for severe depression but this
must be given only in well equipped centres by
well trained specialists.
However, the best of modern machines are
not capable of listening, caring, sharing with
sympathy and loving kindness. This “third di
mension” of healing recognises that it is our
relationship to our neighbours, our environment,
ourselves and the God we believe in that gives
meaning and purpose to life.
Probably the most meaningful or relation
ships and most powerful healing force In life
Is love.
zation O — O ral rehydration
Action for each community to take
• Have a communal rubbish dump
• Put a fence around the rubbish dump
• Keep streets and children's play areas clean and
free from dangerous objects and garbage
• Fill in holes in the streets and children's play areas
• Make sure that the well or standpipe is clean, and
that spilt water can drain away
• Dig drains to carry away waste water and rainwater
from each household or communal area
N — N u t r i t i o n A —V i t a m i n A
E Fionai H^Iuse
Issue 18th June 1991
How to keep drinking water clean
• Keep the container against a wall, away windows and
the cooking area
• Keep drinking water in a clean container, such as a
bucket, in a clean place
• Keep the contaier off the ground, away from children
and animals
• Always keep a clean cover over the container, even
when it is empty
• Make sure that the container has no leaks or cracks,
and that the lid completely covers the mouth of the
container
• Clean the cover every day, with boiling water if
possible
• Rinse the bucket or other container for drinking water
inside and outside each time it is empty
• Always use the same container, such as a mug, to
take water out of the bucket. Do not use this container
for any other household tasks
• Pour the water from this container into a clean cup (or
clean hands) for drinking
• Never put hands or fingers into the drinking water
bucket
|
• Do not put hands or fingers into the cup; hold iton the
outside or by the handle if it has one
• Keep the mug upside down on top of the cover
Handwashing
You should wash your hands with soap and water:
• after using the latrine/defaecating;
• before cooking;
• before eating, or feeding children;
• before breastfeeding;
• after touching animals and poultry or anything dirty;
• after eating.
Keep a special cloth for drying hands; do not use
clothes, which may be dirty.
Text of "How to keep your neighbourhood clean”, "How to keep drinking water clean" and "Handwashing” has be
extracted from ‘Dialogue on Diarrhoea’ AHRTAG, 1 London Bridge Street, London SE1 9SG.
Editor
Dr. Sukant Singh
Head, Dept, of Community Health, CMAI.
Managing Editor
Ms. L.M. Singha'
Communications Officer, CMAI.
Consultant
Dr. R. Seaton
Dept, of Community Health
Published by: Dr. D.S. Mukarji, General Secretary, Christian Medical Association of India & Printed at Mayar Printers, New Delhi.
All correspondence may be directed to:
Christian Medical Association of India, Plot No. 2, A-3, Local Shopping Centre. Janakpuri,
New Delhi-110 058. Tel:5552046 Telex:76288 CMAI IN Fax:011-5598150
A BI-MONTHLY BULLETIN ON PRIMARY HEALTH CARE IN COMMUNITY HEALTH
no memoci in
the madness -
T is a matter of great sorrow
to all the cases mentioned above
is an incendiary fury which is
ready to ignite at the slightest frus
tration, the causes of which must
be examined not only in terms of
political, economic and social fac
tors but at a much deeper ■— psy-.
chological — level.
,. .
that we Indians arc showing
an increasing tendency .to
adopt anti-social and violent means
to get what we want The phenom
enon seems to have achieved epi
demic proportions; no day passes
without newspaper reports ■; of
destruction of property and mur
derous frenzy erupting in some part
of the country. What has happened
in Ayodhya epitomises the viru
lence of a disease which threatens
the very life of the nation.
The situation is frighteningly
complex. No one can underesti
mate the pain caused by economic
disparities, religious bigotry and
caste hierarch
ies. No one
denies the role
of
political
forces
both
within and out
side the country
which exploit
the people, es-:
penally
our
youth, in the
name of injus-'
tice. But how
does one’ ex
plain the sense
lessness of viol
ence that has
been unleashed
on the families
of Punjab po
licemen or is
seen during the
Bihar pogroms?
At times, the ■
violence is a
part of some
ideology, as for
example,
be
hind
the
Naxalitc move
ment in West
Bengal.
But
how does one
account for the
aggression that
erupts . when
suffering.
x
. It is this empathic ability which
is then elaborated by culture into’
mutual obligations, group values
and group symbols which ensure
strong ties. between people. It
would not be an exaggeration to
say that while the history of hu
manity has been largely written in
LeT us first look at the psycho
terms of wars, all , major
biological roots of violence. It has civilisations have links with and
to be admitted that violence is a much of human progress has ori
part of nature. One lives by eating gins in this nascent sense of empa
other life forms and this is possible thy which first makes its appear
only through violence. Violence ance at the age of two.
Children learn through a process
against members of one’s own spe-'
cies is also prevalent in the animal of identification — that is by.
kingdom. Ethologists tell us that it modelling themselves on . others:
fathers,
' '
mothers, teach
ers, friends and
even mythologi
cal heroes.
Healthy so
cieties nurture
empathy by the
way of strong
cultural .tradi
tions, operating
through ’ adult
figures one can
trust and who
therefore qual-’
ify as suitable.'.
In time, this
kind of learning
helps' the child
to grow up with
an insight that
others arc as
important
as
oneself
and
one’s objectives
are, in fact, bet
ter
served
through a mu
tual ■ give and
take.
So strong is
the need for
identification,
especially dur
ing
adoles
cence,
that
students are not allowed to copy
in examinations or when tickets to
a coveted cinema show are sold
out?
The irrationality of such aggres
sion strikes one even more when
it is self-directed as in the case of
the self-immolations which follow
ed the move to implement the
Mandal Commission report.
Most of the children who dous
ed themselves with kerosene were
too young to be.emotionally in
volved in the complex philo
sophical issues behind the Mandal
Commission controversy. Finally,
what defence could be offered for
the happenings in Ayodhya? If
pride in Hindu culture was the aim,
the destruction of the mosque was
the best way of ensuring the oppo
site. What seems to be common
is the intraspecific violence which
helps in distribution of populations
(thus, leading to more equitable
availability of food). It also helps
in selection of the strongest genes
and the formation of hierarchies.
This kind of violence must have
played much part in the formation
of primitive human groups but
there arc certain checking mechan
isms against aggression which are
also a part of our biological make
up, without which, the intraspecific
violence would have led to the an
nihilation of species.
One such checking mechanism
is a desire not to hurt another be
ing. This desire is based on a
cognitive understanding of similar
ity with the other and the related
emotion of empathy which arouses
a sense of pain when the other is
I
PV HAT makes the durrent situation in
the country so frighteningly complex is .
the irrationality of the recent violence. .
Making a psychiatric diagnosis of the ag-.
gression, R.L. KAPUR feels a deeper
understanding of militant enthusiasm is ■
necessary before a cure is found. ...
when cultural values are confusing
and the role models- inconsistent,
there is a tremendous feeling of
helplessness and despair.
As a result, some just opt out
of adulthood, preferring to lead a
dependent, escapist existence.
Some allow the aggressive instinct
— always lurking in the back
ground — to take over and lash
out desperately at the slightest
frustration. Others arc driven to
follow small men with limited vi
sion just because they appear to
be clear and consistent..
These observations arc relevant
to present day India. There is no
clear-cut understanding of one’s
Continued on Page II
No. method.in the madness
of both arms. One soars elated
above all tics of everyday life. One
is ready to abandon all for what
... seems to be a sacred duty ...
rights and responsibilities as a instinctive inhibitions against hurt
member of a nation. Those who ing and killing one’s fellows, lose
brought the nation into being arc much of their power. Meh enjoy
gone and those currently claiming the feeling of absolute righteous
power as national leaders are poor ness even while they arc commit
role models. No wonder, the peo ting atrocities...”
ple of India, especially the youth, ’ Lorenz says that a similar re
are showing the kind of reactions sponse is also shown by chimpan
mentioned above.
zees when defending their respect
ive groups. While in our primitive
ThERE is one more psychologi ancestors this kind of aggression
cal insight pertinent to the phenom emerged to defend a group of con
enon of violence which I would crete individuals, now, through a
like to highlight. Lorenz talks of ■process of cultural conditioning,
Militant Enthusiasm,' a particular the same response occurs when
kind of' communal aggression one believes that the customs, rites
which has a . psycho-biological and symbols of one’s immediate
group arc being challenged.
basis.
Lorenz goes on to examine the
In this state "... a shiver runs
down the back and ... the outside trigger mechanisms for such a re
Continued from Page I
sponse. These, are, among others,
an inspiring leader figure and the
presence of others who are emo
tionally charged in the same
fashion.
■which seems to have disappearec
from the school curricula, but
value education is at its best when
the young are exposed to the real
ities of life. .
I am strongly in favour of a
When i read about the commu
moratorium on formal education
nal riots in India, Lorenz’s descrip for 1-2 years after school, so that
tion jumps to my mind.
the young go and work with the
What can a psychiatrist offer as voluntary service organisations.
a solution to the crisis faced by
Finally, there is a crying need
the nation. One is, of course, a lit for new leadership. As mentioned
tle deeper understanding of the above, the young arc thirsty for
phenomenon. If the above account, , good role models but they are also
brief as it is, makes possible this good judges of hypocrisy. Those
understanding, I would be happy. who believe in broader values and
However, there arc a few other aspire for leadership will have to
things which come to mind.
demonstrate these by personal
There is a pressing need for a example. Gandhiji was no freak
crash programme on universal edu phenomenon.
cation. Education brings informa
(Dr R.L Kapur is Professor of
tion and the more informed people
Psychiatry and Deputy Director.
arc, the less inclined they will be
National Institute' of Advanced
to be led by small men. There is a
Studies.
Bangalore).
need to resurrect value education
"TEE LANCET^
The leading Medical Journal of London
Issue March 28, 1987
Round the World
From oiir Corrapandcnts
Pakistan
REVOLUTION IN MENTAL HEALTH CARE
IN most pans of the developing world, sen-ices for menial illness
barely exist outside the major centres of population. Several million
people with epilepsy, schizophrenia, or severe depression either
receive no treatment at all or get treatment
*
which is harmful or
ineffective. Mentally liandicapped children face a variety of
experiences ranging from neglect, confinement, or victimisation to
the expenditure of their parents’ resources on spurious cures.
Psychiatrists have tended to preside over largely custodial mental
institutions which are the legacy of the colonial past, and otherwise
tend to provide outpatient care fur triose able to travel to see them.
The integration of provisions fur the menially ill into primary
care was encouraged by the World Health Organisation and
pioneered in India about ten years ago? It has now been developed a
I step further in Pakistan. In this model, psychiatrists find themselves
i doing three things they have noi done before: providing training
*
course
to enable primary-cure phj sicians and multipurpose health
I workers to carry out the additional clinical work, engaging in
I cxtcn.M»«. health vduraik.:i activkn , v.;th community and religious
I leaders; and providing a backup sen ice on a sessional basis in the
'Hie new service in Pakistan has been started in a rural area with a
population of 400 (XX) near Rawalpindi. Attention has so far been
focused on five conditions: psychosis, epilepsy, depression, mental
handicap, and drug dependence. The multipurpose health workers
I routinely visit each house in tire villages to check on immunisation,
( tuberculosis, and sanitation and to distribute oral rehydration salt
for children with diarrhoea. They have now taken to showing die
villagers five coloured cards. Each card has a picture ofa person with
an illness together with basic facts about the illness; and villagers are
asked to say whether they know of anyone widi the condition. The
.campaign has led not only to a staggering increase in the number of
(patients aiming to treatment for the five illnesses but it has also I
/ caused the villagers to start using the clinics for general health care to I
[a greater extent.
I
additional symptoms confirm it, and how die illness is managed.
THE LANCET, MARCH 28, 1987
The primary-care physicians have die most complete form of these
charts on die walls of their offices and they are used to Instruct the
multipurpose health workers. A simplified version of these charts is
displayed in the wailing rooms of the primary health clinics.
The most exciting recent development has been the work in the
schools, since children are the eyes and cars ofa village. Teachers set
aside five minutes each day for health education, and they have been
extensively briefed by die visiting psychiatrists. ITie campaign has
components of prevention, treatment, and rehabilitation and it has
been Introduced with three slogans: “smoking is injurious to
healdi”, “menial illnesses are not caused by jins (spirits), they
respond to treatments like physical illnesses”; and “it is a grievous
sumo laugh at someone with a menial or a physical disability”. This
campaign has caused a striking additional increase in referral rates to h
the primary’ health clinics for epilepsy and mental handicap, as well q
as increases in referrals for lhe oilier three conditions.
One 11-year-old burst into tears after his teacher described lhe
symptoms of psychosis: “Sir, we had thought my faiher was
possessed by spirits. 1 now know him io be menially ill”. The boy’s
father had been confined to the house for four years with violent
behaviour related io hallucinations: the story has a happy ending.
'l he service was sei up without additional resources, odier than
die preparedness of psychiatrists and primary-care physicians io
allocate their time differently, and die costs of navel and die
printing of curds and chans. ’Hie staff of die’primary-care clinics is
die same as ii w as, and the cost of psychotropic drugs has been met
by savings on expensive tonicsand placebos. Most imjxiriani of all,
the community leaders are endiusiasiic, as they see the
achievements' of the pnmary-care workers.'Now that lhe new
service is well into its second year,, it is possible iu begin to get a
clearer idea of die resource implications. One of die primary-care
physicians who has had special additional training in psychiatry
spends his lime travelling between lhe basic health units giving
advice on the more difficult cases, and each unit is visited once
weekly by an academic psychiatrist from die university department.
The larger basic health units serve approximately 60 OJu people and
have a small number of beds for severely ill patients: some of diese
beds are now used for menial illness, and diereare two small wards
in the Tehsil Genera! Hospital, which serves the entire area.
Acidemic psychiatrists visiting die rural centres now come
accompanied by dieir medical students, who assist by taking
histones from patients and their relatives. !i seems likely that when
these students become primary-cure physicians dieinsclves, they
will have a very much clearer idea about die way in which mental
illness presents Ln general medical settings than will ,students trained
entirely within die walls of die hospital'.
-------------------------- c^'^z
----------------- iXiZ15 i/jV'
HH-S-IJ-
EASTERN MEDITERRANEAN REGION
HEALTH SERVICES JOURNAL
SERVICES
JOUBNAt'
DE
REGION
DE L/;
DE SANTE
.
MED’TERRANEE ORIENTALS
’WORLD HEALTH ORGANIZATION
REGIONAL OFFICE FOR THE EASTERN MEDITERRANEAN
ORGANISATION MONDIALE DE LA SANTE
BUREAU REGIONALE DE LA MEDITERRANEE ORIENTALS
COMMUNITY-BASED“RURAL MENTAL HEALTH CARE PROGRAMME
Report of an experiment ?n Pakistan
^
*
Mubbasher
ABSTRACT
Shakeel J. Malik
,
*
Javed Rasool Zar
.
**
RESUME
Mental well-being is an integral part of WHO’S definition ofe’health. The existing institutionally-based mental
health services in the developing countries are grossly inadequate owing to shortage of specialist manpower and
1 limited economic resources. An alternative approach is to decentralize mental health services through integration
with general health services at primary health care level. In a WHO suppor&d project carried out in rural parts of a
sub-district in Pakistan during 1985-1986, 117 medical officers, -J5 medica) assistants and 6)7 multipurpose health
workers were- given short training courses in mental health with $e help of specially prepared manuals. Following
this training, four existing rural health centres started providing mental health services to the local conmunity.
Within a period of about a year, over 1700 cases of various types of common mental illness were seen. These included
cases of depression, psychosis, neurosis, epilepsy, mental retardation, organic syndromes and drug dependence.
Supervision and referral facilities were provided by the visiting team from the department of psychiatry of the
neighbour!ng,medical college. The essential neuropsychiatric drugs, limited to three or four medicines, were provided
by the local -health department. The carmunity response was very supportive of these mental health services, rhe’
experience suggests that it is both feasible and practical to deliver mental health services integrated with general
health services at primary health care level in developing countries. However, in order to ensure the success of
these programmes adequate supervision and referral facilities along with continuous supply of essential
neuropsychiatric drugs are considered necessary.
La sant£ mentale fait partie de la sante telle que definie par POMS. Les institutions pour les services de
sante mentale existantes dans les pays en voie de ddveloppement sont generalement inadequates, en raison du manque de
special isles et des ressources 6conaniques limitdes. Une approche possible est de decentraliser les services de sante
mentale en les integrant avec les services generaux de sante au niveau des soins de sante primaires. Au cour d’urf
projet aide par POMS, dans une zone rurale au Pakistan durant 1985-1986, 117 nuSdecins generalistcs, 75 assistants
n»edicaux et 617 auxilliaires de sante ont rcqu une courte formation en sant6 mentale utilisant des manuels
specialement prepares. A la suite de cotte formation quatre centres de santd ruraux ont comnencd A offrir des
services de sante mantale a la coniTiunaute locale. En Pespace d' une annee environ plus de 1700 cas de maladies
mentales communes de types varies, ont 6t<§ regus dans cas centres. Ils comprennent des cas de
*
depression, de
psychose, de nevrose, d'epil6psie, de retard mental, des syndromes organiques et de dependence medicamenteuse. La
supervision a die assurde par des dquipes venant du.ddpartement de psychiatric, de la facultd de medecinc voisine.
Les medicaments essentiels de neuropsychiatrie limites A deux ou trois ont 6t6 fQajShiijs par le centre de sante local.
La reponse de la communautd A ces services de santd mentale a el6 trAs favorable. (.'experience suggdre qu1 i I est A 1.
fois possible et pratique de fournir des services de sante .mentale. integers avec les services giSiuSraux de santd a<
niveau des soins de sant6 primaires dans les pays en voie de developponent. Cependant afin d'assurer 1'e succAs A c.e
progrannies une supervision adequate, un systeme de reference et Papprovisionnement continu en medicaments essential
sont considAnSs ccmne needssaires.
‘Department
of
Psychiatry,
Rawalpindi |
Medical College, Rawalpindi, Pakistan.
I
“Deputy
Director,
Health
Services,
Punjab, -Pakistan.
14
“‘Regional Adviser, Merittil Health, WH<
Eastern Mediterranean Region, Alexandria
'-'
*
Egypt
EHR Health Services Journal
(d)
INTRODUCTION
Mental well being is an essential
element of health and the goal oE Health
for All by the year 2000 cannot be
achieved unless mental health is-"' given
appropriate
attention.
Accordingly,
prevention
and
control
oE
mental,
neurological and psychosocial problems
’should be
given higher priority
in
national programmes than is now the case
in many countries. At a recent inter
country meeting in Damascus [1] it was
noted ’that some 300 million people in the
world suffer Erom one or other of the
various types oE problem in this area. OE
'these,
some
40 million
suEEer
Erom
psychoses and related conditions while an
estimated
25 million
suEEer
Erom
epilepsy. Alcohol and drug dependence are
now ravaging younger age groups [2,3].
Existing
health
care,
including
mental health care, has so Ear failed to
provide Eor the needs oE most of the
world's population. The existing systems
are, Eor the most part, centralized,
hospital-based,
specialist-focused
and
disease-oriented;
health
care
is
delivered by medical personnel via a
one-to-one doctor/patient relationship.
In developing countries in particular,
‘these systems have produced a form of
care inconsistent with the principle of
social equity.
A WHO study group [2] reviewed the
mental health services in developing
countries and concluded that:
(a)
the need for mental health services
is as great in rural as in urban
areas;
(b)
decentralized
mental
health
services could be operated at the
primary health care level in rural
and
urban
areas
in
developing
countries; the methods of treatment
provided are effective and seem
acceptable to the community;
(c)
,
mental
health
care
could
be
provided by general physicians and
by auxiliaries, including community
health workers, after they have
undergone
limited
psychiatric
training; this approach has been
adopted in many centres, which have
produced training manuals in local
languages;
some mental health skills should be
taught to all medical staff, not
just to enable them to help the
mentally disturbed but also to
improve their delivery of all forms.
■sof medical care.
in many developing countries, where
specialist
manpower
and'
material
resources
are
limited,
extension of
mental
health
services
through
the
existing Infrastructure of the health
systems might be one way through which
mental health care could be provided to
the millions of cases in the vast rural
areas who are currently not receiving any
kind of modern mental health service
[4,5]. The present report describes the
experiences which have resulted from a
WHO-supported project in Pakistan, the
aim of which is to extend mental health
services to rural areas.
OBJECTIVES OF THE PROJECT
Generally,
> to develop a model for the extension of
mental health services to rural areas
through the existing infrastructure of
primary health care.
Specifically,
> to develop a set of priority disorders
in mental health for inclusion in primary
health care services;
> to provide an effective basic training
in mental health care to primary health
care personnel;
> to organize a system of referral for
mental health cases from the primary
health care facility to the referral
facility;
> to
develop
service;
an
effective
follow-up
► to stimulate community effort in mental
health care. ,
.The - project,
with
the
abovementioned objectives,
was started
in
*
Tehsil
Gujar Khan in 1985, covering an
area and population of the entire tehsil.
*sub-district
EHR Health Services Journal
15
RURAL MENTAL HEALTH CAUK
A social and demographic profile of the
field practice area is given below:
was carried out at the tehsll hospital
and at the Department of Psychiatry,
Rawalpindi Medical College.
' SOCIAL AND. DEMOGRAPHIC PROFILE
e Tehsil Gujar Khan District ^Rawalpind^
Situation
Total area
Distance from Rawalpindi
No. of villages
Total population
Rural population
Density of population
per square mile
Ratio male:female
No. of cinemas
No. of police stations
Major drops
Total no. of mosques
Total no. of commercial
banks
Total no. of
cooperative societies
Total number of post
offices
Literacy rate
(a) male
(b) female
No. of primary schools
No. of middle schools
No. of colleges
north-east of
Rawalpindi,
Pakistan
562 square miles
50 miles
380
417 000
378 000
742
1052:1000
2
3
wheat, bajra
1020
20
project
had
76
25%
7%
54
four
distinct
Phase I
The first phase involved collection
of background information on the social
and other characteristics of the project
area, the existing health facilities and
the current health problems. In addition,
interviews with health personnel were
arranged in order to assess current
mental health knowledge, the extent of
mental health care provided and their
willingness to take up mental health
work J The extent of the community's
perception of mental disorders was also
elicited. During this phase a weekly
psychiatric clinic was set up in the area.
Phase II
The
second
phase
involved
the
training of primary health care personnel
in a task-oriented manner. This training
16
The third phase involved monitoring
of the mental health care personnel. Data
was maintained regarding case identifica
tion, patient care, treatment provided,
referral and outcome.
Phase IV
The fourth phase dealt primarily
with analysis of the results and an indepth study of the attitudes of the
health staff and of the community towards
mental health.
DESCRIPTION OF THE PROJECT
The planning of the project was
done in close collaboration with the
Deputy •• Director of Health Serv , ’ and
the staff at the rural health centres and
basic health units. Cooperation was alsc
obtained from the union council, district
council and the local community leaders.
The project coordinator visited the are..
extensively over a number of weeks an<
addressed many prayer meetings in mosques.
147
PHASING OF THE PROGRAMME
The
phases.
Phase III
For provision of services, f’ou.
rural mental health centres with in
integrated rural health complexes a
Mandra, Daultala, Qazian and the Civl
Hospital in Gujar Khan. Each of thee
rural
health
complexes
coordinate
further with between six and eight bas!
health units.
A team from the Department
Psychiatry, Rawalpindi Medical Colleg
visited the rural health centres, t
basic health centres, the union counc
.and the district council in order
reate a climate of better understand!
and motivation in the community ;
amongst the health care personnel. Th,
visits were also helpful in assessing 1
prevailing
attitudes, ... both
In
community and amongst tjte health worke
to mental health care., tine 'of the m
important objectives was to determine
health care facilities remain unutili
even
when
they
are
available.
record-keeping system envisaged by t
programme was also pre-tested.
EHR Health Se, .ices Journal
TRAINING OF HEALTH STAFF
The training of health
the following objectives:
had
staff
(a)
to provide., basic 'knowledge about
•the importance of human behaviour
in healtfi and disease;
(to)
to make health • personnel familiar
. with the wide prevalence of mental,
• neurological
and
psychosocial
disorders in primary health care;
(c)
to
enable
recognition
and
management
of
the
following
priority
disorders:
severe
depression,
neurosis,
psychosis,
epilepsy, mental retardation, drug
dependence.
Training
physicians
of
primary
health
care
■ t
This training was carried out at
the Department ■ of Psychiatry, Rawalpindi
Medical College, and the rural health
centre
in
Daultata.
The
training
consisted of lectures, case discussions,
field work and visits to rural mental
health centres. The medical officers were
encouraged to start mental health clinics
on a pilot basis. The difficulties they
encountered were reviewed by the visiting
teams from the Department of Psychiatry.
Training of multipurpose health workers
With a view to decentralization the
multipurpose health workers were each
trained in their own region. They were
given
lectures
followed
by
case
discussions and exercises to practice the
knowledge acquired. A .manual, written
especially for them, was also provided,
its aims being to train them to identify
patients suffering from acute-psychosis,
epilepsy,
depression,
drug abuse and
mental retardation. The manual, lectures,
discussions and exercises were all in the
local language, Urdu. The multipurpose
health workers were also trained to
educate people about the dangers of
heroin, charas and other drugs, to care
for and treat patients with convulsions,
and to refer patients to hospitals for
expert management if and when required.
COMMUNITY ORIENTATION
A
massive
community-orientation
programme was launched, aimed at reaching
Weekly rural psychiatric clinic given by the Dept.
of Psychiatry, Rawalpindi Medical College.
as many of the public as possible. To
this end teams from the Department of
Psychiatry, Rawalpindi Medical College,
addressed prayer congregatons, especially
Juma (Friday prayer) congregations. The
community was also reached through the
school system, the local health facility
and
through
the
village
headman,
"numberdar" or "punchiayat". Pamphlats,
handouts and other literature on ®-.'che
subject were extensively distributed and
health committees were formed in ’^ach
basic health unit. The members of these
health
committees
included
religious
leaders, teacher.s, councillors' an® other
influential people of the community.
PROVISION OF ESSENTIAL DRUGS
As part of the project, essential
drugs have been provided at the different
levels of
the health care delivery
system. The multipurpose workers have
been provided with phenobarbitone and
chlorpromazine; medical assistants with
phenobarbitone,
chlorpromazine
and
imipramine; and the medical officers at
basic health units with phenobarbitone,
chlorpromazine, imipramine and injection
fluphenazine
decanoate.
The
medical
officers at the rural health centres have
diazepam in addition to the above drugs.
8
DEVELOPMENT OF REFERRAL SYSTEM
The
personnel
EHR Health Services Journal
trained mental
are expected to
health care
Identify the
17
RURAL MENTAL HEALTH CARE
ASSESSMENT
TABLE I. PRE" ANO POST-TEST
PERFORMANCE OR HEALTH PERSONNEL
Op
Assessment score
Post-training test
Tier of health /re-training lest
personnel
*Grade
3
C
0
A
*Grade
8
C
0
3
10
33
74
46
58
13
Nil
’
Mil
Nil
3
72
13
29
33
Nil
Multipurpose
health workers
Nil
Nil
7
664
189
335
59
84
«A - Above 70%
B - 60-69%
C - 40-59%
0 - below 40%
Medical
officers
Medical *
assistants
Phase II: Results of training
Total no. of persons trained
Medical officers
Medical assistants
,
Multipurpose health workers ''
853
117
75
671
Analysis
mentally
111
during
visits
to
the
villages
and
to
work
in
close
collaboration
with
the
health
care
delivery system. Special referral cards
were introduced to enable quick referral
from the periphery to the centre and
back. A community mental health care
centre was established in the Department
of
Psychiatry,
Rawalpindi
Medical
College, to coordinate the activities.
RESULTS
Phase I: Study of the attitudes of the
health staff and the community
Total no. of people interviewed
Medical officers
Multipurpose health workers
Community leaders
(numberdars, patwaris, masjid imams)
Patients
317
57
79
The health personnel were evaluated
in a pre-test assessment which took the
form of a written test during their
training workshops/classes. In addition
to ' continuous
monitoring during
the
courses all the participants underwent a
post-test assessment. Performance ability
and knowledge were counted on a scale of
grades, A, B, c and D, roughly equivalent’
to 70+%, 60-69%, 40-59%, and less than
40%,
respectively.
The
majority
of
personnel
showed
marked
improvement
between pre- and post-test assessments,
as shown in Table I.
Phases III and IV
Following
monitoring
of
mental
health care personnel and through the
data collected,
the response of the
TABLE II.
NUMBER
FOLLOWED UP AND
HEALTH CENTRES
1
1985
Community' '
The
community's
approach
towards
mental health care was punctuated with
patients
*
1986
537
Mandra
Health personnel
The main constraint experienced by
the various tiers of health personnel was
inadequate
training
and
skills
in
detection and management of psychiatric
disorder.
Even
if
a
disorder
was
diagnosed
there
were
no
suitable
facilities for drugs and referral.
OF
PATIENTS
REFERRED AT
SEEN,
MENTAL
| Total
53
128
Analysis of knowledge/attitudes
18
score's of taboos and myths based on
ignorance, lack of mental health care
facilities
and
exploitation
by
nonqualified
healers.
The prevailing
attitude was that mental disorders are
inflicted as punishment from God and are
untreatablei and that if treatment is
possible at all it is extremely expensive.
Referral
Folios«-up
1 1985 1986’
*
1985 1986
Nil
170
138
Oaultala
Qazi an
32
469
5
13
230
Nil
37
„
,SS
|
Gujar Khan
43
Nil
1?
Nil
29
Nil
19
Nil
45
1
I
487
____ 1
‘Data relates to the period January-June 1906 only.
EHR Health Services Journal
•
RURAL MENTAL HEALTH CARE
TABLE III. DIAGNOSTIC BREAKDOWN OF PSYCHIATRIC ILLNESS IN VARIOUS
MENTAL HEALTH CENTRES
-■
Daultala
Total M
F
Mandra
Total M’" F
Mental
*disorder
Total no.
of patients
Depression
592
207
77
130
148
47
Neurosis
432
152
48
104
108
51
Gujar Khan
Total M
F
Total M
F
101
148
43
105
89
59
30
57
96
44
52
76
40
36
I
Psychosis
180
|
55
20
35
60
30
30
45
20
25
44
17
27
36
26
10
42
20
22
45
25
20
21
10
9
42
4
Epilepsy
168
Mental
retardation
274
95
55
40
68
37
31
65
37
28
46
Organic
syndrome
24
10
6
64
5
3
2
7
4
3
2
Drug
dependence
68
28
26
2
15
13
2
17
16
1
8
2
7
1
1
*Diagnostic c lassification as used in the training manual "Rahnuma-i-tarbiat".
community
in
bringing
mentally
ill
patients to the rural centres was shown
to be positive. This is reflected in
Table II. A diagnostic breakdown of cases
is shown in Table III.
The impression received after one
year Indicates quite strongly that there
is widespread community acceptance of
delivery of mental health services at the
primary health care level. In the past
the mentally ill.patient from rural areas
had to be taken to the Department of
Psychiatry at Rawalpindi (20-50 km) or to
the
mental
hospital
in
Lahore
(about 200 km). As a result of the new
service, many mental patients who had
been ill for a number of years received
adequate psychiatric treatment for the
first time. Another significant change
■noticed by health staff was that, as a
result of the introduction of mental
health trailing, health staff started
spending more .time in talking to patients
and families. This led to an increase in
the total attendance at the rural clinics
and,
consequently,
better
overall
utilization of services. The cooperation
of health staff at primary health care
centres was generally very good and they
seemed
to
like
their
new
role
as
providers of mental health services.
However, for the success of the project,
adequate > supervision,
quick •referral
facilities
and
continuous
supply of
essentia! drugs were considered essential.
CONCLUSIONS
(1)
A significant proportion of patients
attending general health clinics in
the
developing
countries
have
psychiatric
problems
which
go
undetected.
(2)
The existing primary health care
staff working in such countries, can,
with
»nly
limited
training,
recognize
the majority of
these
disorders,
and
can
intervene
effectively by providing treatment
and follow-up.
EMR Health Services Journal
«<a
19
KUKAI. MHN'l'Al, HEALTH PARK
(3)
Specified
treatment
leading
to
reduced
disability
in
defined
neuropsychiatric disorders can be
provided through the health service
structure existing in the developing
countries.
(4) .The
social
functioning
of
°.-individuals
who
are
seriously
disabled
due
to neuropsychiatric
’ disorders
can
be
Improved
by
- stimulating community -action through
.education.
' REFERENCES
[1]
World Health Organization, Regional Office forthe
Eastern
Mediterranean,
Intercountry
meeting on national programmes of mental
health
(Damascus,
Nov.
1985),
Document
WHO/EM/MENT/113-E (1986).
[2]
World Health Organization, Mental health care
in developing countries, a critical appraisal
of "research findings (Report of a WHO study
group), Technical Report Series 698, WHO,
Geneva (1984).
[3]
World Health Organization, Organization of
mental
health
services
in
developing
countries. (Sixteenth report of IVHO Expert
Committee on mental health), Technical Report
Series 564, WHO, Geneva (1975).
[4]
Sartorius, N.,
collaborative
20
Harding, T.W.,
The
study
on
strategies
WHO
for
extending mental health care, I: The genesis
of the study,
Am. J.
Psychiatry, 14(^ 11
(1983) 1470-73.
[5]
Murthy, R.S., Wig, N.N., The WHO collaborative
study on strategies for. extending mental
health care,
IV: A training approach to
enhancing the availability of mental health
manpower in a developing country, Am. J.
Psychiatry 140 11 (1983) 1486-1490.
[6]
Hubbashar, M.H., A case for the mentally ill,
conmunity-based
mental
health
programme,
Booklet
brought
out
by
Department
of
Psychiatry,
Rawalpindi
Medical
College,
Rawalpindi(1986).
[7]
Zahni Saha, Rahnuma-I-Tarbiat, A manual for
the training in mental health of multipurpose
health workers
(in Urdu),
Department of
Psychiatry,
Rawalpindi
Medical
College,
Rawalpindi (1986).
EHR Health Services Journal
rm
MENTAL HEALTH AND MANPOWER:
THE COST DF
MENTAL ILLNESS AND THE EFFECT OF APPROACHES
TO VOCATIONAL REHABILITATION
Dr.Ashok Sahni
Professor of Behavioural
Sciences and Health Mgmt.,
Indian Institute of Mgmt.,
Bangalore.
_I_._ Intro du ction
I want to thank all of you, members of the Tamil Nadu
Branch of the Indian Association of Occupational Health,
for the opportunity given to me to participate in this
I want particularly to express my sincere thanks
meeting.
to Dr.S.Nagraj, Hon.Seeretary, for his kind invitation
requesting me to give a talk at this important occasion.
The subject for my talk is: Mental Health and Manpower -
The Cost of Mental Illness and the Effect of Vocational
Rehabilitation.
In this paper,
with the following issues:
employees?
I would attempt to deal
(a) Who are the mentally healthy
Their characteristics?
(b)
Cost of Mental
Illness (c) and the Effect of approaches to vocational
rehabilitation.
In this context,
I shall particularly
like to discuss the role of industrial medical officers
in promoting mental health in industry.
II.
Mentally Healthy and Mentally unhealthy Employees
Mentally healthy, productive, growth-oriented and
successful organizations differ from the sick, unproduc
tive, short-term profit oriented and stagnant organiza
tions.
The difference lies in the goals of the organiza
tion, nature of human resources, the philosophy of manage
ment toward human resource utilization and the infra
structure availability for effective human resource
utilization.
The difference in the two types of organi
zations is primarily due to the mental health of the
Talk given at the Indian Association of Occupational
Health Meeting, Tamil Nadu Branch, March 11, 1979.
2
employee^. _/JJUe sti-’o:rf':-ari'ses"w'h at are the characteristics
How far are they different
of mentally.jhe althy-'-empi-byee s?
from the mentally- not--’-healthy employees?
The mentally
healthy individuals have the following characteristics
(Jahoela,
1.
1958).
'
-
The mentally healthy person is able to get along with
others. He adjusts himself to the group and the prevai
ling norms.
In other words, success comes with the
ability to work with associates,
2.
not against them.
The mentally healthy person acts to solve problems
as they arise.
He faces up to him problems and then
does something about them.
3.
The mentally healthy person enjoys work.
He gets
satisfaction but of doing a job and this contributes
to his on-going state of mental health.
In other
words, those who have a zest for working, may be said
to be mentally healthy.
4.
The mentally healthy person controls his emotions and/
or directs them into harmless outlets.,
5. The mentally healthy person plans ahead without fear
of the future.
6.
The mentally healthy person establishes goals for him
self that are within the limits of his capacities to
reach and. then .he strives to -his utmost to achieve
t he se goal s.
7.
■ - -
The mentally healthy person accepts himself the way
he is — physically, mentally and socially.
8.
The mentally healthy persons are highly motivated and
goal-directed.
They integrate.their goals with the
goals of the society and channel their creative ener
gies toward betterment of the so.ciety.
9.
s
The mentally healthy persons have the ability to
control their frsutrations and emotions and channel
these emotions’ toward” ccri’-s-t ructive ends.
3
10.
The mentally healthy persons are able to relate with
the world, accept each persons the way he/she is and
show genuine concern
toward the welfare of other human
bei ngs.
On the other hand, mentally unhealthy or mentally sick
persons do not have clear goals; their motivational orien
tations are directed toward satisfaction of animalistic
needs; they live in the past or in the future rather than
in the present; they have excessive anxieties, fears and
show neurotic and psychotic behaviours; they are not aware
of their abilities and potentialities; rather than being
engaged in productive-constructive behaviours, they tend
to show high grievance behaviour, sickness,accident prone
ness, frequent visits to the medical doctors and hospitals,
and are passive destructive in their behaviours.
Cost
III.
of Mental Illness
No clear survey in India has been made as to the degree
of mental illness in industry.
Be it in the form of effects
of indecisiveness, alcoholism, drug addiction, psychopathic
and psychotic behaviours,
and other emotional disorders.
Newspaper reports and other surveys, however, clearly indi
cate the degree of job dissatisfaction among employees at
various levels of the organizations, both in public and
private sectors; low productivity and profitability of
organizations; high degree of absenteeism and escapism
from work;
investments made of employees through Employee
State Insurance schemes and other welfare schemes, strikes,
lock-outs and other delays and bottlenecks experienced in
the process of achieving the organizational goals. These
' people-problems are almost common in all types of organi
zations -- a factory, store, laboratory, hospital, office,
major private or public sector organization.
-: 4
:-
For the purpose of this paper,
I would like to illus
trate the cost of one type of mental illness, ie.
absenteeism
from work which is an escapism from dissatisfying job and
organizational climate.
According to the latest available statistics (1974),
there are approximately 22 million people working in the
organised sector of Indian economy.
This includes approxi
mately 13 million in the public sector and 9 million in the
private sector.
The
absenteeism rate reported ranges from
8% to as high as 30$.
If we take one per cent of the employ
ment force as being absent from work due to sickness, we
will hav.e approximately 220 thousand people being absent on
Let us assume the average compensation per
a single day.
employee is Rs.20/- per day.
ing days a week
At the rate of five full work
(in most of the industries it is 51/2 days
working week), we would have a loss of Rs.114.40 crores during
a year.
If we include absenteeism from work on other grounds
-- there are possibly hundred other different re.asons -- the
figure will have to be multiplied by at least 20 times.
As managers, administrators and supervisors, you are
certainly concerned with what are the causal factors of this
absenteeism.
Many administrators, however,
feel that some
degree of absenteeism is nfirmal, just like many individuals
feel that getting sick once in a while is normal.
As a he alth ■ professional ,' it is possible to have good
There are enough examples all
health and not get sick.
round that in spite of serious sicknesses, persons have been
very productive.
However,
several attempts have been made
to study the causation of absenteeism.
For example, Newton
(1950) in a study of absenteeism, compared machine shop
employees who tended to have more absenteeism over a twoyear period with those who tended to be relatively absencefree.
The two groups were matched as far as possible on
age, length of service,
and other variables.
He found that
the high-absence employees were less emotionally stable
than thS ones with low-absence rates.
5 :-
Another study of absenteeism among female employees in
a telephone company was conducted by Plummer and Hinkle(1952)
They compared 20-year service employees who had the highest
absence records with 20-year service employees who had the
lowest absence records in terms of medical case histories.
It was found very definitely that the high-absence group
had a much greater number of emotional disorders and other
kinds of disorders which had an underlying emotional basis.
I conducted a comprehensive study of approximately 400
professional managers, engineers and scientists in several
industries and studied the personality factors related to
absenteeism.
In the last 12 years,
I have also maintained
statistics on graduate and under-graduate students with
regard to their absenteeism.
In both these studies, I have
found that the absenteeism group tends to be high in their
lying, neurosis, tend to be emotionally less stable, are
less willing to assume responsibility, live in either past
or the future,and have
IV.
low’ ego strength.
Preventive and Rehabilitative Programmes
A. Management Responsibilities
The question which the organizational leaders and the
managers are likely to ask is: What can the management do
to minimise sickness behaviours in their organizations? As
indicated in the beginning of this paper, almost every socia.
system has inherent, potentials for stress and sickness. How
ever, some of the following measures could be initiated in
an organization for prevention of sickness situations in
the organization.
1.
The organizational leaders should have clear objective
for the organization and the various members of the top
management must whole-heartedly accept those objectives
and commit themselves-to achieving those objectives.
This will minimise the climate of ambiguity at the top
which usually filter's down the organization in the form
of neurosis.
6
:-
2.
In the light of the above objective, the organization must
clearly and sincerely establish policies and practices for
the effectiveness of the organization.
The effectiveness
of the organization is not only the result of achievement
of its goals but basically the result of effective utili
zation of ..its human resources.
The organization must be
sincerely committed to the development and utilization of
its human resources.
3.
Keeping in view its objectives of maximum utilization of
human resources, the organization must create meaningful
jobs for its employees on a continuing basis. This . re quires
that the organization must have an organizational develop
ment department separate from the personnel administration
department.
The organizational development department's
responsibilities are to create meaningful and enriching
jobs for its employees and ensure that there is a maximum
match between the jobs and the job holders.
4.
The organization must be adaptable to the changing social,
economical, political and technological developments. Thus
the organizational structure must be flexible so as to
accommodate internal and external resources as well as
constraints.
Flexible and adaptable organizational struc
ture brings innovation, creativity and involvement of the
people toward achievement of the. .gp.als .and objectives.
5.
The organization' must select employees who are .growthoriented and later provide conditions and opportunities
for continuing growth and development of its employees at
various levels.
Besides organizational responsibility,
however, the individuals must take sincere efforts toward
their personal and professional development.
6.
To promote a mentally healthy organization, the employees
at various levels must have a positive attitude toward
themselves as well as others in the organization. Favour
able inter-personal relationships, commitment and goaldirected behaviours will result in creation of a healthy
environment in the organization.
B.
Responsibilities of Industrial Medical Officers
The jresponsibilit ie s of industrial medical officers and/
or health institutes in' an industrial setting can briefly
be classified .into, four categories:
1. Humane care of the sick person
(both physical and mental)
2. Early diagnosis, treatment and rehabilitation ofthe
sick person.
3.
PreTention of sickness (both,.physical and mental).
4.
Promotion of positive health (both physical and mental)
in industry.
7 :-
1 • Humane cara of the sick person — both physical and
mental
The progress in medical and behavioural sciences has shown
us that all problems, both physical and mental, are caused
and thus can be treated.
Until recently,
some of the physi
cal and mental problems, particularly the mental problems,
such as alcoholism, drug addiction, psychotic behaviours,
particularly paranoia, schizophrenia, psychosis, and socio
pathic behaviours ware considered to be the result of demonic
or satanic origin of man and as a result were not treatable.
Individuals suffering from such symptoms were institutionalised,
like criminals, isolated from the community and the loved
ones and made to suffer until death.
Since 1961, the medi
cal, psychiatric and psychological associations around the
world have clearly stated that all such problems or 'sick
nesses', like any other sickness, are treatable.
It is thus
the responsibility of the industrial medical officers to not
only cure but provide care.
Care is more than cure.
Care is
not’ only practicing the art of medicine, but also treating
the individual as a human being with love,
understanding.
affection, and
The industrial medical officers have, no
doubt, to take care of a great number of patients and pro
vide minimum care including cure and as a result cannot
provide the best attention and care required.
But at the
same time it is the responsibility of the industrial medi
cal officers to provide the best humane care possible.
2. Early diagnosis, treatment^ and rehabilitation of the
sick_£crson
The industrial medical officers interact with the employ
ees at throe levels:
(a)
at the time of medical examination,
(b) when the employee visits the hospital or the medical
officer visits the employee at home or at the work setting,
and (c)
interaction with the members of the family of the
sick person.
A good physician who has perceputal ability and cogni
tive flexibility will be able to identify the individuals
8 :-
at the_jime.’ .of. -medical ex ci min at ion who arc prone to sick
nesses and are likely to experience strains due to stresses
in the organization.
This the physician can only do if
they educate themselves and are aware of the organizational
dynamics and the environments in which the employees have
to work.
It is well documented in research that employees
who have high degree of absenteeism rate and accident prone
ness visit more time the hospitals and come up with grievances> have emotional problems, particularly low level of
emotional stability, low degree of frustration tolerance
and have high degree of worries and anxieties in life.
At
the time of the employees' visit to the hospital, the
physician, in the process of diagnosis and prognosis, must
become human to interact with the patient, show interest
in the employin the employee's work and needs,
and home situations.
interests
Similarly, in those situations where
the physician has the opportunity to work with the members
of.the family of the employee, the physician
should be
perceptive enough to study the family environment and gather
information which might have bearing on the employee's work
behaviour.
Keeping in view the work environment and the family
environment, the physician should provide the cure and the
care.
He is expected to deal with simple facts of stress
such as anxiety, frustrations, dejections and mild dep
ressions.
Like the family physician, if the resulting
symptoms become very disabling or of grave nature he should
refer the patient to specialists fur consultation and treat
ment.
This required that he should, to some extent, be
effective in psychological and psychotherapeutic techniques
as he is in the medical techniques.
In simple language,
he must understand the patient as a human being, under
stand his needs,
his conflicts and defenses and know how
to help him solve the problems.
The art of medicine
requires that the industrial medical officers should be
9
able to recognise the relation between the stress of
circumstances and the patient's health and should develop
the abilities to handle ■ successfully the emotional and
personality factors in illness.
The more severe cases
should be refe'red to the experts and, if necessary, the
patient be admitted for medical and psychiatric help.
3• Prevention of sickness - both physical and mental
Each organization is a miniature, authoritarian, social,
political and economic in nature.
As a result, it influen
ces the health and particularly the public health aspects
Your role as industrial medical
of the organization.
officer is not only to provide medical care but also to
promote public health in the organization.
Your role,
however, is certainly advisory rether than legislative.
Most of the medical officers have no direct authority
either in medical or related policies affecting the health
of the employees.
Still, however, as a medical officer,
you are professionally responsible to work with the top
management in developing and promoting public health
policies in the organization such as clean drinking water,
hygienic bathrooms and lavatories, clean and hygienic
kitchen and canteen services,
noise in the industry.
and minimal smoke,
dust and
Such preventive measures will not
only minimise physical sicknesses but also create a physi
cal working environment condusive for better morale and
job satisfaction.
Most of the mental sickness problems are due to stresses
in the organization and the resultant strains experienced
by the individuals'.
All of you, however, know that the
degree of stressers experienced by the individuals are
affected by the perceptual systems .of the employees. The
industrial medical officers thus have to se'rve as coun
sellors to the employees and help' them alleviate the
anxieties and strains.
Major stressers are uncertainty
of jobs, relationship with colleagues, inequitable
t
.10
:-
policies cf the organization, the attitude of the supervi
sors toward the employees, lack cf role clarity, quantum
of work, high standards of performance required, and the
demands from the personal life of the employee-.
4.
Pr omc t ion_□f _po sitivc__he al t h_i n_indus t ry_
As all of you know, the positive health is different
from absence of sickness.
Positive health is the result
of not only having a sickness free body and mind but
also
a continuing programme of maintaining healthy body and
having positive attitudes, goals, carefully chosen occupa
tions and continuing opportunities for fulfilment from the
work.
If such conditions ex'ist in any industry, the
employees are likely to experience minimal stresses and
strains.
The industrial medical officers should advise
the management in promoting health education, family health
work orientations and social adjustment programmes in indus
try aimed at total well-being pf the employees.
The indus
trial medical officers should work with the departmental
heads and the top management in suggesting jobs which
provide the best opportunities, to the employees for utili
zation cf their knowledge and skills and continuing fulfil
ment from the work.
The industrial medical officers can
help create an environment of trust, openess,
sharing and a sense of belonging.
creativity,
Such an environment
will result in maximum creativity end goal achievement for
the organization and maximum health .and happiness for the
employees.
To perform the above roles and responsibilities, theindustrial medical officers should be truly - professional
so as to provide the best health service to all irrespec
tive of their race, religion, sex and creed;
should have
the orientations of continually learning, not only from
books but learning from interactions with the patients;
should have the ability to communicate effectively with
all kinds of employees at various levels of the
11
organization; should have the positive attitudes and confi
dence so that they can project the image of a healthy human
being to those with whom they interact; should be highly
motivated- and missionary in nature so that the quantum cf
work and the infrastructure in which they work do not easily
frustrate thorn to perform their challenging roles; and
should have the highest self-esteem' and self-image which
comes from commitment and dedication to the chosen pro
fession.
The industrial medical officers shculd work with the top
management and in fact should be- on the Board cf the manage
ment of the company to help develop organizational and
personnel policies which will minimise mental health prob
lems at work.
My observations, based on my interactions
with the medical officers who have participated in my'
various training programmes in the last two-and-half years,
is that most of the medical officers are treated like employ
ees and not even given the adequate recognition and impor
tance as professionals which they deserve.
that the Indian Medical Association,
It is my hope
Indian Association cf
Occupational Health and other professional bodies will
strive toward a situation wheri'the management will give
the respect and acceptability to the medical officers and
the medical officers of the industries will serve on the
Board cf the management of the companies.
I wish you, one and all, a great success and, be.st wishes
for your challenging role as a health professional in your
organizations.
Thanks again for the opportunity given to
me to share my thoughts on the subject with you.
ar/10379
12
REFERENCES
1,
Ajit Singh, The Lonely Manager. Lok Udyog,
April 1972, 977-80
.
2.
Brown, J.A.C. The Social Psychology of Industry,
Baltimore: Penguin Books, 1954, 258.
3.
Buck, V.E. Working Under Pressure.
Staples Press, 1972.
4.
Davis, F. Uncertainty in Medical Prognosis, Clinical and
Functional in E. E. Rreidson and T. Lorber (Eds.)
Medical Men and Their Work, Aldine-Athertor, Chicago,.:
1972.
5.
Dwrivedi, R.S. A Psychological Attempt to Diagnose
Personality Difficulties among Indian Managers.
Indian Management, May 1969.
6.
Eaton, J., The Assessment of Mental Health. American
Journal of Psychiatry, 108, August, 1951, 81-90.
7.
Jahoda, M. Current Concepts of Positive Mental Health.
New York, Basic Books, 1958.
8.
Kornhauser, Arthur., Toward an Assessment of the Mental
Health of Factory Workers: A Detroit Study. In
Human Organization, Vol.21, No.1, Spring 1962,
9.
Lanter G.P., Environmental Constraints Impeding Managerial
Performance in Developing Countries. Management Inter
national Review, 1970, 10 (2-3), 45-52.
10.
Levinson, Harry, Emotional Health in the World of Work,
New York, Hasper & Row, 1964.
11.
Lotia, C. Managerial Problems of Public Sector in India,
Bombay, Menaktalas, 1967.
12.
Mills, C.W., White Collar. New York: Oxford University Press
1953.
13.
Narain, Laxmi., Managerial Turnover in Public Enterprises,
Lok Udyog, May 1972, 11-16.
14.
Plummer, N. and Hinkle, L. Life Stress and Industrial
Absenteeism: Concentration of Illness and Absenteeism
in one segment of a Working Population, New York.
15.
Ronan, W.W. Work Group Attributes and Grievance Activity,
Journal of Applied Psychology, 1965, 47, 58-41.
16.
Sahni, Ashok., Management and Organizational Climate for
Research and Development, Manpower Journal,
December, 1978.
17.
Sahni, Ashok., Stress in Managers and Professionals in
Indian Organizations. Indian Management, Vol.17,
No.10, October, 1978.
18.
Sarien, R.G.(Ed.) Managerial Styles in India.
& Sons, Agra, 1975-
19.
Sayles, L.R. Behaviour of Industrial Work Groups. New
York: Wiley, 1958.
20.
Selye, Hans. Stress Without Distress. New York.
New American Library, 1974.
21.
Shaffer, Lawrence F. and Edward J. Shoben, Jr. The
Psychology of Adjustment. New York: Houghton-Mifflin
1956, Mi 585-590. '
—o—
10579
Ram Prasad
The
MH - B-lq.
reaching the unreached
by R. Srinivasa Murthy
n (he last (wo decades there has been
If :| a major shift in the organization of
g health services all over the world.
'i-1' There have been efforts to "depro
fessionalize" many health activities, to
decentralize services and to place in
creasing emphasis on providing services
for "priority problems" for everyone.
This shift can be viewed as a "public
health" or "community" approach as
compared with the earlier emphasis on
individual health care. In this context,
the present article attempts to highlight
possible ways of providing mental health
care in peripheral health centres of deve
loping countries, and in particular of
India.
Traditionally, mental disorders have
been considered as a problem of the
affluent countries. The organization of
services is thought to be too complex and
expensive for developing countries. Thus
it is not surprising that there is. at
present, very little recognition of men
tal health needs within general health
services.
The reasons behind this relative
neglect of mental health needs are not
difficult to understand. Firstly, until
about a decade ago there was very little
reliable epidemiological data relating to
the distribution and prevalence of mental
disorders in the population. Secondly, in
the past the major effort in planning the
services was directed towards establish
ing mental hospitals and clinics. These
mental hospitals were more often custo
dial than therapeutic. Thirdly, there has
been a severe shortage of trained profes
sionals, and few of those available have
been working in urban centres. Fourthly,
the general public often view mental
disorders from religious, superstitious
and magical standpoints. This has lim
ited the effective utilization of even the
available services. Fifthly, there have
been no meaningful models for the pro
vision of services suited Io rural socie
ties; the research efforts of the profes
sionals have only recently been directed
towards this field. Lastly, the supply of
psychotropic drugs is limited and very
few welfare agencies exist to undertake
rehabilitative work.
It is not unusual t<f hear health plan
ners, administrators and medical profes
sionals make comments like “Is it a
problem?", "Can anything be done?" or
“Don’t we have more important health
problems?".These doubts arc especially
relevant in developing countries where
the funds available for health services
are limited and there is a more obvious
need to control communicable diseases,
improve nutrition and provide immuni
zation.
Above: Even today, acutely ill patients in
some countries are managed by being res
trained in chains rather than by drugs and
hospitalization.
(Photo WHOIR.S. Murthy)
Right; Too much emphasis in the past was
placed on large central mental hospitals.
more often custodial than therapeutic.
(Photo WHO/E. Schwab)
At this point a brief consideration of
the magnitude and the public health im
portance of mental health will illustrate
the need as well as the scope for organiz
ing services. Epidemiological sludie
from different parts of India during the
last decade have shown that different
forms of mental disorders are prevalent
in all cultures and communities. The
prevalence of different forms of psy
choses is about one per cent, and if
mental retardation and epilepsy are in
cluded it is about two per cent. This
figure represents the severely ill, requir
ing care.
What about their "community ef
fect"? it is estimated that about one-fifth
of all the disability in a community is due
to mental disorders, .and these cause a
still greater degree of social disruption.
For example, the frequency of marriagerelated problems in schizophrenia were
shown in a Chandigarh study to be about
ten limes that for the comparable general
population. A significant number of
students with schizophrenia do not com
plete their studies. The effect on the
family members is another aspect of the
problem: nearly half of them resented a
schizophrenic living in the family. The
effects of psychotic depression in terms
of individual suffering, loss of produc
tion and the risk of suicide illustrate the
importance of treating acute psychoses.
But mental health care is not just the
care of psycholics. Health scr.ices are
burdened in their routine w.-il, with a
significant proportion of patients with
emotional disorders. Studies earned out
at a big referral hospital at Vellore,
South India, and in the peripheral health
centres of the Raipur Rani Block, in
North India, have shown f at nearly
30 per cent of general out-patients have
mainly emotional problems. These cases
are most often mis-diagnpsed. leading to
costly and time-consuming investiga
tions and treatments. This mal-utihzation of the limited health services can be
avoided if primary physicians and health
workers are trained in mental health
In addition to the above traditional
problems, there are others. Some exam
ples are the growing problem of drug
abuse and dependence, adverse effects
resulting from the break-up of the joint
family system, and the ill-effects of in
dustrialization and urbanization. In a
developing country like India, social
upheaval is inevitable as a result of at
tempts to increase the rate of develop
ment and modernization. If adequate
plans are not made, there is every likeli
hood that these problems will soon
become the chief burden of the welfare
services. Planning ahead and prevention
are the two most important needs in
this area.
There are other sources of avoidable
mental health problems in developing
countries. A good example is the prob
lem of mental retardation. There is grow
ing evidence to show that malnutrition
and anaemia in the pregnant mother, as
well as poor nutrition in the first two
years of life, contribute significantly to
the incidence of mental retardation. Pro
fessor Sethi's study of rural families near
Lucknow suggests that a majority (72 per
cent) of the retarded in the community
were of the mild retardation group. It
was further noted that this could arise
mostly from environmental factors, espe
cially from "nutritional deficiencies".
Similarly the high rate of first cousin
marriages (as much as 40 per cent) in
some communities of South India may
contribute towards certain forms of men
tal retardation. There is scope for prevent
ing the above groups of problems
through public education, legislation and
the provision of adequate maternal and
child health services. This preventive ap
proach is also relevant for implementing
such mass health activities as immuniza
tion and family planning.
Against this background of needs, the
available services and the awareness of
mental health problems in the peripheral
health centres arc very’meagre. There arc
fewer than one psychiatrist per million
population, about one-third of the medi
cal colleges ii i India do not have depart
ments of psychiatry, and the mental
d happy scene of village children dancing.
Nevertheless, a variety ofmental disorders are
prevalent In all cultures and communities.
Indeed about one-fifth of the disability in a
community is due Io mental disorders, which in
turn cause a great deal ofsocial disruption.
(Photo WHOIE. Schwab)
health training of basic health workers is
negligible. Thus even today most acutely
ill individuals are managed by being res
trained in chains rather than by drugs
and hospitalization.
Fortunately, in the last 30 years, there
has been a significant increase in trained
personnel and training facilities in India.
What has been lacking is a coherent
national policy and a commitment to
provide basic mental health services to a
majority of the population in the quick
est time possible with the minimum of
expenditure. This is the challenge facing
mental health professionals in develop
ing countries.
A wide network of health facilities
exists in the rural and urban areas of
India. The basic unit is the primary
health centre (PHC) catering to about
100-120 villages with a population of
about 100,000. There are two to three
medical officers in each PHC along wijh
other additional health staff. In-patient
facilities for eight to twelve patients are
available. The PHC is connected to the
peripherally situated subcentres (six to
ten per PHC) manned by auxiliary health
staff—health supervisors, multipurpose
workers and dais (nurse-midwives). Thus
there arc provisions for the rural popula
tion to get medical services through a
network of subcentres and PHCs. In
addition, the multipurpose workers visit
each household periodically to collect
vital statistics, provide care for minor
illnesses and give health education.
More than 5,300 PHCs and 33,000
subcentres distributed all over the coun
try have been unable to provide effective
health care for a number of reasons, the
chief of these being the lack of supplies,
supervision and support. The drug bud
get of the PHC is Rs 6,000 (H.70 rupees
= USS I) and that of the subcentres
Rs 2,000 per year. The average per capita
expenditure on drugs works out at less
than one rupee per year, out of the ten
rupees spent on health services. This
drug scarcity imposes an important limi
tation on the effectiveness of the existing
health staff to provide curative services.
The problem of drugs becomes very
clear if the following example is consid
ered. Out of the population catered for
by the PHC about 900 epileptics requir
ing drugs can be expected. The treatment
of these 900 with phenobarbitone, the
cheapest drug, would cost more than the
total drug budget of the PHC! At present
health workers have no sedatives or psy
chotropic drugs with them and even at
25
reaching the unreached
Left: Recent evidence shows that rural life
itself may be beneficial in pre venting chronic
mental illness. Studies also show how impor
tant it is to avoid the dangers • r social isola
tion which result front moving mental patients
to hospitals away from their communities.
(Photo WHO/E. Schwab)
Right: In the grounds of an Indian psychiatric
hospital. Today's emphasis is on inlegiutlng
mental health care with general health ser
vices. and on placing respon sibililyfor primary
care upon those health workers who are closes!
to the community, leaving more comple r prob
lems to be dealt with by marc intv nslrely
trained staff.
(Photo ll'HO/S. e.ochar)
the PHC the availability of the basic
psycho-pharmacological agents is quite
inadequate.
Other limitations are the lack of
mobility of health workers and medical
officers which prevents proper supervi
sion and support. The same problem
hinders the functioning of a proper refer
ral system from the subcentres to the
specialized institutions. These arc in
herent problems of the rural areas and
are as relevant to mental health care as to
general health care. Existing personnel
can, however, be used to advantage by
stepping up training, support and sup
plies. and this should result in quick
benefits. The existence of large numbers
of traditional healers and practitioners of
indigenous sy stems of medicine is another
source lor providing care to the rural
populations.
What attempts have been made in the
past to provide services? Efforts were
26
mainly directed towards increasing the
number of trained mental health profes
sionals, increasing such facilities as hos
pitals and clinics, and improving the
training in psychiatry for medical gradu
ates. Any hope of having enough trained
professionals and facilities is unlikely to
be realized in the near future, nor is there
likely to be a mass movement of doctors
to rural areas. There is also a danger of
social isolation in moving patients to
hospitals away from their communities.
Indeed recent evidence shows that rural
life may be beneficial in preventing
chronic mental illness. A more important
reason for abandoning or lessening the
emphasis on imported professional
models is the lack of funds available for
fresh programmes which require massive
inputs in training, building and rehabili
tative services.
The alternatives, for the present, ap
pear to lie in decentralization, increasing
community participation and deploying
available health workers and staff in the
periphery, flic aim should be to provide
care for "priority conditions" in the
shortest possible time. The choice of
priorities should be based on community
concern, prevalence, disability caused
and amenability to treatment. Acute psy
choses. severe depression, epilepsy,
chronic psychoses and mental retarda
tion can be chosen on the basis of above
criteria. Next, the emphasis should be on
integrating mental health care with the
general health services. An essential part
of this approach would be the strength
ening of medical personnel and facili
ties by increased support from the psy
chiatrists. The emphasis is not on the
psychiatrist nor on the health worker as
such, but rather on a change in their
roles and their mode of work, so as to
place responsibility for primary euro
upon those closest to the community,
MAY 10, 1981
frustrations and energy. Their
otherwise strange behaviour Is
perfectly . acceptable here. The /
implication here is that their con
dition arises from
suppression,
stress, and related psychological
rCW?th‘so much 6peculation. it
is not possible to unequivocally
state that any one
particular
theorv is correct. It is
obyious
that **a vital piece is missing from
the puzzle that is Gangapur.
Through all this
muddle of
theories, one fact remains unal
terable: the devotees’ belief in
Datta Guru. To them, he is die
all-pervading force. He is the em
Photos by the author
bodiment of the gods Brahma, \ isnnu. Mahesh, and is identifiable by
his three heads. The legend dates
Also, though one cannot imaback
approximately five him-.
.giw them as being gymnastically
died years; and begins about two
Mined, they perform headstands
miles away from the village, at
on cold concrete, their bodies - the confluence of the
Bhima
contract and flex In postures of
and Amar <Hia rivers, called San
' nil kinds, the most common being
gam. An atmosphere of tranthe foetal position. Their speech is
ouility surrounds this area. De
fies
take
a
dip
in
the
sacred
•hurried and distorted, but they
ia-.e the ability to speak clearly
river and pray for sahatlon. ISn« sometimes even give answers
is believed that the second avatar
re questions put to them by onof Datta Guru meditated here.
’ too efs They have been known He was called Shrl Naraslmvim
tv converse in a language alto- Saraswatl. He was an ascetic and
ad .er alien to them, but this apstories abound about his miracu
to be a rarity. Another lous powers, among them
bis
,trait shared universally is their
ability to heal the sick. It is lc
ubr.ost continuous recitation ot lieved that he did not diel likean.
ordinary mortal, but that he Loailv disappeared from the earth.
The legend still lives strong in
people’s minds. At any
given
Se of the year, there ore more
than a thousand visitors at Gan aX?l”» fifth o' lhe popula
tion of the village They mam y
consist ot rural devotees.
Ou.
the years there’s been an JncreaX’milux of the more cunou.
urban dweller, as the word gia
dually spread. And that word is
ujeonscious- but identical beha«w>r patterns. For instance, un‘ife the mainstream ot devotees
Jin move around freely in the
Utiple, not one of the ‘possessed’
minority Venture beyond the last
stone-step leading to the in
lier enclosure that houses the idol
o' Datta Guru. This is strange
slice nobody restrains
them.
'either physically or verbally, front
going beyond this Invisible bounfiai.v. Whatever be the status quo,
ft is apparently unspoken and
liceerstood.
“Hair in wild disarray she writhes, shakes, sings, chants and screams’
During.every aarti in
the temple at Ganagapur
in Karnataka a trans
formation takes place
in the behaviour o£ some
of the devotees: they
suddenly writhe and
twist on the ground in
a “self-punishing fren
zy”. contorting into al
most impossible postu
res. their speech hurried
and distorted. This state
is commonly known as
■ possession. N R U P E N
MADHVANI
recently
visited Ganagapur and
provides some answers
to this strange pheno
menon.
some bruises treated. But for
mer® serious complaints the young
man visits the next-door temple
of Datta Guru. These complaints
range from headaches to constric
tion of the chesx and £■«««•“
cramps in the stomach. Si
doctors had been consulted, h
of them were unable to ala
his malady and finally in
peraiion he had decided xo
this temple that so many fl-----and relatives had expressed such
faith In. Once in the temple he
noticed that his various illnesses
seemed to fade away. But, dur
ing the time when aartis are held.
a transformation in him takes
place. He writhes on the ground
in a self-punishing frehzy. He
loudly chants the name of Datta,
rpHE small clinic just outside
•*Lite Ganagapur temple
precincts in Karnataka is thirty-loot girder that supports
run by a qualified doctor. the corrugated roof over the Tem
Though an outsider, he's been ple quadrangle. After the aarti.
• Here for several. years. Inihas done. Ho does not compre
' tially, he was sceptical about he
hend what is happening to him,
the goings on at the temple. only that he feels better alter hav
His attitude now is that lie ing come to Ganagapur. A little.
cannot complacently shrug apprehensively, he expresses the
that a spell has been cast on
off . the phenomenon. If he fear
him by someone wishing to co
did, he would be closing his him harm. The doctor admits that
mind on the subject of spiri It Is possible. Occult
tual “possession" for the sole seem to flourish In r
reason that it isn’t discussed The victims or stibjec see
large, female. It
comprehensively in medical sud
women are highly sust
books.
gins more so.
He tatro«cce« » young man, a
BA', who is at the clinic io get
Ealra bat >•; nnuui
A possessed
tn. name ot Datt
*
sad, taarlab- D
I,
the completion ot e.iu»
Sie trance-llke state , ends.
. clear cut explanation is nor
. ,',‘iHble of this strange and bl«
'phenomenon at Ganaga-all“ There arc a vanoty ot theoW .■ one ot them is that these
ne’iu are possessed by an alien
^•'ttaouBhiheuse ot the occult.
X roMt becomes active during
ftSi Ot the aarti, performed
‘J awaken tile slumbering deny.
lu An-act Is thereby established
A ,c°en th« tw0 and CO!,S€tlu€Utl?
■ b,el A « a contest ot the aroused
ot good (represented by
mid evil (the alien spirit).
Are is achieved by the ejec■£’ of this spirit from the body
‘
"t has wrongly occupied. Ul• lately, this depends, to a peat
Aient on the will and strength
of 'lie individual.
’also believed that antidotes
?.■ m Tantric and Mantrio texts.
n-’-M-e is. however, little Ilkelldevotee: ^contest between good and
tAd of encountering a genuine
ntric, though there are the usual
evil
Ta voters residing in the hand“f°dliaramshalas in the village
Claim to know the "Wired
energy. Over
several weeks.
:• pattern ot behaviour has been ’‘‘..dotes. But their abilities a.e
sdletably the same and srrarme- JJ^ted more to merceuery man
S‘’'lAtl'lmoie'<down to earth theory
, • , mt the people who come hero
,’.c not really possessed. What
..-’re doing is merely “letting
JJw r hair down". In Ganagapur.
The Ganagapur temple: waiting for Datta Guru,
the “all-pervading force.”
■
U,e ,e« «! “t*» W
”i e°"5’'
Jose Faria, a priest
from Goa. was the first
hypnotist to liberate
hypnotism from ‘’esote
ric and useless theories”.
But despite his achieve
ments, he died in dis
grace, ridiculed by the
public.
*
AN
an unrecorded date in
1781, exactly two centu
ries ago, Jose Custodio Faria,.
a 25-year-oId, dark-skinned
Indian priest from Goa,
climbed to the pulpit of the
royal chapel in Lisbon, Portu
gal, to preach the Sunday
homily to the then reigning
monarch. Dona Maria I, and
her Court.
As .he gazed at- his expectant
audience, the young preacher —
who had just returned from Rome
wh$re hjj. had earned a doctorate
in ihealosy —lost his nerve. Cold
sweat trickled down his
back,
' his.lhroat felt dry, end his mind
went -blank. Just then he heard
Jhls ’ father, who stood 'directly
the pulpit, whisper to him
0F r:is :ij-ive Konkani: "Cater
re baji5' (chop off these vegeta
bles). The result was. immediate
and dramatic. For no apparent
reason a wave of relief flooded
his being. The nervousness va
nished. He cleared his threat‘and
preached eloquently.
Faria never forgot his father’®
words and their astonishing im
pact on • him. The episode threw
up a question which worried him:
how could just a few words have
such a profound psychological
effect on the listener? He found
his clue over a decade
later in
France.
. Bj
* this time Faria’s father, a
prominent figure in the
Portu
guese Court, had fallen
under
suspicion of instigating a revolt
in Goa against the Portuguese.
And the suspicion now threaten
ed to engulf the son as well: so
he tied to France and lost no
time in getting drawn into the
French Revolution. He even led a
Convention. In the thick of hos
tilities, the priest, now known as
Abbe Faria,
befriended a Mar
quis Chasienet de Puysegur, who
had been a disciple of
Anton
Mesmer, the Austrian
‘magnetist’ who claimed to cure
all
kinds of ailments with the help
of convulsions occasioned by a
‘magnetic fluid’ from the planets.
A French royal committee assign
ed co investigate Mesmer’s claim®
had
concluded
that
“Imaffination without magnetism cause
*
eonvuleiomt; magnetism without
The statue of Jose Faria in Panjini, Goa
Mesmer had
been
banished hypnotise people after they have
repeatedly
hypnotised.
from France, and Puysegur had been
proceeded » with his
master's Faria also considered the focuscures ’ without eliciting
convul ' ing of attention as the immediate
sions from his patients,, and with cause of lucid Bleep. He could pro
out resorting to theories of mag voke in deeply hypnotised sub
muscular
feats
netic fluids. His cures were usual jects all the
by
Char
ly accomplished simply by sooth later demonstrated
cot. By suggestion he would pa
ing talk.
ralyse an arm or leg, muscles of
Talking to
Puysegur,
Abbe the eyes and tongue and so on.
Faria , found
in the
Marquis’ He could make his . subjects shiver
procedure an echo of his father’s with- cold, or sweat with heat;
powerful Injunction: "Cater re often the sensations would
be
baji”. So he theorised that sug confined to just one part of the
gestions,
skilfully
implanted, body. Post-hypnotic suggestions
could cause psychological.
and (that is, suggestions to be acted
physiological
changes in people. upon after being aroused from
He opened a school where he ex a trance) did not
escape Fa
plored and demonstrated the power ria, and he was the first to dis
of suggestion.
By merely order cover the importance of ' deep
ing his subjects, imperiously to hypnosis In surgical operations.”
"Sleep.!,” he would throw them
Dr. Bernheim,
the
famous
into a trance, which would later French hypnotist, a
contempo
be known as the hypnotic trance, rary of Freud and the latter’s
but which Faria himself termed teacher, concurred
with
Dr.
Tucid sleep.
*
Moniz: "It is not to James Braid
hypnosis
Dr. Egas Moniz, the
Portu that the discovery' of
guese Nobel Prize winner in me is due; only the name...To waria
dicine, and also a biographer of belongs the undoubtable
credit
Abbe Faria,
credits the latter of having established for the first
with astonishing advances in hyp time the theory and technique of
notic techniques: "It was Faria hypnosis by suggestion, and of
liberated it from
who discovered the
importance having neatly
of practice in hypnosis. W® all esoteric and useless theorie® that
know that t-i la muoh easier to hid tho fcruth about IV
*
But Faria died In
disgrace,
ridiculed hi public and
banish
ed to servo as a chaplin in a re
mote •chapel. He planned a trea
tise on the subject extending to
lour volumes,
but only
one
came to light. It was called De
La. Cause Ihi Sommeil
Lucid®
(On the Cause of Lucid Sleep).
After Faria, hypnosis' continued
to suffer from disrepute,
frgm
which it was rescued by James
Braid, a British medical man who
gave the phenomenon the name
of hypnosis. But it was only after
World War H that systematic ex
ploration and exploitation of hyp
nosis began. During the War,
shell-shocked and wounded sol
diers were effectively, cured by
using hypnosis as an. anaesthetic.
In the three and half decades
since, great strides have been made
in the understanding of hypnosis, ■
both in its theory and in its appli
cations. It is today believed to bb
a peculiar state of mind in which
the unconscious is open to sugges
tions from the outside, without
Dr. Milton Erickson:
interference or interception from
the conscious mind. This state of persuading the uncon
consciousness is achieved through
at least ‘two processes. The fust
scious
consists in relaxing the conscious
mind to an extent which forces
it to drop its guard sufficiently
hypnosis
Is
to
shock the conscious i
io enable the suggestions to pene
trate the unconscious.
This . is mind and paralyse it with fear
usually done by telling the sub? ’ or some other strong emotion so
ject, in a monotonous fashion, that Its reasoning and responding
to relax and relax and relax, un faculties are temporarily suspen
til he is asleep. At the end of it, ded and the unconscious mind •
Abbe
it is only the conscious, mind that can be penetrated. When
is asleep, but the
unconscious Faria suffered his celebrated stage
mind is alert and obeys sugges fright, his conscious mind was
and
tions to- stop feeling pain, to para almost totally inoperative,
the
unconscious
responded
im
lyse an arm, to hallucinate, to
remember long forgotten events.. mediately to the symbolic injunc
tion of his father to discount
the intelligence of th® audience
Faria was addressing.
Suggestions need not be verbal ;
to b© effective. Dr. Milton Erick
son, one of .the most accomplished
-hypnotists of our time, who died
last year, describes how he used to
paralyse a subject’s hand in the
act of shaking it iu
greeting.
"I shake hands normally”, he said.
"The ‘hypnotic touch’ begins when
I let loose. The' handshake be
comes transformed from a firm
grip into a gentle touch by the
thumb, a lingering drawing away
Hypnosis merely actualists the of the little finger — just vague
potentialities of human beings enough sensation to attract atten
by getting the unconscious mind tion. As the subject gives atten
to supply the necessary - motiva tion to the thumb, you shift to a
tion that the conscious mind may touch with your little finger. I
sever contact .so gently that the
lack.
exactly
The other technique of inducing subject does not know
when —■• and the subject’s hand is
left .going neither up nor down,
bus cataleptic”.
Erickson was born colour blind,
tone deaf and, at the age of 17,
was paralysed by polio and able
only to move his eyes. But by lear
ning self-hypnosis he slowly per
suaded his unconscious to restore
the use of his muscles.
Hypnosis is now in widespread
use as an anaesthetic in obstet
rics and dentistry; it has been
used io enhance creativity by re
ducing the time needed to perform
a work of art and by eliminating
writers’ blocks. It has no match
as a'cure for psychosomatic ail
ments, like ulcers, migraine and ,
stuttering.
Stage hypnotists gave hypno
sis a bad name from which it has
not yet fully recovered: but they
also maintained it In the limelight
at a time when 'scientists tended
to ignore it-. Today. it has again
regained * modicum of respecta
Jose Faria : dying in dis bility.
;
; -4
S. K. WtS
grace
20
THE HINDU, Sunday, May 10, 1981.
Behaviour
with them appropriately.
(3) Take care of your needs for
affection recognise -and support
them Also build your self-esteem
(4) Love people (not manipulat
ing them) and use things instead
of loving them.Gifts are only a
substitute for real love.
(5) Develop
your
whole1
personality/parent, (your value i
system) taking care of your child, |
(emotional part) having joy, fun
and laughter, being creative and I
developing your adult (logical part)'
Cancer is a result of stress build- to deal with your problems adequat-1
up from six to eighteen months ely.
before the attack Most of us have
(6) Take over the responsibility
stresses in life, but how we deal for your health by paying attention
with them is the crux of the problem, to nutrition, physical fitness, stress
Is a psychological approach a management and environment -by
substitute for medical aid? It is being in communion with naturenot a substitute for medical treat- be aware of stressful events and
ment It is a booster enabling the adequately handle them.
patient to recover quickly The
(7) Develop a sense of identity.
psychological approach is preven- choose a good model to pattern
tive and prophylactic, enabling a your behaviour and life and have
normally nealthy person (present a purpose and a will to live
standards) to attain “Arogyam"
(Tamil word for high level of health)
®) Deal adequately witn stress
a very high level of physical, emo- caused by self-image, interpersonal
tional, mental and spiritual wellbeing, relationships, life styles and life
Tho
„.„-i,„i„
nl-.i nnn.n.rh.. transitions (stages)-having a mentor.
The psychological approaches wjse
orsGod |n «hom you
Tatecha^o" yourself accepting btrd'en'your problems 0°“ who^
The right way to
§©[lw® probtaBiis
Each individual reacts to events in
life in his own way. This behaviour
pattern is determined early in
childhood. With this background
how can a mature person deal
with problems? This article, the
second in the series on “The way
to a stress-free life” deals with
understanding our feelings and
analysing them to tackle life situa
tions.
UR
feelings
are
generated by thinking
and beliefs. We have
four major feelings: Glad (Happi
ness): Mad (Anger); Sad (Sorrow)
and Scared (fear, anxiety).
Other feelings like guilt, jealously,
resentment, self-blame are varia
tions or combinations of these major
feelings.
We may look at the same incident
but each one of us may have
different feelings depending on what
we tell ourselves.
If four of us are walking along
and see two people fighting with
glass bottles and see a heap of
stones nearby, each one can get
the following feelings:
„
internal uuniiiuis
imufiiui
conflicts these diseasesi we can learn successful patterns
of tackling troublesome situations
Scared because I might get in- s|ow|y disappear
jured. Sad because I tell myself,
— ■
Sickness is an escape mechanism! (anchoring).
Why can't two people live
Improving our self-esteem and
unconsciously used to avoid facingI
peacefully?"; Angry because I tell
problems and solving them. This. self-confidence helps in taking care
myself. "It is a puny fellow (or
is especially common among of our emotional needs.
a friend) who is getting beaten
children, women and weak-minded
Excessive competition leads to
up" and I get angry and go to aeo„ie"
“ " ..... .......
stress and anxiety which are the
his rescue, Happy because the H H ’
major causes of all diseases Relaxafellow who is getting beaten up , v.
’hat Is the right way
What
way to aoW
solve1 tion, inner calm, being aware of
refused me a favour or belongs problems? We have values, ideals> our strength and using and develop
to a different social class whom and beliefs which govern our ing our potential are far more ImporI hate and guilty because I cannot behaviour and actions. We have1 tant than comparing ourselves with
go to his help.
our feelings, the emotional side■ others. Motivation should come
These feelings are learned or of purselves. We have wishes and1 from within for achievement rather
we decide upon them early in our goals. We have to face the realities' than competition and comparison
life. They depend on certain beliefs 'of the world. Taking into account1 with others. Such inner motivation
which are unconscious. Bringing all these factors, if we arrive at1 does not cause anxiety and stress.
these early incidents and beliefs a pragmatic solution and implement1
We are under stress when we
to our conscious awareness helps it, it will lead to a healthy self
F work. It is good to balance it with
us examine them on the basis of This process touches all parts of
relaxation every day. Many confuse
current realities and change them,
our personality.
recreation with relaxation. During
Our beliefs and expectations (IrraIn this way. the decisions we1 recreation many compete leading
tional. impossible and dispropor- arrive at are done after due delibera-■ to stress. Playing a game for the
tionate) about ourselves, others and tions. If the results are not positive,. fun of It leads to relaxation. Even
quality of life and the world around we do not condemn ourselves or holidays are sometimes stressful
us cause stress, frustrations, anx- feel depressed, since we cannot: since they are overplanned and
leties and sadness and are succeed in all our endeavours. We1 rushed through.
responsible for negative emotions take disappointments with equaniProgressive muscular relaxation,
ano diseases.
mity.
removes muscle tension and
We learn the different feelings
The Bhagvad Gita Is a form1 improves blood circulation, calms
from our parental figures in our of psychotherapy which Krishna1 the body and the mind. Self-hypearly childhood They label the used to help Arjuna resolve his
1 nosis adds to tranquility of the
experience and the feelings. Instead inner conflict
mind.
if they ask us what feelings we
Qur present way of dealing withi
Visualisation will help improve
experience, they give us permission feelings and problems is learnt: self-image, self-confidence, coping
to experience appropriate feelings, when-we were young or by our with problems and feelings. It can
How do unsolved
problems reactions to early incidents. They.■ lead to a detached view of problems
cause disease?
If problems are operate from out of our awareness. and help find better solutions.
not solved and are swept under They were appropriate when wei
Stress and anxiety cause most
the carpet they lead to diseases, were younq. They may not bei of our diseases. Keeping track of
Being aware of them, confronting so now. The beliefs and valuesi our stress and problems and
them, solving them in a pragmatic which we learnt and which governi feelings help us in isolating the
way. leads to health. When a person our behaviour can be brought toi causes.
is in a fix and faced with a problem our awareness and dealt with ini
Maintaining
a
diary' on
which he is not able to solve and the light of current reality. Our-’ the following lines helps: Stressful
feels overwhelmed, conversion reactions and behaviour can then. Incidents prior to illness. Self-talk
reactions take place causing the be changed appropriately. By relax-,. — what u
„ yuu
lD11 yuulacH
do
you tell
yourself HUUU
abouti
following type of diseases: (1) Tern- 'ng (self hypnosis) and regressing the incident? Feelings — what
porary
---------------------paralysis, speech
------- >. disability;
................
we.......
get in touch
-k .with
vitk ,kthe oarlloof
earliest Ifeelings
_ II_________
are evoked
I—U l®«kby the Incident?
-J—.n
(2) Temporary blindness, deafness incidents when we set up the pattern Action taken. Any problems unand (3) Skin reactions and diseases. of coping with feelings and solved/solved—what was the proWhen a solution is found for his problems, or through neurolingistics cess of problem-solving?
yourself with all your faults, and
,
ftem and free
strengths; make mistakes and not yourself and
feel unduly guilty. Take calculated
— ■
'
(9) Keep a close watch on what
risks and find your hidden potential,
become aware of your strength, you are telling yourself.
developing it and enjoy using it.
R. Rathnam
(2) Own your feelings — treating
(To be continued)
the mind and body as one; deal
Dennis the menace
'THANKS FOR THE MEAT AN'THE POTATOES AN THE BREAD...
AH' IF I DONT MENTION THE CARROTS, I KNOW YOU LL
UNDERSTAND *
20
THE HINDU. Sunday. May 17, 1981.
Behaviour
Family relationship key to
wellbeing
Family Welfare Ladder
health and family health.
Strife and quarrels and tension
between parents, cause stress and
anxieties in children and they may
develop asthma, short sight etc
Nagging may cause and reinforce
good model for them to pattern alcholism in the spouse. Husband's
their behaviour and life; gives each behaviour may cause mental illness
person the time, space and opportu of the wife. Over-anxiety of parents
nity for developing his total persona may make children rebel and undue
~—1
lity. his values and Ideals, his joy pressure on them to study. excel
amily Lil e Style
^haviour Pattern
Self-actualisation
Harmony, peace.creativity
and realisation of
full potential of the
individual and family.
Family wellbeing depends on
the kind of relationship that
exists among the members.
The key is consensus after
due deliberation with
everyone's involvement in
tackling a problem.
I
11
I
I
Traditional Famib
Life Pattern
T
:
Growth
Awareness, diagnosis,
ENSIONS are the basic
confrontation and
cause of illness Relationship
family therapy
problems cause tensions
Education
Individual and family
which further aggravate them lead
counselling, training
ing to quarrels, and later physical
family discussions.
S’
and mental illness. Family health
depends on whether the family
Neutral
point
No
discernible
illness
or
wellbeing
allows its members to express their
feelings appropriately — listens
Control through guilt anger.
Signs
to their feelings: allows them to
sadness, fear. etc. (power
participate in solving family pro
dynamics) discounting others.
blems that affect them — using
their feelings and their.
a proper, process — recognise
problems.
their problems and deals with them
adequately, improves the self-image
Symptoms
Frequent illness of family
and
self-confidence
of
each
member, cold relationships.
member, gives them adequate sup
runaway children, lack of
port and allows them to grow
unified goals and united
according to their skills, aspirations
approachtoproblems—everyonr
and
dreams,
his
contract
with
his
and
conform
makes
them
ill
and dreams, accepting them
pursuing their separate goals.
reality
and
his
goals
Neck,
shoulder,
back
and
joint
unconditionally with all their faults
These are crucial for personal Pains ara symptoms of suppression
excessive drinking, smoking.
and strengths, provides them a
K
of anger towarcjs someone A
drug addiction.
healthy family which is bound by
Broken family, separation.
Disease disability
"Ci Gr ■■ love where open expression oi
divorce
feelings and opinions and needs
Death of family
are a'lowed
Sources of Tensions and their causes and cures
Sometimes parents in their
BHHHB^HBRSSgEBliB anxiety try to provide for children
LEVELS
CAUSES
CURES
CAUSES
what they had missed m their own
Social
Awareness, providing healthy
Ilves These messages may often
Peer pressures, peer expectations.
atmosphere
and activities; allowing
be non-verbal not spoken
may
relationship
social pressures, poor social
spoil children or if children are
each person and family to grow.
support, poor models for
compelled to do something it may
adequate social support.
emulation.
interfere with their growth eg . colAwareness, allowing each person
Family
Undue expectations, secret wishes
lege education for a child whose
to grow according to his abilities
relationship
of parents for the children—
father did not have one Very often
and wishes, support and love.
trying to realise their
parents seek to complete their ununfulfilled desires through their
fulfilled lives through their children
children, over control, over
The non-verbal messages, which
anxiety, putting down.
are generally beyond our consiousSelf awareness, taking charge
Personal level
ness, are very powerful Their
Unexpressed feelings, unresolved
of one's own life, self
(Inner
impact makes or mars a family
problems, poor self image, lack of
esteem, relaxation, coping with
and its
Conflict)
identity, purpose in life
feelings and problems, taking
If your child is anxious or scared.
insecurity, lack of love.
care of own psychological needs.
acknowledge
relax yourself and
touch the child for a few minutes
_____Personal Health ■ pass.ng on relaxation messages Fee|ings. I.ke food. sh
Give them positive attention, they limits, ideals; (2) exchanging informa
I say you would take care of cessed through
,
Pr0*
tion, facts, examining probabilities
gjMBS i>' ..j
.7Tj' I'M It After a few days, the child will whatever is not
,body and arff 'in "a family each person ex our goals; (3) exchanging feelings
be able to hook its adult (logical »iiminated
an ed should be presses his feelings and voices sharing love. joy. having fun anc
■
and watch how you deal
his opinions and a pragmatic solu laughter and joking, sharing our
Power
dynamics
‘
or
w™
,
with the scaring situation and be
tion is arrived at taking into acanint dreams; (4) expressing concern.
-----==g=l^^g emboldened to deal with it in a and flow m a family cPa™erPlay the realities of the world, it tends love, appreciating and encouraging
□....... way
way
emotional P/oblems p“Jlany
similar
to be an emotionally, mentally and and (5) requesting help.
Anger is an emotion which people
Person physically, a healthy one.
When we analyse communica
°f exPressin9' Som® of guilt Somep^°,do things out
The key is consensus after due
tions in a family, if this pattern
think that expressing anger breaks °r 9“ f
or
use tantrums
with
everyone s is not present, something is missing
relationships
Appropriate
ex9
what they®?8 88 a means deliberations
involvement
and
wl,lin
9r®
i
?.u
nthe
.
in
relationship.
pressions improves relationship.
,' 9their power
Want. or exercisWe communicate with each other
H. Rathnam
9
*
"f
' ve and concern
in the following patterns:
Communicating va|ues' °Pinion9'
Behaviour
THE HINDU, Sunday. May 24, 1981.
What holds good for
personal and family wellbeing
applies to organisations and
society. Promotion of selfesteem of the employees,
provision of proper outlets
for suppressed feelings and a
consensus approach to
s^iement of problem
contribute to the healthy
working of an organisation.
mg the best out of the workers
As tensions build up appropriate
outlets have to be provided Helping
them develop values and having
fun m life help total development
of personality When feelings like
anger do not find an outlet, the
person or group is emotionally
disturbed and not m a position
to deal with situations in a mature
way An outlet restores their ability
to solve problems and the organisa
tion is -estored to health
Problems which are not tackled
quickly cause ill-health Instead of
discounting them, dealing with them
openly listening to the feelings
and opinions of everyone and arriv
ing at a pragmatic consensus lead
to tne healthy functioning of the
organisation
. The Western type of democratic
NEXPRESSED feehngs. un,deY0ld of ,fedl,n9
This approach by majority vote is a
problems
°fL.
alfeell
P9s ,n’erfere ,wlth cause of social ill-health The losers
1
.rresolved
esolved problems,
low IL
*"e9
’led
""‘ ’
----------------------S
__ ____
W^selfesteem
andi sense of» tne normal ralatmnenm
reLaB0^, Po m:
ma^9 are unwilling partners and create
insecurity are factors that affect P™2fmS?lv'n9 dlffl?uJ- Relaxat,on 'social tensions Consensus based
on the
the Indian
tradition
the health of any organ.sat.on,
and gu'ded exerc^ a"4 «
best democratic
proce^’fo/'^l
U
Most of the problems in mstitu- some well known methods of organisational, family and personal
tions arise from the way employees promoting healthy feelings and gett- health
_________________
Putting down a person or a
9rOuP towers his or its selfesteem
d0Pe 10 oeost sefcon
-oeaca ne.ps aecoe a-me out
:ne ces: oj: of ,ht?,r |,vos 7his
“
■mproves
mp-ores the problem-solving
prociem-splvmg orc
process
organisation and
'
cess in
m an
an organisation
and e
at.
the seme
same time helps the person
and the group to take care of
I the emouona,
emotional neeos
needs
|„,e
I Stress, which is the cause of
[diseases and strife is a result of
the interaction of a poor self-image
and
poor interpersonal
relationships Insecurity leads to fear
which is converted later into anger
leading to violence, strikes and
riots A sense of security contributes
to emotional balance
Just as oxygen is essential for
a healthy body, persons and groups
feel the need tor attention either
positive
or
negative
An
organisation paying positive atten
tion to the staff and motivating
1 them reaps good health Negative
! attention like threats and punishi ments can also help it function,
[but not in a nealthy manner
I Sometimes violence and riots will
An organisation under tension
out caused
pausec by
oy resentment
, esen--er.out
and suppressed fee.mqs Tbs is
comparable to inadequate brea-r
,ng and oxygen sucply when ,
person is emotionally disturbed
Communication, s.m.lar to blood
circulation in a body, is essential
for an organisat,o/ to functlon
healthily When emotions are put
down the muscles become rigid
interfering with the blood supply
Similarly groups in an organisation
when emotionally disturbed build
up insulation around, them and it
would be difficult to communicate
with them The same can be extended to society where social
groups function healthily or unhealthily Social health can also be
improved by following the above
principles
tia1 and participants go back to
their homes every day and tryout
these skills at home
The
improved
relationships
makes them and their families
participate eagerly in these pro
What is the present behaviour grammes Skills learned at home
of Workers and Trade Unions'? are transferred to the workspot
Most of them are operating from and social life These programmes
the negative aspect of their critical are intended to improve themselves
parent ego state and .rebellious by managing themselves well. *mchild ego state They need inputs prove their family by managing
their families well, improve their
to develop the positive aspects
Many sick and malfunctioning organisation by managing tneir
units have been nursed back to work well and improve the
health by the following approaches . community
The
aim of
organisational
Listening to the feelings and pro
blems of individuals and groups. development is to get maximum
and responding to them positively results out of the organisation Re
helping them get their eonotiona sults are produced at the lowest
needs fulfilled — giving vent to
their frustration through humour
laughter and exercise, givng them
and the organisation a sense and
unity of purpose and a will to
live and survive, by implicit trust
in the employees and in the genera.
goodness of human beings and
expecting them to oehave in a
responsible and mature manner
Mature workers have good atten
dance. productivity and safety re
cords To help workers become
mature.
Quality
of
Life
programmes have been run to im
prove the organisational climate
at the most crucial interface nearest
to the production line, where real
action takes place These, run for
six days of six hours have enabled
the participants to become aware
of themselves, aware of others.
improve
relationships.
reduce
tensions, cope better with feelings
and problems, become more
mature, improve their happiness.
their family's happiness and thus
their health and their family s health
These programmes are non-residenwith his feeling and problems, and
providing outlets for feelings and
opinions of work groups, the
Personnel Department can take
tne organisational health to a higher
leve.
What makes an organisation
sick or sound?
unhealthy ideas is lowered
The Personnel Department (like
the doctor) bongs the organisation
only upto the neutral point in the
organisational ladder of wellbeing
By educating the worker to deal
ORGANISATIONAL
WELLBEING LADDER
Traditional Personnel
Change in managerial style
Department
DEATH-------------
New personnel function
Disease
------------------------------------------------------------- si
?!
Symptoms Signs Neutral Education Growth Self- o 2
1 Point
actuali 3 co
sation 82,
Malfunctioning.
gherao. violence,
r
Grievances, low morale, low
strike, lockout.
productivity.
absenteeism.
destructive
boredom, baseless’complaints, irra
When a group is emotionally un- competition
tional behaviour, dissatisfaction.
balanced, it is liable to be influenced
high rate of employee illness
by external negative forces and
ideas which lead to malfunctioning Go-slow, work-to-rule. demonstra
of the group and the organisation tions. token strikes, in-fighting and
Their capacity for resistance to
unhealthy competition
.evel by the workers
To cite two instances Ac
(250 workers) where
thieving
gamp.mg
organisation withm three w
A multmationa1 compa
workers m three facton
City) was able to help
and three groups mer
a smgie company-led ur
a seven-day program
Union leaders ano he
look at things m a matur
way Even violent ie
mature leaders
R. R
To be contin
anctined suicides
Ishikawa, a liquor a bigger factor in mur.der than In suicide-— least among average
because
mother-child
KIYOO
store owner, came home other
shinju
not develop
to find his two young sons propensity toward
On a- mirror, written in lip
stick, was the message: “Thank
you for caring for me-for a long
time. I am taking the children
with me. Sayonara. Sayonara.”
'•But Sueko Ishikawa, her wrists
^slashed, was still alive. She was
^•rested and charged with liomiBde in the deaths of the
two
fSoys, one aged five and the other
*
| nine months.
<\n average of one child, 13 or
younger, is killed by a parent
every day in Japan — more than.
countries
of the
oyako-shinju.
Many scholars here view the phe
nomenon as the radical tip of
an iceberg of troubles.
Japanese police keep no statis
tics linking suicides or attempted
suicides to specific homicides, but
a 1977 Welfare Ministry survey
indicated that about 17 per cent
of all homicide victims in Japan
were children killed by a parent
who committed or attempted sui
cide. Why?
Scholars cite a weakening of
the family as society’s main pil
lar and the stress that women suf
fer as a result of the continuing
limitations placed on their role
in Japanese society.
For suicide general, as
well
i»s for fathers who take the lead
in the family suicides, motives
a quarter of all the
country’s
homicide victims. In most cases.
the murderer is the mother, and
frequently she is intent upon com
mitting suicide.
Typically it is an urban house
wife. aged 25 to 34 with marital
troubles or an illness in the fami
ly, further burdened by raising a
child or two with little or no help
from either her husband or his
parents.
What Sueko had attempted is
what Japanese call “oyako-shinju,”
parent-child suicide.
Japan’s suicide
rate
ranks
10th in the world, according to the
Demographic Year book for 1978,
yet wtlcldes la Japs® apps-w to be
are linked to their position in
society, said Tadaydshi Shimamura, associate professor of the
Japan Red Cross Women’s Junior
College. Dr. Katato Momose, who
formerly worked for tho
Tokyo
Medical examiner’s office, called
it simply “face.”
But for suicidal women,
the
reasons almost always are per
sonal ones, Shlmamura said.
Changes in family life — and
resultant new pressures upon a
mother — rank high among them,
professor Klnjl Tamura of Toyo
University said.
Scholars such as Hlnoshl Insmura, a Tsukuba University psy•hopathologiiit, believe that family
strangled to death, their
bodies placed symbolically be
tween the mattresses on
which he and his wife had
slept.
at
Japanese — and
did
until
sometime in the early decades of
file 20th century, and were chieily
the result of poverty.
Since the end of World War
II. however, mother-child shinju
committed for reasons of poverty
has. all but disappeared. Family
disharmony has taken over as the
chief cause, Tamura said.
Spurred by Japan’s postwar
economic boom, population shifts
from rural to urban areas hir.o
brought the nuclear family to the
fore, Tamura said, and the mo
dern-day housewife finds her
self without the help and advice
that her predecessor used to get
from their husband’s parents liv
ing together in the old three-gene
ration households. She also gets
precious little help from the hus
band who devotes most of his time
to his job.
Indeed, some husbands pay eo
little attention to their families
that in most cases of mother-child
shinju the father was unaware of
his wife’s concern, Shimainura
said.
Opportunities for women to work
have grown, and mothers who do
have a job almost never commit
shinju. Shimamura said. Job op
portunities,
however,
remain
limited in terms of personal gra
tification and many Japanese
housewives lack ekills for reward
ing jobs.
But why do mothers hili their
children?
Partly, -it is because the coun
try has provided few institutions
to care for orphans, Tamura
said. Reluctance to impose ' a
financial burden upon relatives is
another factor.
Most of. all, however, mothers
kill their children because they
do not consider the act to be.tfiurder.
“In Japan, the unit of society
is the family, not the individual,”
Inamura said. -“The family pro
vides all kinds of help to an in
dividual even after tho indivi
dual becomes an adult. But if
something goes wrong, shinju can.
occur. It’s a bad part of a good
social system.” ’
In essence, the murder of a
child by a suicidal parent —
particularly a mother — is -re
garded as an inseparable part ■ of
the parent’s own suicide, Tamura
said.
The great strength that makes
Japan’s society such a stable one
— its homogenity of values —
also can make it a fearful society
for the small minority who fall
out of step with the mainstream.
Tamura cited
another factor.
Buddhist teachings which hold
that all who die become saints and
achieve bliss.
Among
other factors,
this
creates a public
sympathy for
those who commit Shinju..
If sympathy is widespread for
the person who commits suicide,
however, it is not for those left
behind.
Momose said that every mem
ber of a family in which suicide
occurs is branded with a social
stigma — a presumption, that
there is “something wrong” with
him too. Other relatives also suf
fer, he added.
Sam Jamesoa
Science ® Health ® Sport
tlon and management of basic
mental illnesses such as epi
lepsy and psychosis by giving
short training courses to the
doctors,
nurses and
multi
purpose workers running Pri
mary Health Centres and sub
centres in rural areas.
A one-and-half-year evalua
tion of the
NIMHANS' stra
tegy in 120 villages
in Ban
galore District has shown that
the cost of treatment using
the approach averages to only
Rs. 20 for
each
epileptic
patient
and Rs. 50 for each
psychotic patient.
Dr. Ravi Kapur, head, psy
chiatry department at NIM
HANS
is extremely proud of
the simple techniques his insti
tute has
developed to train
ENTAL illnesses have an
incidence higher than
that of leprosy but there is
as yet no national program
me for their relief. Studies
conducted in India show 30
to 40 million suffer from
psychiatric problems.
To
serve these people, there are
less
than
2,000
mental
health professionals in the
country,
all
concentrated
in urban areas.
If
Western-style
mental
health care is adopted as a
model
for India, its
extra
ordinary high cost will only
ensure that mentally deranged
people remain without succour,
for probably
a century
to
come.
For
instance, if
the nine
hundred epileptics found in a
population
of 1,00,000 usually
covered by a Primary Health
Centre, were
to be
treated
with
phenobarbitone,
the
cheapest drug available, the
entire drug budget of the cen
tre would not be adequate.
Responding to this situation,
the National Institute of Men
tal Health and Neurosciences
(NIMHANS) here, has develop
ed a low cost strategy using the
staff of Primary Health Cen
tres as surrogate psychiatrists.
No
additional facilities or
staff are called for. The stra
tegy is based on early detec-
M
poverty and affluence tend to
aggravate mental stress.
There is also little differ
ence
between the urban and
rural areas of India, accord
ing to a recent study conduct
ed in Chandigarh by Dr. N. N.
Wig,"head of the department
of psychiatry at the All-Indla
Institute
of Medical Sciences
in New Delhi. Dr. Wig found
27 new oases of serious men
tal Illness each year for every
1,00,000
urban people and 34
new
cases per 1,00,000 rural
people.
Many
such
cases go un
treated.
NIMHANS found, in
the villages outside Bangalore,
that
all psychotlcs had been
ill for more than two years
and one-third of them ill for
more than 10 years. The majo
rity of the epileptics were ill
for more than
three
years.
Over four-fifths of the affect
ed
were disabled
because of
One to two per cent of India’s 700 million
people suffer from mental illness: the
majority live with their plight, as Western
style mental health services are beyond
their reach. RITA MUKOPADHYAY des
cribes a simple and cheap strategy adop
ted by NIMHANS to treat these unfortu
nate ones.
fect
as much
as one t°a^°
per cent of tne ^Ount of
stress^and H^heTfUcan0Se
treatedMOwltherslm^^^^s^as
are^rnore dl^Tt^Jo-
varying
between 15 days
to
one month. The doctors to the
health
centres are trained to
diagnose
and treat P^chosis
while multi-purpose
workers
are trained to recognise these
conditions and follow-up the
patients
being
treated. The
nurses are trained to educate
the relatives ..and neighbours
of
the mentally
ill. It has
been found that the best way
of giving health education is
to
demonstrate
a recovered
patient.
The NIMHANS
team seeks
active
community
participa
tion. Cured patients from the
same village
are often asked
to
accompany
the team of
psychiatrists and social work
ers
on their
regular visits.
Community members are also
involved
in detection of psy
chiatric cases.
To
Identify
mental cases
within
a village, Drs. Kapur
and Mohan Isaac find it costs
one-tenth to
ask
just one
member, aged 25 or over, from
each family in the village about
mental
symptoms in others,
Instead
of interviewing every
adult
in the village. All the
psychosis
and epilepsy cases
can be discovered in this wav
The more detailed survey only
^l^ls. t0 identlfy
cases *
ha?workNe^^elye^^
PHC health workers and he
believes the country can now
launch a rural mental health
programme.
Mental health care has been
partly neglected in develop
ing countries because of the
erroneous
belief that the in
cidence of mental illness in
these
countries
is less than
that in the developed coun
tries, where the fast pace of
life creates greater stress. But
more
recent
surveys
have
shown that the incidence of
mental Illness is almost the
same in both types of societies.
In other words, each society
has its own quota and nature
of
stress. Extremes
of both
their Illness.
The popular
belief among
mental health specialists that
villagers are not sophistica
ted enough to seek help for
mental disorders has also been
found to be wrong by NIM
HANS. Over half of those with
psychiatric
symptoms
do
actually
consult
a therapist
— usually a traditional hea
ler — and virtually everyone
with
Illnesses normally con
sidered
serious by
trained
psychiatrists (like epilepsy and
psychosis) consult a therapist.
NIMHANS Is training the
PHC staff for treating only
epilepsy
and
psychosis be
cause these two conditions af
the majority of people treated
*About
™PrSV<cdenCt°nSofera^
with ^thSr V g&W
is vita, for
"Meh
the succS16 of °therV^^oubt
strategy when
the country
n?PS1\e<i ,aU over
the effic&cy and1Srib2fed on
the staff7 of
SJSatlon
of
Health Centres
Primary
which thev
attributes for
Dr. Kapur,
ho^ewr®11 knownthat if the PHc^S'i
argues
work with
e£n ■£? were to
efficiency, it
Per cent
step forward fnr
x a ^ajor
^e. given> id bi?aekntalt heaith
the moment.
cse future at
SCHIZOPHRENIA
RESEARCH
ELSEVIER
Schizophrenia Research 16(1995) 17-23
Gender differences in disability: a comparison of married patients
with schizophrenia
Radha Shankar *, Shantha Kamath, A. Albert Joseph
Schizophrenia Research Foundation, (I), C-46, 13th Street, East Anna Nagar, Madras-600 102, India
Received 11 March 1994; accepted 25 August 1994
Abstract
Gender differences in disability constitute a fertile area of research, as disabilities need to be measured and evaluated
in the social context which defines role expectations and consequently the role performance. This paper reports on
the differences in disability in married patients with schizophrenia, as marital status is an important determinant of
role expectation. The study sample constituted 30 married patients, of both sexes, who satisfied DSM-III criteria for
schizophrenia, and were living with their spouse at the time of assessment. Disability was evaluated using the DAS
(modified version). The findings indicated that women were more disabled than men on many of the evaluation
parameters (p<0.05); there was also a strong correlation between negative symptoms and disability variables in both
the sexes. While a correlation between PSE syndromes and disability variables was seen in the case of males, the
relationship was not seen in females. Stepwise regression also revealed that negative symptoms predominated among
the factors associated with global disability in both sexes. Most of the reports in the literature reveal that women are
less disabled than men. The findings of this study, that women are more disabled than men, is discussed in the context
of the social conditions prevailing in India.
Keywords: Gender difference; Marriage; (Schizophrenia)
1.
Introduction
The last two decades have witnessed an increas
ing interest in conceptualising, defining and meas
uring disability consequent to mental illness. The
impetus to develop a sound conceptual base and
refine the measurement of disability has been
prompted by several concerns. The first stems from
the recognition that disability merits independent
attention as an outcome parameter in the longitu
dinal study of illnesses such as schizophrenia.
Second, understanding the constituents of
disability is fundamental to the development of
• Corresponding author.
0920-9964/95/S09.50 © 1995 Elsevier Science B.V. All rights reserved
SSDI 0920-9964(94)00064-6
programmes towards disability amelioration and
psychosocial rehabilitation. Lastly, a sound defini
tion of disability is crucial for framing legislation
to determine eligibility for social welfare benefits.
Anthony (1972) has suggested that an under
standing of psychiatric disability should be derived
from the deficits that influence the living, learning
and working environments of an individual.
Dejong et al. (1985) have stressed the need to
study social disabilities in the context of a matrix
of expectations which society has towards the
individual. Liberman (1987) has also emphasised
that disabilities should be measured and evaluated
in a social context, and that such an approach
would help to formulate the appropriate skill
acquisition paradigms. Although the phenomenon
R. Shankar el al./Schizophrenia Research 16 (1995) 17-23
of disability is closely linked to role expectation
and role performance, there are very few reports
that have studied disability from a gender based
perspective. Bachrach (1988) has described social
"disablements to be more severe in women as
compared to men, and has advocated a system of
care which is sensitive to the special needs of
chronic mentally ill women.
The literature has reported a favourable trend
for females on most of the course and outcome
parameters that have been the focus of research
(Leff et al., 1992; Watt et al., 1983). These mea
sures have included time spent in psychosis, pattern
of course of illness, and social adjustment. The
later onset of illness in the' female sex has been
one of the explanations offered for the better
outcome in women, as it allows for women to
develop those social skills that can mitigate the
disability arising out of the illness.
Gender-based comparison of disability is likely
to be compounded where the role expectations of
women are linked to their marital status, as in a
traditional society like India, where unmarried
women stay in their parental home and have no
clear cut role definition. This paper compares
disability in married individuals of both sexes who
have received a DSM-III diagnosis of schizophre
nia. It is important to study this group of patients
for the following reasons.
1.
Little is known about the lives of married
patients with schizophrenia, as the marriage rates
in this population are low, (Haverkamp et al.,
1982)
2.
A relatively homogenous group (for example
a group of married patients) with clear cut role
expectations may inform on the gender differences
in disability consequent to a schizophrenic illness.
2.
Materials and methods
The study was conducted at the Schizophrenia
Research Foundation Madras, India, a non
governmental organisation that offers an active
out-patient and day care programme for patients
with schizophrenia.
2.1.
The sample
60 consecutive married patients (of both sexes)
registered between 1989-1991, (and satisfying
DSM-III criteria for schizophrenia at the time of
their inception into the centre) were included in
the study. The patients had been residing with
their spouses continuously for a minimum period
of one year prior to entry into the study. The
sample was essentially urban, from the city of
Madras and its suburbs. While the sampling pro
cedure made no conscious attempt to match the
sexes on duration of illness or age, both variables
(by coincidence), were highly comparable between
the males and females who constituted our study
sample. The mean age of the males (n = 30) was
38.60 years (SD 8.431) and that of the females
(n = 30) was 38.433 years (SD 8.250). The mean^
duration of illness for males was 12.467 years (SE^P
6.146) and for females was 11.033 years (SD 5.756)
thereby resulting in a very homogenous study
group.
2.2.
Method
Cross-sectional assessments were done by two
trained psychiatrists (RS and SK) on patients who
fulfilled the inclusion criteria. The instruments
administered were the Present State Examination
(Wing 1974), Schedule For Assesment of Negative
Symptoms (Andreasen, 1982) and the Disability
Assesment Schedule (World Health Organisation,
1988). The DAS (modified version) contains three
sections: Section one deals with overall behavior;
Section two measures social role performance in
the context of a multiplicity of roles (household
activities, marriage, care of children, occupation^^
etc.); Section three deals with factors that have the^F
potential to modify disability, (these include assets
like supportive relationships and abilities that are
above average). Specific liabilities are also rated in
this section. The DAS also includes a global clinical
rating on the overall level of disability. All ratings
are on a six point ordinal scale with 0 indicating
no dysfunction and five indicative of maximum
dysfunction.
The DAS and SANS were administered using
the spouse as the informant. The Present State
R. Shankar el al./Schizophrenia Research 16 (1995) 17-23
Examination and SANS interviews were conducted
independent of the DAS interview. Disability
assessments were performed by the psychiatrist
who had not rated the patient on the PSE and
SANS. Interrater reliability exercises performed at
the beginning of the study and on every tenth case
was 90%. Several clinical and sociodemographic
variables were studied. These included age, age at
marriage, socioeconomic level, employment at the
time of marriage, current employment status,
number of children, all PSE syndromes and ratings
on the SANS. Disability was computed for each
domain separately, the time frame for assesment
being set as the level of functioning in the preceding
one month. In addition, global disability was also
analysed independently.
Analysis was done using the SPSS-PC; Chisquare or z-tests were used to compare the vari
ables. Correlation analysis was performed between
global disability and the PSE syndromes as well
as between global disability and the SANS items
for both sexes independently. Similarly, a stepwise
regression was performed to determine the factors
associated with global disability.
3.
Results
a diagnosis of schizophrenia prior to marriage
(p<0.01). The mean age at marriage for males
who had been ill before marriage was 30.17 years.
The males who had fallen ill after their marriage
were married at a mean age of 25.28. This differ
ence was not significant, however.
The mean age at marriage for the 21 females
who had fallen ill after marriage was 22.04. In the
case of the nine females who were ill before
marriage, the mean age at marriage was 23.77, a
difference which was not significant (Table 1).
All 60 patients had traditional marriages,
arranged by the families and in most of the cases,
the spouse had either not been informed about the
illness or had been told that their partner had
suffered from a minor nervous problem and needed
to take some sort of medication. Consanguinous
marital unions were equally represented in both
the sexes and only 28% had married a first or
second degree relative. Eight female patients had
no children as compared to 10 males who were
childless. However, 10 of the females (33%) and
only 2 of the male patients had three or more
children (p <0.01).
Table 1
Gender differences in socio demographic and clinical variables
3.1. Gender differences in sociodemographic and
clinical variables
Variable
As mentioned earlier, there were no differences
between the sexes either on mean age or duration
of illness. 30% of the males had a college level
education as compared to 6% of the females,
a difference that was statistically significant
(p<0.05). However, 60% of the patients in both
sexes had a school level education. At the time of
assessment, 18 of the males were employed and
only 3 of the females were employed, (p <0.001)
(the three employed women held clerical positions
in government undertakings, while 9 (50%) of the
men had white collar jobs); 22 men were holding
jobs at the time of marriage as compared to five
women (p<0.001). Socioeconomic status (80% of
the sample belonged to the low and middle income
groups)and family structure (65% nuclear families)
were comparable between the two groups. 23 of
the males and only nine of the females had received
Currently
18
3
employed
Age at
22.56
29.03
marriage
(in years)
Employment status at marriage
6
Unemployed
25
4
Temporary job
0
Permanent job 18
5
Had a job not
attending
2
0
No. of Children
0
8
14
1-2
20
2
10
3+
Residual syndrome
4
Present
0
Absent
30
26
Global scores
1.667
2.333
attention
Male
n=30
Female'' z7'
Significance
ji-30/'
16.48352 p< 0.001
4.48
p <0.001
24.99299 p <0.001
6.67787 p<0.01
4.28571
-2.16
p<0.05
p<0.05
20
R Shankar et al./Schizophrenia Research 16 (1995) 17-23
A comparison of the PSE syndromes between
the two sexes revealed no differences except for
residual syndrome, which was more common in
women (p <0.05). There were also no differences
in any of the SANS items except for inattention
during mental testing, for which women had a
higher score (p<0.05).
3.2.
Comparison ofdisability scores
Women had higher scores on all the disability
items except on parental role where men had more
deficits than women. The differences in disability
scores reached statistical significance for the
following items: slowness (p<0.01), participation
in household activities (p<0.05), social contact
friction outside the household (p<0.05)and infor
mation seeking behaviour (p<0.01). Women had
higher Global disability (mean 3.033) as compared
to men (mean 2.5333 p<0.05). Global disability
was dichotomised into low disability and high
disability with global disability scores of 0, 1,2
representing the low disability group and scores of
3,
4, 5 falling in the high disability group. 17 men
(56.6%) and only nine women (30%) had low
disability scores (p<0.05) (Table 2).
3.3.
Correlation between disability and PSE
syndromes and SANS variables
Correlation analysis was performed for global
disability between the PSE syndromes for both
Table 2
Gender differences in disability variables
3.4.
Factors affecting disability
Factors which influenced global disability (socio
demographic, PSE and SANS variables) were inded
pendently determined in the two sexes using a
stepwise multiple regression analysis (Tables 3 and
4
). In males, 6 variables contributed significantly
to the global disability (r=0.87). Important vari
ables included depression, attention, intimacy and
avolition apathy. In females, seven variables were
found to influence global disability. These included
age at marriage, employment at marriage,
hypomania and grandiose and religious delusions.
(r=0.86). As in the case of the males, Intimacy
Table 3
Regression coefficient of the effect of sociodemographic and
clinical variables on global disability in men
Variable
Male
Female
/-value
Significance
Slowness
1.4333
Participation
1.6333
in household
activities
Social contact
0.3000
friction
Information
1.633
seeking
behaviour
Global disability 2.533 '
High disability
n=13
Low disability
n=17
2.1667
2.667
-2.90
-2.08
<0.01
<0.05
Variable
sexes independently. The relationship between
global disability and the SANS variables was also
analysed in a similar fashion.
In the case of female patients there were no
correlations between any of the PSE syndromes
and global disability; in males, the analysis
revealed that the syndromes of depressive delu
sions, general anxiety, delusions of reference, and
self neglect were all positively correlated with
global disability (p<0.01). However, global scores
on avolition apathy, anhedonia asociality and
attention were strongly correlated with global
disability (p <0.001) in both sexes.
0.9333
-2.20
<0.05
2.5667
-3.43
<0.01
3.033
n=21
n=9
-2.16
4.34389
<0.05
<0.05
Global attention
Ability to
feel intimacy
Other signs
of depression
Social unease
Recreational
interest and
activities
Global rating
of avolition
apathy
Constant
SEB
B
0.184445
0.384943
0.055172
0.081496
Sig.r
t
3.343
4.723
0.0029^
0.000 if
0.951491
0.263716
3.608
0.0016
-0.382518
-0.302873
0.189781
0.076715
-2.016
-3.948
0.0562
0.0007
0.144395
0.639787
3.629
0.0015
0.686036
0.375536
1.827
0.0813
Multiple r—0.9359, r2=0.8758,/= 25.864, p<0.05.
R Shankar el al./Schizophrenia Research 16 (1995) 17-23
Table 4
Regression coefficient of the effect of sociodcmographic and
clinical variables on global disability in women
Variable
Impersistence
at work
Ability to
feel intimacy
Age at marriage
Hypomania
Grandiose and
religious
delusions
Global rating
attention
Employment
status at
marriage
Constant
B
SE B
Sig. t
i
0.250182
0.072854
3.434
0.0024
0.245409
0.089565
2.740
0.0120
0.088734
1.506143
1.003098
0.019024
0.391817
0.292310
4.664
3.844
3.432
0.0001
0.0009
0.0024
0.270906
0.94347
2.871
0.0089
-0.274768
0.116871
-2.351
0.0281
-2.938832
0.706296
-4.161
0.0004
Multiple r=0.9305, r2 = 0.8659,/=20.298, pcO.05.
and attentional deficits were among the variables
that influenced global outcome in the females.
4.
Discussion
As the profiles of age as well as duration of
illness were comparable, the study could effectively
assess gender differences in disability in chronic
schizophrenia. As can be seen from tables one and
two, differences in occupational functioning are
significant between the males and females who
constituted the study cohort. A higher percentage
of males were employed not only at the time of
the assessments, but also at the time of marriage.
In urban areas, only 9.17% of the female popula
tion is involved in income generating activity as
compared to 48.94% of the male population.
(Census of India, 1991). Therefore, the differences
in occupational functioning between the sexes in
our study sample is consistent with the social
norms of Indian society, where males have to fulfill
the role of the wage earner, and females that of
the homemaker. A comparison of the age at mar
riage with the mean of the general population has
also revealed some interesting findings: the mean
age at marriage for the urban male is 25.09 years
(sample survey, Tamil Nadu, Census of India
1991), whereas the mean age at marriage for male
patients who fell ill before marriage is 30.17 years
(SD 6.998) and for those who fell ill after marriage
is 25.28 years (SD 4.112). The age at marriage for
the urban female is 20.25 years. (Sample Survey,
Tamil Nadu Census of India, 1991) The females
in our study appeared to have married later than
the general population. The mean age at marriage
for the 21 females who fell ill after their marriage
is 22.04 years (SD 4.61) and is 23.78 years (SD
2.728) for the nine females who were ill before
marriage. The literature also reports that women
are likely to get married before the onset of illness
(Seeman, 1986; Reicher-Rossler, 1992), a finding
that has also emerged to be significant in our study.
A comparison of clinical profiles revealed
differences in positive symptomatology between
the two groups. Residual syndrome was more
common in females as compared to males. There
was also a trend for depressive symptoms to occur
more frequently in men as compared to women,
although this difference did not reach statistical
significance. Reporting on a five year follow up of
first onset schizophrenia from India, Thara et al.
(1992) drew attention to the presence of PSE
syndromes of depressive delusions and hallucina
tions in males and obsessive symptoms in women.
A comparison of negative symptomatology
revealed that both the male and female patients in
our study cohort showed a significant presence of
negative symptoms.
Biehl et al. (1986) have documented the correla
tion of negative symptoms with high disability
scores, and also the predictive power of this
relationship for future disability assesments. The
World Health Organisation Study (WHO, 1979)
has also reported on the relationship of negative
symptoms and social role performance and has
posited that functioning in the interactional
domain is particularly influenced by the presence
of negative symptoms.
The significant findings of this study (amongst
both the sexes) include: (1) the weak correlations
between disability and positive symptoms; (2) the
strong correlation between negative symptoms
and disability; (3) the correlation between intimacy
(which is a measure of the ability to establish and
R Shankar et al./Schizophrenia Research 16 (1995) 17-23
maintain intimate relationships in the context of
the marital role) and global disability.
Other negative symptoms like attentional im
pairment and avolition apathy were also been
found to influence global disability.
In discussing the relationship between disability
and negative symptoms, it is important to highlight
the problem of criterion contamination while using
the DAS and the SANS as the instruments of
measurement. For example, the section on social
role performance of the DAS was rated on the
basis of level of occupational functioning, lack of
interest in one’s job or a lack of initiative to obtain
employment; whereas a similar rating is reflected
in the SANS item dealing with impersistence at
work or school in the avolition apathy subscale.
Also items dealing with sexual functioning of the
patient appear in both the DAS and the SANS.
Hence, the strong correlation between disability
and negative symptoms is not entirely unexpected.
It is, however, appropriate to point out that this
relationship between the negative symptoms and
disability was equally significant in both the sexes.
Reporting on a gender based comparison of
disability and clinical symptomatology, Chaves
et al. (1993) have highlighted the correlation of
positive symptoms with global disability in the
case of males but not so in the case of females.
They have hypothesised that the social roles of
women were more interactional and less instru
mental in nature and therefore likely to be influ
enced by psychotic features. In contrast to the
above report, the positive correlations between
disability and positive symptoms in the case of
males but not so in the case of females have
emerged as a significant finding in the present
study.
Most studies focussing on gender differences
have reported a worse clinical outcome for men
(Watt et al., 1983; Salakongas, 1983) In their five
year follow up study of first onset schizophrenia
in India, Thara and Rajkumar (1992) have not
only corroborated this finding, but also reported
that one third of the men in their sample had lost
their jobs and another one third had erratic
occupational functioning. The authors attributed
the better outcome for women to the greater social
support they received, and also to into account
the fact that women are relatively exempt from
the pressures of wage earning and economic diffi
culties which constitute the major stressors for the
urban male.
Chaves et al. (1993) have reported that males
had higher disability ratings in the DAS section
on overall behaviour but no gender differences on
social role performance; also, the men were more
globally impaired than women. In contrast to the
present study, however, their sample was skewed
towards men who were never married.
We would like to offer the following explana
tions for the lower disability ratings in the males
who constituted our cohort.
1.
There probably exists an a priori and perhaps
an intangible selection process, in that only the
employed and possibly better functioning males
have marriages arranged for them by their famili^t
This is borne out by data wherein 22 males
involved in some sort of wage earning activity at
the time of marriage, and 4 of the male patients
who were not employed at the time of marriage
had worked in a temporary capacity on and off
prior to marriage. Also, families appeared to have
delayed arranging a marriage for 23 of the males
who were ill before marriage, probably as measure
of caution to allow them to develop occupational
skills. Our sample therefore may have comprised
of males who had acquired some of the gender
appropriate social and employment skills and be
perceived by their families as suitable for fulfilling
the marital role. Since most of the women had
fallen ill after marriage, it is probable that a similar
selection process was not operative in the case of
the females at the time of their marriage.
2.
The importance of adequate occupational
functioning and-involvement in income generatu^
activities and their contribution to the overSF
outcome in India has been emphasised by Thara
et al. (1992). Since the primary role expectation
of married males is in the area of wage earning,
and as the males in our study were functioning
adequately in this sphere, it is possible that this
may have influenced the perception of the spouse
leading her to perceive her husband as being less
disabled in other spheres as well.
3.
Marriage and the demands of child rearing
may have had a detrimental effect on the function
R Shankar cl al./Schizophrenia Research 16 (1995) 17-23
ing of the women. Most of them live in nuclear
families and .support for day to day activities of
running the household are not readily available.
This is in contrast to the finding that more male
patients (in comparison to female patients)
received financial help from either their parents or
inlaws (p <0.01)
Consequently, the stress faced by women in
fulfilling their social role obligations may be
accentuated.
It is also interesting to note that the significant
differences in disability between the sexes were
found in those areas which are critical to the role
of a woman as a home maker, viz. slowness,
participation in household activities and social
contact friction, especially with neighbours and
friends. Many of the male spouses spoke at length
about the additional domestic responsibilities
they were undertaking as a result of their wives’
inability to perform adequately in the role of
the homemaker.
4.
The sampling procedure adopted was one of
convenience and the ratio of male patients to
female patients who attend the centre is 2:1. It is
therefore likely that the better functioning married
female patients do not access our service, in con
trast to the males who seek help in order to
maintain their crucial wage earning acivity.
In both the sexes, negative symptomatology has
constituted the main variables influencing global
disability. These have included attentional deficits,
and the related deficits of avolition apathy and
impersistence at work.
However, the contribution of the PSE syn
dromes of hypomania and religious grandiose delu
sions to global disability amongst females cannot
be adequately explained. These PSE syndromes
were rated in very few patients and the occurrence
of type 11 error due to the sample size cannot be
excluded. Additionally, our study suffers from the
handicaps of convenience sampling and a crosssectional design, thereby limiting the generalisabil
ity of our findings.
There are however, some trends to suggest that
marital status may influence disability patterns in
sexes differently. But it must be emphasised that
as “social role performance” is a function of
“social role expectation”, it is important to explore
23
such differences in larger samples, in social settings
where role expectations of spouses differ from the
one prevailing in a traditional society such as India.
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services in a prospective study of first onset schizophrenics.
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Chaves, A.C., Seeman, M.V., Mari, J.J., Malief, A. (1?93). *
Schizophrenia: impact of positive syptoms on gender social
role. Schizophr. Res. 11, 1 41-45.
Dejong, Giel, R., Olsk Stooff, C.J. and Wresman, D. Social
disability and outcome in schizophrenic patients. Br.
J. Psychiatry 147, 631-636.
Leif, J., Sartorius, N., Jablensky, A., Korten, A., Emberg, G.
(1992). The International Pilot Study Of Schizophrenia.
Five year follow up findings. Psychol. Med. 22, 131-145.
Liberman, R.P., (1987) Psychosocial interventions in the
management of schizophrenia, overcoming disability and
handicap. Presented at the 140th Meeting A.P.A. Chicago,
Illinois.
Reicher-Rossler, A., Fatkenher, B., Loffer, W., Maurer, K.,
Hafner, H. (1992) Is age of onset in schizophrenia influenced
by marital status? Soc. Psychiatry Epidemiol. 27, 122-128.
Salaokanga, R.K.R., (1983). Prognostic implications of the
sex of schizophrenic patients. Br. J. Psychiatry 142-145-151.
Seeman, M.V. (1986): Current outcome in schizophrenic
women vs men. Acta Psychiatry Scand. 73, 609-617.
Thara, R. and Rajkumar, S. (1992) Gender differences in
schizophrenia, results of a follow up study from India.
Schizophr. Res. 7, 65-70.
Watt, D.C., Katz, K., Shepherd, H., (1983). The natural
history of schizophrenia: a 5 year follow up of a representa
tive sample of schizophrenics by means of a standardized
clinical and social assessment. Psychol. Med. 13, 663-670.
Wing, J.K., Cooper, J.E., Sartorius, N. (1974). The measure
ment and classification of psychiatric symptoms. Cambridge
University Press, Cambridge.
World Health Organisation (1979). Schizophrenia: an inter
national follow up study. Wiley, Chichester.
World Health Organisation (1988). WHO psychiatric disability
assessment schedule. World Health Organisation, Geneva.
Physical and Mental Disabilities
□a Akash is not drunk! He drools and slurs over his speech
because he suffers from cerebral palsy - a result of permanent
brain damage which makes it difficult to co-ordinate his move
ments, or to sit or stand as we do. This damage which occurs
before birth, at birth, or as a baby, cannot get worse nor better
with time. However, Akash's movements and body posture can
with encouragement and appreciation. Repeat this information
correctly, to advance 2 steps.
00
Have another turn for inviting eight year old Satya to par
ticipate in the Spelling Contest. He is very intelligent and could
easily win the prize! Though he can neither sit nor speak, he is
learning to communicate in a different way. 40 - 50% of those
who have cerebral palsy have average or above average intelli
gence as the damage is only to the parts of the brain that con
trol movement and posture. This is sometimes not known.
00 You did well to stop Rini's companions from ridiculing
his clumsiness. He walks with irregular steps, bent forward and
with his feet wide apart to maintain his balance. The children
now understand Rini has poor balance because of the damage
to some parts of his brain. Advance 2 steps.
am
Go back 5 steps. Rahul was disturbed by the pity and
embarrassment in your eyes. He senses he is a 'family dis
grace; that he was not expected to be 'like this' 1 He wants
people to look at him as a person with special strengths, recog
nizing his determination to do as much as he can for himself.
Bring this message to people in a street play.
00
You did well to let Anwar know how much everyone
appreciates his efforts at exercises not to allow his joints to
stiffen, his muscles weaken, or his thinking processes slacken.
He has become the hero of his neighbourhood for trying to do
everything he can for himself. Take 3 steps forward to organize
a party for him.
00
No, you are quite wrong. The disabled are not always
dependent and a burden. Most disabled persons have the same
need for independence, achievement, and self-actualization as
we do. Miss 2 turns to get rid of this generalized negative atti
tude.
0H
Move back 2 steps. Nevermassage those with cerebral
palsy. It further tightens the muscles. Also, never massage in
the early stages of polio as it only spreads the virus.
00
Miss a turn to insist that pregnant women need to be well
fed. One of the main causes of disabling conditions in India is
protein and calorie deficiency. Underweight, anaemic babies risk
cerebral palsy and mental retardation. 35% of the babies bom in
India every year weigh less than two and a half kg.
00
Well done I Advance 4 steps for delaying your sister’s
marriage until she is 18 years old. Asha, at seventeen, had birth
difficulties because she was so young. The baby suffered brain
damage due to a lack of oxygen during a difficult and prolonged
labour. The result - he is now mentally retarded !
□H
Asha's goitre is not a mere cosmetic problem I Iodine
deficiency, which causes goitres, affects the development of the
brain in early pregnancy and in the newborn child, causing mental
retardation, hearing and speech difficulties, stunted growth; it
is also linked with spontaneous abortions, still birth, and low
birth weight. Repeat this information correctly for another turn.
difficult to learn normal growing or developmental skills at the
same pace as others. They are much slower.
□0
Missaturn to explain to Uma that people with M.l. usu
ally have normal intelligence. However, because of a traumatic
environment together with chemical imbalances in the brain, they
are not in touch with the real world (psychosis) or could find it
difficult to cope with life (neurosis).
Two children are born mentally retarded every hour in
areas where the soil lacks iodine. If there is no iodine in the soil,
there will be no iodine in the crops, vegetables, and fruit.Miss a
turn to stress the importance of using iodized salt.
□0
Exposure to direct sunlight and moisture can destroy
iodine. Advise people to use air-tight containers for salt and to
finish it within six months of buying it. Fish is also a rich source
of iodine. Rememberthat all of us need 0.15 mg of iodine every
day. For pregnant and lactating women it is a must.
sn
Deforestation leads to the erosion of the top soil which
contains iodine. The entire foothills of the Himalayan region,
other deforested areas as well as flood prone areas are red alert
zones for iodine deficiency disorders. Organize an eco-health
awareness programme challenging people to protect the envi
ronment to safeguard their own and the mental and physical
development of their children.
00
Children of mothers with severe iodine deficiency are
stunted, unable to walk, talk, orthink normally. Those of moth
ers with minor deficiency look normal, but mental retardation
shows later in poor performance at school. 90% of the brain
growth and development occurs during early pregnancy and con
tinues until the age of two during which time iodine is essential.No
brain damage can be corrected later by iodine intake. Repeat
this information, to advance 2 steps. If not, go back 4 steps.
00
Advance 3 steps.Clarify Om's ideas about mental retard
-ation. Explain to him that mentally retarded persons find it
00
00
Miss a turn.Encourage Anup who is depressed that
mental retardation cannot be cured or removed by surgery, and
that it can only be minimized or prevented from becoming worse.
other turn.
00
Miss a turn. Tell people the importance of treating a child's
fits. Frequent fits damage a child's brain and affect his I her
thinking, learning and mobility. If too frequent or prolonged, fits
can even cause death. The child can also fall down stairs, or
into a fire during a fit.
00 Appiah spent time explaining some of the known causes
of mental retardation to many anxious mothers : poor inad
equate nourishment, uro-genital infections, alcohol and drugs,
even some medicinal drugs, severe head injuries, epileptic fits,
exposure of pregnant working women to x-rays and toxic sub
stances. If you can repeat this information correctly, have an
H0Move 4 steps ahead organizing talks on diseases in a
pregnant mother which cause mental and physical
disability:German measles, Aids, Diabetes, Hypertension, V.D.
Thyroidism, shingles (herpes zosta) and RH incompatibility.
Q0
If your first child is mentally retarded, do you know
that it is mandatory for both parents to undergo a chromosal
test before the birth of the second child to ensure that the child
is normal ? The test can be done at St.John's or at NIMHANS,
if you are in Bangalore, or at any genetic counselling unit in a
recognized hospital.
Q0 Advance 3 steps. Persuade Mr. Desai not to send Arun
to a Home for the Disabled. He would benefit more from the
real life experiences in his daily life at home: from the personal
attention of the family and their involvement in his management,
and from the interaction with children of his age in his own
neighbourhood.
00
Don't hesitate to admit your disabled child to a regular
school. Being with non-disabled children will increase his selfesteem, ensure greater self-acceptance, and challenge him to
increase his range of activity. Miss a turn. Meet children attend
ing school with the non-disabled to check out the advantages
and disadvantages for yourself.
00 You will learn a great deal by sitting next to a disabled
stimulate his mind and challenge him to do better. His capacity
to socialize and to communicate also improves as he gets to
meet many children.
00
Miss a turn. Aovid playing strenuous games that make
those with the Down's Syndrome jerk their necks. No somer
saults either as these are dangerous as well.
Move back 2 steps. Amina was badly bitten by Ravi.
If you had quickly held his nose firmly, he would have been forced
to open his mouth to breathe and Amina could have pulled away.
000 As a career guide, you told
Shekar to follow the
existing vocational programmes for the disabled; assembly line
work, chalk making, etc. Miss 2 turns for not identifying his
special interests and skills, his family resources and their ideas
that might have led to more relevant vocational training pro
grammes.
000The children of the colony got overtheirfearof Anjali,
00
“the 'strange mad child' their parents had told them to avoid, and
began to play with her. They then convinced their parents that
Anjali was like themselves in many ways and helped them to
correct their misconceptions of retardation and to accept the
little child.Organize a drama for Mother's Day to help mothers
acccept mentally challenged children, be it their own or some
one else's. Advance 4 steps.
00
for parents of mentally challenged children. Sustain their morale
as they must provide for stimulation and challenge forthe child
without which the he/she cannot tap his/her full potential.
child : to be observant of his needs and those of others; to
celebrate his strengths and your own; to accept problems as
they come along and to persevere despite odds, to be helpful.
Go back 4 steps and reflect on this.
Well done! Take 2 more turns for helping Maithili, who is
mentally retarded, to develop her capacity to think and to ab
sorb what she reads by discussing with her the books you
bring her. Do the same for the TV programmes she watches.
Go 4 steps forward. You organized indoor and outdoor
games which have worked wonders for Srinath. The games
000 Have another 2 turns to create more support groups
000You noticed some children were teasing and avoiding
the disabled children in your school. You did well to organize a
playto focus their innersuffering caused by rejection, mockery,
a lack of respect and understanding which is much greaterthan
the problems and inconvenience resulting from the handicaps of
appearance, speech, hearing and movement. Move 4 steps
ahead. Many of the non-disabled told me that your play had a
deep impact on them.
HHED
Miss a turn. Aruna is normal and intelligent. Her
tantrums, screaming, running out of the house, breaking and
throwing things around, are not signs of mental retardation, but
of boredom, pampering, efforts to get attention or what she
wants.
000
Advance 5 steps to organize more meetings to cre
ate an awareness that the Disabled have no rights and must be
given them.They seem to be an invisible section in our society.
0013
Is Murugan a result of his own past or that of his
parents. "How can you say this is bad Karma?" he asks. "You
cannot tell how actualized a disabled person is; how inwardly
peaceful or spiritual. All you can see is the exterior." Miss a
turn to think about his views on karma.
Outlook]t
T
traveller Leh
GO PLACES!
rAvv-’S
----- -----!------------------------
www.outlooktraveller.com
Knocking on
Heaven’s Doer...
'ICTOR Hugo
once talked of
A Bird's EyeView and An Owl's
Eye-View of his
favourite Paris. Flying
into Leh over the
Himalayas, with a
bird's-eye-view like
none other, I suddenly remem
bered the old Frenchman. Gliding
across the Himalayas, the last
frontier of all my dream adven
tures...it dawned on me 1 was
doing the forbidden... but before
I knew it, we landed in Leh on
a clear sunny morning.
Compelled to stay indoors on
my first day (which was good in a
way I later realised), I decided to sneak out after
dark when all my fellow travellers had happily
succumbed to the temptation of their warm
quilts. Nights in Leh often go without power
and the first thing that caught my eyes in the
moonlit darkness was a 'Fire on the
Mountain’...a castle on a hilltop, set ablaze by
what I later discovered were just unromantic
halogen lamps! And that was my first impres
sion of the magnificent Leh Palace, watching
over the sleepy town like an aging monarch
over his subjects.
On the second day, I drove out of Leh along
the desolate road, into cavernous terrain. And
the sheer expanse of flatness, arid flatness in
burnt sienna, instantly shocked me out of my
V
Ayurgram, Bangalore
3 days/ 2 nights
Cost: Rs 9,500 per couple
Accommodation in standard
cottages, all meals, cost of
^treatment as per progra
mme, a consultation with
the chief ayurvedic physic
ian, daily sessions of yoga
and meditation, transfers.
Sterling, Ooty
4 days/3 nights
| Cost: Rs 5,999 per couple
Accommodation, welcome
drink, bed tea and breakfast,
2 bottles of soft drink or
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■ and all taxes.
OUTLOOKS August 27,2001
high-rise urban sensi
bilities. The blinding
sun beating down on
the unforgiving bar
renness all around,
the whole place
looked bombed out
like a nuclear test
site, with the eerie
drone of a stray
Indian Air Force heli
copter hovering above.
Returning from Alchi on the last
day of my visit, my worldview
changed. Looking out of the jeep
window to where the dust was
swirling up in the air, for the first
time in my life I felt I was in a
holy land. Blessed by the benevo
lent spirit of Bon and Buddhism,
which broods invisibly, like a
huge prehistoric bird, on the end
less expanse of a primeval country. The chartens (stupas) and Gompas that appeared out of
nowhere looked like pathmarks of that divine
spirit. And that benediction in the air is what
we felt in the least when we reached Leh sans
punctures and breakdowns on the 230-km
stretch from Kargil.
The Hinayana Buddhist way of life, the foot
prints of travellers through the ages and the
unbridled reign of the elements... together
evoke a passion that rends the still air. And
there's something more that Ladakh inevitably
does, I realised... it makes you come
back...albeit on a battle-worthy Gypsy but
without the pistols and the whisky shots of
the Wild West!
— Avishek Ganguly
For more details, log onto ww.oullooktraveller.com
51
COVER STORY
The ubiquitous free market with its promise of the
modern and its emphasis on a brutal productivity
ethic has only reinforced traditional structures of
exploitation. India's untouchables—there are many
kinds of them—stay out of sight... till calamity strikes.
By SOMA WADHWA
HAINED to a tree for two years, Asainar has
little hope of escaping his madness. Or the
insanity that surrounds him at the Erwadi
dargah in Tamil Nadu. Where hundreds of
mentally ill like Asainar are left to rave, rant
and rot. Some are shackled for days, others for deca
des. Two weeks after 27 mental patients were charred
to death in one of Erwadi's many hellish 'mental
homes' near the dargah, the others are still fettered
and already forgotten in India's amnesiac collective
consciousness. On that fateful morning, the inmates
had shrieked and struggled violently to free themse
lves from the shackles even as the blaze consumed
them. But Asainar, the odd inmate, still bound to his
tree at Erwadi, a pilgrim's village in Ramanathapuram,
is oblivious of their horrific tragedy, and to his own...
This is the tragedy of being an Unequal Indian. Of
managing to eke out a tenuous survival on the fri
nges, a member of a multiplying underclass that no
one cares for. Maimed and marginalised by the
nation's history as also by the processes of her frene
tic progress. They are our weakest citizens—too face
less, voiceless and geographically segregated to mob
ilise themselves into protesting groups. Abandoned
variously by the State, community and even their
C
COVER STORY
families. Because of caste, gender, disability, illness, age, or for
being born into paucity.
They are 21st century India’s oustees, left to a hardscrabble near
destitute existence. They include:
• Landless migrant labourers building our highways.
• Scavengers scraping excreta off our latrines.
• Beggar widows pleading for our charity.
• Children of pauperised tribals sold for survival.
• The disabled or mentally unsound, who are discarded and
chained at temples and dargahs like at Erwadi.
• Stigmatised and shunned patients of ailments like aids.
"Historically, marginalised populations, like say the Dalits, always
existed in India. But today, the types, numbers, degrees of margina
lisation and neglect have increased manifold and taken on grim
proportions," says Dhirubhai L. Sheth, political sociologist and edi
tor of development journal Alternatives. Indifference and callous
disregard for those who don't find a place in the feelgood middledass-India Club is increasing alarmingly. Says Sheth: "Poor relatives
have been disowned." Which in turn, observes public interest
researcher Akhila Sivadas, has given rise to a new underclass that
never existed before. Old people’s homes are not new institutions,
not even in a society like India where family ties and values have
till recently been rather strong. But with productivity becoming the
new buzzword in these times of the unbridled market, the ‘unpro
ductive’—comprising the old, sick, disabled—has led to the bur
geoning of the new underclass. In more humane times, however,
these people were taken care of by the family. Their sense of econ
omy, largely uncontaminated by the germ of efficient productivity,
allowed that. The village barter economy and the joint family
premised on an agrarian economy are two such key instances.
Says Sivadas: "Now, they've all been left to fend for themselves
in neo-pragmatic, monetised India." With its welfarist values on
the wane, the State has ceased making any' meaningful interven
tions to help the weakest, adds jnu sociologist Imtiaz Ahmed,
"thus completely leaving them to the vagaries of their existence".
MENTALLY DISABLED
How many: 7 million with severe psychiatric disability, 25 mil
lion need psychiatric care
No. of mental health centres: 36 government run, a handful
private ones
Mental Health Professionals Available: 3,500
Mental Health Professionals Needed: 400,000
What the Law says: The Mental Health Act, 1987, stipulates
that the government will care for the mentally ill. lays down
procedures for care by mental institutions, forbids chaining
(Sources: SAARTHAK, India)
Revisiting Erwadi’s macabre realities verify these theories on gro
und. Last year, an Institute of Mental Health report on the asylums
that proliferate in Erwadi testified: 87 per cent of the 550 mentally
ill in tin-shed asylums are without toilets, average period of stay for
inmates 15.8 years, "no patient is given any medical treatment".
The government did nothing for these ill. Nor does the modern
nuclear family, with its own peculiar economic compulsions. "My
son Zakir left me here," sobs Mohammed Kasim, 73-year-old inmate
at Erwadi’s Shifa Mental Home, "He wouldn't give me enough
money, and then say he didn’t like me begging on the streets."
Kasim's story of abandonment finds a chilling echo in distant
Vrindavan. Where thousands of poor old widows, discarded by
their families, end up singing Lord Krishna’s praises for sustenanee. Five branches of the Vidhwa Bhagwan Bhajan Ashram here
Sole out 250 grams of rice, 50 grams of pulse and a princely Rs 2
per widow for eight hours of mandatory chanting. The indignity,
sheer inhumanity that is unleashed as the hungry old women
clamour and battle for this pittance is repugnant. Exhausted cha
nters till moments ago, they turn fanatic fighters determined to
get a bite of charity before anyone else does. Widow pushes
widow, kicking those who are older, weaker, for a place in the
queue that promises deliverance from starvation for the day.
Pompous men in authority bombard expletives from the sidelines,
threatening the hapless women to fall in line.
The frenzy subsides, till another such queue is to be formed in
the evening, to distribute Rs 2 per widow. For now, the first few
women walk out clutching small polythene bags half filled with
5OIIle
u<n Most proceed
w to
w beg ------------------------some ii(x
rice anu
and dal.
on Vrindavan's
streets for
)
WIDOWS
How many: 16,000 in Vrindavan, Mathura, Barsana, and Gokul
in west Uttar Pradesh alone
Where they largely come from: West Bengal
How much do they earn: 250 gms rice, 50 gms pulse and Rs
2 in lieu of eight hours of mandatory chanting daily for Bhajan
Ashram, Vrindavan
Proposed Policy: A West Bengal government-sponsored
survey on the Vrindavan widows, released in March 2000,
recommends widow pension and setting up of old-age homes
in Vrindavan. Besides, it also suggests a joint investigation by
the UP and West Bengal governments into alleged trafficking
of women in and around Vrindavan.
_ —
WIDOWS OF VRINDAVAN RICIAND SHOVE IN THE QUEUE FOR MEAGRE FOOD AND RS 2
she is, I don’t want to know. And I don’t want to talk about it."
For there seems little sense in relating the agonising compuls
ions that pushes a mother into selling the flesh and blood she's
carried in her womb. Yet a Lambada mother living on Hyderabad's
outskirts decides to verbalise her pain, but only after repeated ass
urances of anonymity: "I’ve sold two of my five daughters. My
husband beats me everyday, demands that I conceive a son. We're
construction labourers and have no money to feed our children.
My husband feels a son will bring us fortunes. What can 1 do?"
Nothing really. Not till, armed with its selfish and myopic unders
tanding of progress, middle-class India continues to set the agenda
for development. To mindlessly urbanise, industrialise and encour
age impersonal contractual business and social relationships. And
ironically sometimes use the same villagers, tribals and Dalits they
harm most by these processes to implement their self-seeking plans.
Like on Ladakh's inhospitable heights, where 25,000 migrant labo
urers are paid a meagre daily wage of Rs 80 to lay some of the
world’s highest metalled roads. They are called 'Biharis', because
few know or care to know that these outsiders from Dumka are rec
ent Jharkhandis, a new state which raises very little hope anyway.
MANUAL SCAVENGERS
Number of scavengers/excreta carriers: 8,25,572
How much they earn: Rs 30 a month to Rs 5.000 (when
employed as ‘sweepers' by the government in cities)
Category: Bhangis (also called Valmiki)
What the law says: Employment of the Manual Scavengers
and Construction of Dry Latrines Prohibition Act. 1993: Officials
responsible for the continuance of the practice are liable for
prosecution; so they are now listed as sweepers
(Source: Ministry of Social Justice Report 1998-99)
LABOURERS ON LADAKH ROADS ARE ILL BECAUSE THEY INHALE NOXIOUS TAR FUMES.
more; more to pay rent for the cubbyhole shacks that they share
with others for shelter, and more for times when they won’t be
strong enough to fight others in the exhausting charity queue.
HEIR tired resignation wrenches the heart even more. Sixty
something Jamuna Dey, dumped at the Vrindavan station by
her family 39 years ago, declares: "There's little to complain.
I'm a woman, a widow and old, to suffer is my fate."
This absence of protest rings shrill. "But then, bereft of access to
mainstream language, the marginalised don't have what it takes to
be heard in this country today. That is precisely one of the reasons
for their marginalisation," contends social scientist Ashis Nandy.
English and now Hindi, he argues, are the only languages which
evoke concerned response in a modern India impatient—and
T
MIGRANT LABOUR
How many landless labourers: 25,000 in 13 road projects
Where they largely come from: Jharkhand and Bihar
Caste: Predominantly Santhal tribals
Wages: Between Rs 75 to Rs 80 daily
(These figures are for labourers working on the border roads in Ladakh alone)
unconcerned—with whimpering dialects, "mtv sounds better than
the muddled angst verbalised by people who can't speak our lang
uage, or even cope with our idea of progress," says Nandy wryly.
Like the Lambada tribals of Andhra Pradesh. Who, pathetically
outpaced by the new economy of a liberalised India, have taken to
routine bartering of their girl children for paltry sums of money to
sleazy adoption shops. This year, in April, the state department of
women and child welfare raided such unlicensed adoption centres
in Hyderabad, and the neighbouring districts of Mehboobnagar and
Rangareddy. To find and rescue 192 children on sale. These babies
were appropriately produced before the media as photo-ops, then
promptly dumped in the state-run Shishu Vihar (infant home).
Lambada mothers, meanwhile, are still waiting to be rescued from
deprivation. So excruciatingly needy are they that they've been
known to sell their newborn offspring real cheap to keep the older
ones alive. Soon after the raids, Bhecrni Bai, mother of four daught
ers and Pedda hamlet resident, had confessed to selling her unborn
baby for an advance of Rs 100 to agents of an adoption agency.
Later, when Bheemi's girl was born, the buyers took her away. Rheemi's stone-faced statement to the police was: "I do not know when
ABHIJIT BHATLEKAR
OUTLOOK! August27.2001
An emaciated AIDS patient on the verge of death
THE OLD
How many of them: 77 million, projected at 140 million by 2025
No. of NGOs working for the old: 547
How many institutions for the old: 495
What the law says: Article 41 says the state should provide for the elderly without ways and means of sustain
ing themselves, there are also provisions for the same under the Directive Principles of State Policy and also
under the Hindu Adoption and Maintenance Act, 1956. The states of Himachal Pradesh and Maharashtra have
enacted legislations to ensure the elderly are taken care of by their children. The National Policy for Aged
Persons, 2000, stipulates that the State should encourage the building of Day Care Centres, formation of a sec
ond career, and improve pension and health Care facilities for the aged.
Source: Directory of the Centre for the Development of the Aged, Chennai; Dignity Foundation
GAURI GILL
Sanjay Saha, 16, is a fresh arrival from Dumka. The frail boy has
taken on Leh's hazardous and temporary employment so that he
can feed his mother and sister: "The weather is bad here, we get
dirty clothes to wear, have to pay Rs 700 for food." Sanjay's skin is
charcoal black because of noxious tar fumes, and he suffers from
stomach-aches, shortness of breath, sunburns and wind-chapped
lips. Naseem Ansari, 22, explains why he prefers it to the acute depr
ivation back home: "We don't have our own land in Dumka. And
too many poor people are looking for work there."
O, any work that feeds the stomach suffices, however inhu
man or revolting. Even cleaning filthy dry latrines by hand will
do for those who don’t know how to cope better. That's what
men and women from the Bhangi caste do for survival in affluent
Ahmedabad. Despite patron-saint Gandhi’s strong will to the con
trary. In fact, in many cases, it's the government which employs
them as 'sweepers' to bypass laws banning the practice. Armed with
two small tin plates and a plastic sheet, these 'sweepers’ clean up
nauseatingly stinking public toilets which are always out of water.
Not surprisingly, Bhangis, 'the lowest among the lower castes',
continue to be untouchables for the upper castes even in AD 2001.
They are marginalised and treated with disdain, they say, even by
other Dalits like the Chamars and Vankars. Confesses Bhanubhai
S
58
HIV/AIDS PATIENTS ARE TNE iW UNTOUCHABLES, THE NEW OUTCASTS OF INDIA.
Chauhan, a 'sweeper' in Ahmedabad: "I am very nervous about ent
ering the house of anybody who is not a Bhangi. It would be pom
pous on my part." To be Bhangi is to live a vermin-like existence.
Asked why the Ratnapur Jain temple in Gujarat's Surendernagar
town doesn't instal flushes in its open latrines, the temple author
ity replies matter-of-factly: "Jainism forbids killing germs, flushing
would kill germs." Instead, they get Bhangis to pick up excreta. This
in itself is not a new phenomenon. Gujarat's inhuman social pract
ices vis-a-vis the Dalits, particularly the Bhangis, have a long history. Ketan Mehta's Bhavani Bhawai brought this exploitation before
a larger audience as early as 1980. The productive principle driving
the glittering tableaux of the free market has only exacerbated these
cruel disparities and has made them even more stark. This clearly
shows how the market, with its promise of the modern, has only
served to heighten the age-old traditions of caste apartheid.
And that's not the end of the story. The same process has
simultaneously produced new outcasts, the New Untouchables.
People with hiv-aids. Riddled with prejudice and suspicion: per
ceived as sexually immoral people, licentious gay men, prosti-
OUTLOOK! August27,2001
.
tutes, eunuchs, who could pass on their contagious disease if not
kept away. But with 3.7 million hiv-aids cases already in the coun
try, and many from the upper class, it's becoming increasingly
difficult to marginalise them.
"But it's in the upper-middle class that there's lesser degree of
tolerance," says Somu who tested hiv positive in 1993, and is
being treated by YRG-Care, a Chennai-based ngo working with aids
patients. Unable to cope with Somu being an Hiv-positive homos
exual, his "embarrassed" brother took a transfer to Coimbatore.
Alienated from his family and relatives, and thus more sensitive to
the travails of his kind, Somu has plunged into gay advocacy. But
Chennai resident Jaya still hasn't been able to muster courage to
tell her in-laws about her positive status: "If they know, they’!’.
blame me for both my husband's and my own infection. And in
this they aren't alone. Doctors too are prejudiced. A private hos
pital, on learning of my positive status, refused to admit me for
delivery just a week before my daughter was to be born."
Sheth points out: "The idea today is to atomise. To detach the pro
blem from its rootedness, to isolate and forget it. Not to absorb it
0UTL0H
HIV-AIDS PATIENTS
How many: 3.7 million, Women (15-49 years): 1.3 million,
Children: (0-15 years): 1,60,000
General hospital bed availability: 0.08 per 1.000 population.
According to an expert view, at the current rate of progression,
India would need six times the number of hospital beds it has
today to accommodate just cases of AIDS.
What the law says: Bombay High Court ruling in 1997, MX vs
ZY case says people with HIV/AIDS cannot be refused a job
unless they pose a "significant" risk. A Supreme Court ruling in
1998 in the ‘Mr X vs Hospital Z
* case, while dealing with the
issue of doctor-patient breach of confidentiality, said that an
HIV posilive person does not have the right to marry till she/he
is cured. It was deemed that under Sections 269 and 279 of
the IPC, the marriage of a HIV+ person amounts to “negligently
or malignantly transmitting a contagious disease'. This is being
.^-examined by the apex court.
(Somw. UNAIDS. cowers C: -vo HiV-.MOS Unit. Mumba.1
58
P. ANIL KUMAR
A LAMBADA SOLD HER UNBORN CHILD IN ADVANCE.
within the community, or the family and treat it. And that is why
it all seems even more heartless." Erwadi's mentally ill, Vrindavan's
widows, Ladakh's 'Biharis', the abandoned Lambada children in
Hyderabad's Shishu Vihar, Ahmedabad's excreta carriers are all mis
fits. Clinging onto the peripheries of societies alien to them.
F old, they are doubly marginalised by these societies. For, the
modern Indian family has decided to go aggressively nuclear,
with little time, space and money to spare. Posing an incredible
predicament for the country's growing populace of the aged. Some
are already looking desperately for succour and accommodation.
Says T.C. Narayan, vice-president of the Dignity Foundation, an
ngo working with the elderly: "We receive at least 10 calls at our
Mumbai office every day from senior citizens who complain of
abuse." Barely two years ago, a 76-year-old couple had jumped to
their death from their eighth-floor apartment in Mumbai's Kemps
Corner. Their suicide note said: "Because of the constant abuse and
harassment from our son and daughter-in-law we ended our lives."
And those who live on are often dumped in dargahs like the one
at Erawadi, or temples which abound in places like Vrindavan.
These hell-holes, which had hitherto provided refuge to the victims
of traditional prejudices, are being reinvented to serve the same pur
pose produced by a completely different reality. For her part Meena
Kelkar, 65, managed to get herself into the All Saints Old Age Home
in Mumbai's Mazgaon when her son threw her out nine years ago.
She'd taken a year's refuge at her sister's before moving into the
Home. Her son hasn't met her since. Cheated out of her property
by her brother's family, Jyotsna Gomes was thrown out of the little
tenement she had purchased with her savings at the ripe age of 70.
She was lucky to have met a pastor that day as she sat desolate at a
Station. He brought her to the old home.
But life in old-age homes can be very lonely. In the 17 years that
I
GO
CHILDREN ON SALE
How many: 192 rescued in Andhra Pradesh alone (April 2001)
For sale at: Adoptions centres at Rangareddy, Mehboobnagar,
Medak and Nalgoda districts
Category: Lambada tribals
How much they are sold for: Between Rs 1.000 and Rs 2,000
How much they are bought for Up to Rs 25,000 by Indians,
up to Rs 50,000 by foreigners
What the law says: The Hindu Adoption and Maintenance
Act,1956, stipulates that accepting or giving a child for adop^^
tion has to be done with the court's permission; and such Wf
adopted children are eligible for all rights of a natural (biologi
cal) child. Christians and Parsis are governed by the Guardians
and Ward Act,1890, under which those who adopt remain just
“guardians” of the child. Both Acts ban selling/relinquishing
children, and make them non-bailable offences
Mary Phillip has been an inmate at the Shepherd's widow home
at Byculla, she's had only one visitor. The octogenarian speaks wis
dom: "When you are old, you are nobody."
But surely 77 million old people together can't be nobodies. Why
indeed is it that even as they grow1 in numbers, these dispossessed
and disowned Indians tot up to nothing in electoral politics? Polit
ical analyst Yogendra Yadav has an answer 'Perhaps because they
have no awareness of themselves as groups that might be able to
affect vote-swings and exert pressures. Also, critical to electoral pol
itics is the theory of aggregation, and geographically scattered as the
marginalised are, they don't amount to much." Chat, indeed, is a
grim epitaph for the "dregs" of India's troubled humanity. ■
With S. Anand in Erwadi, Manu Joseph in Ahmedabad. Dhiraj
Singh in Leh. M.S. Shanker in Hyderabad. Priyanka Kakodkar
OUTLOOKb August27,2001
- Media
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