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RF_MH_3_A_SUDHA
-5NATIONAL MENTAL HEz'iLTH PROGRAMMES FOR INDIA (1982)
INTRODUCTION
India is a signatory State to the Alma Ata
Declaration which envisages health for all by the year
2000 as the"goal. Efforts to ensure the achievement of
this goal will have to include approaches and steategies
for the improvement of all aspects of health - physical,
mental and social. While the Government of India is
fully seized with the formulation of a national health
policy since mental health forms an.integral part of
total health, a plan of action aiming at the mental health
component of the national health programme needs tobe
put forward.
The importance of mental health cannot be over
emphasised in the national health planning. The scope
of mental health is not only confined to the treatment
of some seriously mentally ill persons admitted to mental
hospitals but it relates to the whole range of health
activities. Man is essentially a thinking and feeling
being. No scheme of health planning can be complete which
does not take the mental health component into account.
in the past, mental health did not find its appropriate
place in the national and S^ate health planning perhaps
due to a common misconception that prevalence of mental
health illness is low in India, particularly as compared
to the West. In addition,, it was also thought that no
effective treatment is available.
Research studies from different parts of the country
have shown that m<_ntzl ill-n^ss is as common in India as
it is elsewhere and is equally common in rural and urban
areas. Mental illness causes immense'suffering to the
affecting individual and his surroundings, although this
suffering may not be clearly visible to others.
Following major scientific discoveries in the
field of psychotropic drugs, physical methods of treatment,
-6-
psychotherapy and other behaviour modification techniques,
simple/ effective and cheap methods of treatment are
now available for a large number of serious and disabiling
mental disorders. Further, it has been proven.in many
countries including India,- that effective treatment' can
be delivered, for a certain range of disorders,.without
having to solely rely on doctors/psychiatrists.
Just as modern scientific knowledge can help us to
prevent and. treat .disabling mental illnesses', the mental
health skills can be used to improve the' quality of general
health services. There is good evidence to say that
about 13-20%.of-all patients who seek help in 'general
health services both in developed and developing countries,
seeking help for emotional and psychosocial problems.
Current medical methods of dealing with these problems
by unnecessary investigations and costly medicines are
not- only inadequate and ineffective but produce widespread.
frustration to both the seeker and the provider of these
health services. ■ Mental health principles can improve
the.current health delivery'system and thus reduce the
ever increasing threat of dehumanisation of modern
medicine so repeatedly talked in all countries. The
proper mental health inputs in general health programmes
like family planning campaign, immunisations and nutrititon
educational programmes can and will enhance the acceptance
of these health and welfare activities of the country
by the people.
In full accord with the national health policy of
India, and in pursuit of the goal of Health for All by the
year 2000, it is now possible and feasible to draw ~
national programme which wculd not only provide a
minimum mental health care to all at a reasonable cost
but also aim at healthy psychosocial development of the
people. The proposed, plan would also ensure that the
benefit of mental health services would reach to those
who need it most and.that to our vast number of people
living in rural areas and urban slums.
It is obvious that the implementation of the National
Mental Health Plan will be possible only through a strong
commitment of the Governments of the States ns well ns at
the Centre and th .ugh dedicated dndeavOurs by nut only
all health personnel of all categories but also the
personnel working in individual and integrated programmes
of national development and by the active participation
of the cciiimunity.
PLANNING MENTAL HEziLTH SERVICES FOR THE COUNTRY
We have to take' into account the following three aims:
1.
Prevention and treatment of mental and
neurological’ disorders and their associated
disabilities.
2.
Use of mental health technology to
improve general health services.
3.
Application of mental health principles
in total national development to improve
quality of life.
ANALYSIS OF THE PRESENT SITUATION:
NEEDS, SERVICES ZiND FACILITIES
Zi wealth of information is available in India concerning
the prevalence of mental disorders. According to most of the
surveys about 10-20 per thousand of the population are
affected by a serious mental disorder at any point in
time (point prevalence).
This would constitute about 10 million citizens of
India. The figures for neuroses and psychosomatic
disorders are about two or three times higher, thus indicating
that 20-30 million people may require our attention.
Mental retardation is estimated at 0.5 to 1.0% of all
children, while alcohol and drug dependence rates, though
still low as compared to the world scene, reveal a'
disturbing rising trend in pockets, for example alcohol
consumption in Punjab, use of narcotics and Cannbis in
urban student population.
The main burden of psychiatric morbidity in the
adult population consists of:
(1)
Acute mental disorders of varying etiology
like acute psychoses of schizophrenic, affective or of
-8unknown etiology, paranoid reactions, psychoses.resulting
from cerebral involvement in;• communicable diseases
like Malaria, typhoid- or bacterial meningitis, alcohol
psychosis, and. epileptic--psychosis. These conditions
usually lead to temporary disability' but they'cause
much distress, and they can evolve into chronic
disability if not properly treated.
(2)
Chronic or frequently recurring mental 'illnesses,
like some cases of schizophrenia and of periodic or
cyclic affective"psychoses, epileptic psychosis and
dementias, encephalopathies associated with intoxications
or chronic organic disease, . etc. Modern treatment can
achieve stable remissions, or reduce disability in a
significant proportion, of these cases. Epilepsies
constitute' another important group- of disease to be
included here.
(3)
Emotional•illnesses such as anxiety, hys teria,
neurotic depression are often associated with physical
diseases- The majority of these patients would seek
help at the general health services, but failure to
recognise and treat the psychological component'of their
problem leads to prolonged distress and to unncess.ary
and wasteful prescriptions, investigations and referrals.
(4)
Alcohol abuse, and alcohol and drug dependence
appear to be growing problems, associated mainly with the
new stresses of urbanisation and industrialisation, but
their prevalence is also high in rural areas :
The number of new cases of serious mental
disorders which become manifest each year (
(incidence) can be estimated to be roughly
35 per 100,000 or about 2,50,000 in the
country. With the methods for treatment and
prevention available in modern health care,.'.
chronicity and disability can be avoided- in
about 80% of the cases.- Complete and lasting
recovery is possible in no less than 60%.
Reliable- separate data on psychiatric disturbances
among children especially learning and behaviour problems
However,
in school children do not Seem to be .available.
there is evidence that their number is in the order of
1-2% of children. Similarly, psychiatric problems
among older people especially in the large urban areas
are assuming importance due to the weakening of the
traditional"family structure and social support systems.
No factual data are currently available regarding the
less of productivity, of income•and even of life due to mental illness. But it should be pointed out that
suffering due’to mental illness often is not confined
to the affected individual, but it causes severe social
dysfunction of entire families.
EXISTING MENTAL HEALTH SERVICES
2•1
The presently ‘available mental health facilities
in India include about 20,000 beds in 42 mental hospitals
and 2000 to 3000 psychiatric bed-s in general and teaching
hospitals. For an estimated population of 680 million,
there is one psychiatric bed per 32,500 population. Moreover,
it is safe to assume that atleast one half of those beds
are occupied by long-stay patients adding to the shortage
of active "treatment" beds. The psychiatric units and
mental hospitals operate out patient clinics which are
currently the main source of mental health services in
many cities, ^he number of specialised in-patient and
out-patient facilities for children is insignificant.
Self help groups of parents with mentally retarded children
exist in a few cities only.
From the available data
it is safe to
conclude that not more than 10% of these requiring urgent
mental health care are receiving the needed help with the
existing services. The situation is worse in the rural
areas due to the heavy concentration of the services and
facilities in the cities. It is also to be noted that a
simple extension of the present system of care also will
not be able to ensure adequate services to the vast majority
of our population, in the near foreseeable future.
2.2
MANPOWER
(a)
Psychiatrists, Psychologists, Social Workers
and other Para-Professionals_________________
The manpower includes approximately 900 qualified psychiatrists
working in hospitals and having private practice, 400-500
psychologists, 200-300 psychiatric social workers and
and about 600 psychiatric nurses. Of the 108 recognised
medical schools, only half have an academic department
of psychiatry. There are only two dozen centres for post
graduate training in psychiatry with a total output
of about 100 psychiatrist per year. It would be' evident
from .the above, that the psychiatric and parapsychiatric
services in India are woefully inadequate. The problem
is aggravated by the -unequal -distribution of psychiatrists
with majority of them being concentrated in the urban
areas. Hence, even with an increased rate of training
of specialised staff, there is little hope to reach
substantial portions of the rural, population with-in
the next two decades without major changes in the
approach.
3.
STRATEGIES FOR ACTION
In view of the gross disparities between needs
and available services, there are essentially two
approaches for immediate action.
They are not alter
natives since the difference between them lies mainly
in the emphasis and in the level of priority assigned to
different levels, of service development. The first
option would be to direct available resources' to the
establishment a.nd strengthening of psychiatric units in
all district hospitals.
-It would be hoped that these
units would become foci of an expanding mental health
service through setting up out-patient clinics and
mobile teams. In general terms, the approach would be
directed from centre to the periphery.
In contrast,
an alternative' approach would be to train an increasing
number of different categories of health personnel in
basic psychiatric and mental health skills. There
would thus, be a functional infrastructure before completing
in all instances, a physical independent mental- .health
infrastructure. The approach would basically be
directed from the .periphery to the centre.
This latter type of strategy would be truly
innovative in as much as it would allow for a method
of planning according to needs perceived at the grass
root level, and it would allow for a speedy coverage of
the hitherto under or unserved rural poor and other
neglected sections of society within a reasonable
period of time.
As pointed out above, these two strategic, approachesare complimentary. Both will allow a private sector
of mental health care to continue,- but in the second
option the emphasis of. the ptublic sector will" be"
primarily directed towards the poor and the- under-priveleged
The programme when in action will directly benefit atleast 200 million population living in backward areas
of the country. There will be no competition with the
private sector nor will there be competition with
psychiatric services and facilities existing in the.
cities. Of course, the services in the cities would
continue to-have a role as referral source, as well, as
centres of training and evaluative research.
Most mental health facilities in India actually function
as passive recipients of patients. They become operational
only where coping mechanisms in the community fail.
The institutions have little knowledge and hardly any
impact on these coping mechanisms .as they exist and operate
in the community. It is essential that the role of all
mental health .institutions in India becomes more active
in concerning themselves with the social mechanisms involved
not only in the development of mental illness but also
in the more important issue . f maintaining mental, health..
OBJECTIVES
I.
To ensure availability and accessibility of
minimum mental health care for ail in the
foreseeable future, particularly to the
most vulnerable and under-privileged sections
II.
To -encourage application of mental health
knowledge in general health care and in
social development.
To promote community participation in the
mental health, service development and to
stimulate efforts towards self-help in the
community.
APPROACHES TO THE ATTAIN.’'.ENT OF PROGRAMME OBJECTIVES
In order to achieve the objectives formulated above,
the programme will adopt the following approaches
5
•
Diffusion of mental health skills to the
perit-hery of the Health Service System
This would mean that, instead-of exclusively centralising
and concentrating mental health skills and expertise
in specialised facilities, the capacity to provide
ment’l health care will be spread over the existing
network of services, with the aim to incorporate mental
health awareness and skills at all levels of health ■
care. Specifically this calls for reaching the periphery
(i.e. the primary health care structure at the community
level like the primary health centre, sub centre and
village health worker) in the performance of specified
relatively simple tasks. Mental Health care thus must
start,at the grass root level.
5.2
Appropriate apportionment of tasks in mental
health care,
The tasks to be performed at each level (village worker
subcentre, primary health centre, district hospital,
regional hospital) will be specified and a referral
system set up sc that the total system works in an•
integrated- fashions.
The Community Health Volunteer at the village level
(approximately 1 worker' for 1000 population) who is a
community vc 1'unteer and only a part-time health worker,
would be expected to act. essentially as the liaison
person between mental health caring system and the
community. He will participate in case identification
and referral of patients, and will help to supervise
follow up nf atients, and will help to supervise
follow up of y etie'nts in need of long term maintenance
therapy. .The multi purpose worker (M.P.W one for a
population of 5000) who is the first level full time
health personnel of cur. health service structure would
act as the first link with health service system by
providing first -aid care and follow up service.
The. senior an-?, mere experienced primary health care
personnel i.e. Health Supervisors (Health Inspectors,
Lady Health Visiters etc) would be’ entrusted with the
task cf early recognition and management of priority
psychiatric conditions which he/she would carry out
under the supervision of the medical doctor at the
primary health centre. The’medical doctor would have
the over all responsibility of organising and supervising
the primary level mental health care for the whole
population under the jurisdiction of primary health centre
or sub-centre. Details of the proposed activities for
each level cf health staff will be discussed below. The
referral system will operate in a way which will make it
possible that mental health problems are handled effectively
at the appropriate level of the health'system.
5.3
Equitable and. balanced uerritori al distribution
d^~ resources' .""" ~
~~
Coverage cf unserved and under served population will.
receive a high priority. Every effort will be..made to
introduce or strengthen mental health care first in
those regions which are at present deprived of it or
where it is seriously deficient.
5.4
Integration of basic mental health care into
generaTTealtH* services will’ Facilitate fEe.
Application of mental health skills when dealing
with patients-without gross psychiatric disturbances.
It will also enable the health workers to identify
psychosocial problems under the disguise of physical
complaints and manage them mere adequately. And it
will sensitize the primary health personnel to psycho
social factors contributing to ill health and to human
suffering.
5.5.
Linkage to community development
An important approach would be the involvement of
State, district and block leadership in the implementation
of the mental health programme to ensure community
involvement.in preventive efforts directed at psychosocial
problems like alcohol and drug abuse, behaviour problems
of childhood .and adolescence including delinquency and
other negative and eventually avoidable side products
of rapid socio-economic change.
This hoed for linkages calls for further research into
issues of psychosocial factors. It is.also important
for the future development, that linkages with other
sectors of the community be fostered like with housing;
education, town planning, legal agencies, to enhance the
total mental health care awareness as well as for-the
application ..of mental health skills and knowledge for
all persons.
5.6. Mental Health Care Programme
- The service
component will include three sub-programmes, treatment,
rehabilitation and prevention.
(1)
Treatment s ' The focus of the treatment
sub programme will be morbidity categories
(1), (2) and (3), ns outlined in section 2'.
Specified forms of treatment and of.: di agnostic
work will be. implemented: by personnel at the
following leyels of the regional health care
system.
(a)
.Primary Health Care at the village and
Sub-Centre level ;
Multi purpose worker (MPW) and Health Supervisors
will be.- .traihed to deal with .the following problems within - •
his own community under'the supervision.and support of the
medical officer. (1) management of psychiatric emergencies
(e.g. acute excitement, cri-sis situations) through simple'..
crisis-management skills and apj ropriate utilisation of
specified medicines (2) administration and supervision of
maintenance treatment for chronic psychiatric conditions
in accordance with guidance by the supervisors (3) recognition
and management of grandmal epilepsy (particularly in
children) through utilisation of appropriate medicines
under the guidance of medical doctors, (4) liaison with
the local school teacher and parents in matters concerning
the management of children with mental retardation and
behaviour problems, (5) counselling in problems related to
alcohol or drug abuse. These tasks will be performed
in accordance wi'th simple operational instructions
include?, in the MPW's manual. For each task, an appropriate
difficulty/severity level will be specified, beyond which
the problems would be automatically referred to the
next*level of health care.
(b)'
Primary Health Centre
The medical doctors aided by health supervisor
Will be trained to provide the following services s
(1) supervision of the MPW's performances of specified
mental health tasks (2) elementary diagnostic assessment
of cases, using diagnostic and management flow charts, and
performing a standardised basic neurological examination;
(3) treatment of functional psychoses, (4) treatment of
uncomplicated cases of psychiatric disturbance, associated
with physical diseases like malaria, typhoid, mild to
moderately, severe depressive states, anxiety syfidromes
& initial stages of functional psychoses with appropriate
drugs, (5) Management' of uncomplicated psycho-social
problems without the use of drug*. (6) epidemiological
surveillance of mental morbidity in the area and compilation
of estimates of needs which would be submitted periodically
to the next echelon for review and planning future services.
In a way similar to .the MPW’s method of work, ' the medical
officer will be guided by specified cut off points for
referral of problems to a higher level of health service
set up.
(c)
District hospital
There is an urgent need for psychiatric specialists
attached to ..very district hospital as am integral part of
the district health services. The services provided will
include (1) medical consultation, community based with
only a limited involvement of the health service personnel.
The main focus of the sub programme in its initial phase
will be the prevention and control of alcohol related
problems, with time, experience and gain in credibility, ■
however it will be possible to expand, its concerns to
problems like addictions, juvenile delinquency, acute
•adjustment problems (eg. suicidal attempts), and to an
ability to articulate community mental health needs from
the citizens' point of view. The main carriers of this
15
sub-programme will be the medical officer and community
leaders
5.7.
t the primary health centre levels.
Mental Health Training Programmes
Having accepted that mental health-specialists like
psychiatrists would not be enough in the near future in
our country to deliver mental health care to all those
who immediately require it, we have to think in terms of
alternative general health service cadres like general
medical doctors and para-medical health workers, providing
first level of care. As an immediate solution we will ■
have to train as large a number .of health personnel of
all categories as possible in the minimum essentials of
mental health tasks at. their owiv level of performance as
outlined above. However, for future investment, we must
give top priority to the better training of under-graduates..
the future medical doctors.
Currently the amount and. type of mental health
training to medical undergraduates in cur country is grosslyinadequate (According t: recent Medical Council of India's
rules the obligatory psychiatric training during 5-1/2
years of undergraiuate career is only 2 weeks at a psychiatric
centre - which is usually at n- distant mental hospital).
Thus the potential of using these future medical doctors
as agents of a new and better mental health service system
for our country as envisaged in these pages is seriously
handicapped. At present 13,000 new doctors leave the
portals cf our medical colleges in every year. It is very
important that the amount and content of training’ is quickly
altered in such - manner that a newly qualified doctor is
able to discharge his responsibility for better mental
health care of the community.. This single step, on
implementatim can become an important resource of all future
mental health programmes.
Alongwith the better training of mcdicyl under
graduates, it is equally important to include essentials
of mental health traininy in the teaching programmes of
nurses, public health administrators and health .staff or
primary care system. Details of such training programmes
for immediate action are given in.- the following .chapter
"Outlines; of the .plan of action".
5.8
Mental retardation is not mental illness but often
associated with it ns well as physical illness.
Often the mentally retarded first comedo the notice
of the medical services. Thc health workers therefore
should b< able to counsel th.e parents,provide public
education in this subject as well ns have the know-how
to refer such children to approach -social welfare
agencies for rehabilitation. Simulateneously the Integrated
Child Development Scheme (ICDS) personnel should'be given
the know-how t<; refer the mentally retarded ,recognised
by them,-co medical agencies when indicated.
5.9
The group noted the formulation of n.;cheme under
the VIth Plan towards 'the problems of drug dependence and
endorses the action taken in this regard.
6•
OUTLINE OFFLAK OF,ACTION
The plan of action aiming at achieving the above
objectives will consist of a set of targets and of detailed
activities.
6.1
Targets
(a)
Within one year each State of India will have
adopted the present plan of action in the
field of mental health.
■(b)
Within one year the Government of India will
have appointed a focal point within the ■
Ministry of Health specifically for mental
health action.
(c)
Within one year, a National Coordinating
Group will be formed comprising representatives
of all States, senior health administrators,
■ and professionals from psychiatry, education,
(d)
Within one year, a task force will have
worked out the outlines of a curriculum of
.mental health, for the health workers
identified in the different States as most
suitable to apply basic mental health skills,
and for medical officers working at PHC level.
(e)
Within 5 years, ?t least 5000 of the target
non medical or of ejssionaYs will have undc-rg-ne
a 2 week training on mental health care.
social welfare and related professions.
-l'S-
(f)
Within 5 years, at least 20%' of all
physicians working in PHC,■centres will
have undergone 2 week's training in mental
health.
(g)
Creation of the post of a psychiatrist in
atleast 50% of the districts within five
(h)
A psychiatrist at the' district level will
visit all LHC settings regularly and atleast
once in every month for supervision of the
mental health programme for continuing
■education. This programme will be fully
operational in atleast one - district in
every State and Union Territoty, and in
atleast 1/2 of all districts in some
States within five years.
(i)
Each State will appoint .a.programme of ficer
responsible for organisation and supervision
of the mental health programme within 5 years.
Amongst other responsibilities for the programme
he will organise training courses in co-op
eration with the teaching Institutions, and
he will be the focal point of data gathering
including evaluative data.
(j)
Each State will provide additional support
for creating or augmenting community mental
health components in the teaching institutions.
This programme will be operational within 5
years.
(k)
On the recommendation -of a Task Force,
appropriate psychotropic drugs to be used at
P.H.C. level, will be included in the list
of essential drugs in In-die.
Psychiatric units with in-patient beds
will be provided at all Medical College
Hospitals in the country within 5 years.
(1)
6.2.
Derailed activities
6.2.1, Activities within the sole responsibility cf the
-yt- 11
Ministry of Hoaluh, Government of xn-dia, which will
be ^re-requisites to the implementation of the National
Plan.
'
"
•
(a)
Establishment of a Nnti-nnl Adviserv Group
(b)
Nomination’ of an Assistant Director General of
Health Services within the Dircct'.tite General
-,n
-•f Health Services,, specifically for mental-health
action and, whe would also .act as Secretary to
the National-Advisory Group an Mental Health.
6.2.2
Activities within the responsibility of the
Ministries cf Health within th
State Gc-y-.r nmonts.
(a) Adoption of this’ National Mental Health
Programme as .plan of action at the State level.
(b) Appointment of one Programme Officer in their
Directorate for mental health at a seni ;>r
7
7.1
♦
(c)
Creation of the post of 'atlcast one district
psychiatrist in every district.
(d)
Provision of•facilities to the district
Psychiatrist to visit the PHC physicians,
regularly where possible, in connection
with other outreach and. supervisory activities.
NEEDS FOR COOPERATION .-.ND COORDINATION
The programme outlined is clearly and deliberately
reaching’beyond the tr-.1iti.nal tasks of a specialised
psychiatric service.
In the first.instance, it is proposed to use the
Primary Health Care structure to provide basic
psychiatric and mental health services. This means
that atleast at the grass root level of health care,
mental health will he totally integrated into
general health care delivery.
A close cooperation
of mental health professionals with other carriers
of care is thus imperative.
In fact it is hoped that mental health would become
an integral pert of all health and welfare endeavours
in ?ur country.
7.2. A strong linkage of the programme should be with
Social Welfare. In fact, the split between agents of
social welfare and mental health may have its roots
in the artificial separation of psychological (i.c.
intrapsychic) an.’ social (i.e. communicative) phenomena.
It would seem an innovative nchi.vement if this •traditional
splitting of tasks could be overcome in India. •' "The-PHC
physician,of the district psychiatrist would then do
individual as well ns social (c.g. marital) counselling,
and would advise at the same time a rural development .
committee oh questions relating- to a nursery school Or
the opening of a liquor store in the village. A social
worker could bring a destitute for psychiatric
consultation and a psychiatrist would refer .a-"complainer"
to a social worker for help in his social needs.'
7.3
Social, behavioural and learning problems are .
manifesting themselves in schools. Addition of mental
health inputs in the school health is likely to play a major
role in their amelioration. Teacher's would therefore
have to be given adequate orientation in early diagnosis
of most of the common mental health problems.
7.4
Necessary links with the mental hospital .and medical
colleges have already bean- mentioned. They, will be centres
of referral for special cases as well as centres of
various teaching activities. On the other side, it is
hoped that the medical colleges•will take advantage of
the integrated mental health services, to increase the
community health component in their under , an') post-graduate
In addition,, they will be actively participating with
ICMRlothcr research organisations ,-n various research
projects in the fi^ld of mental health.
7.5
The central mechanism of this co-operation will
be the National Advisory Group, the formation, cf which
will be an integral part of the programme. It will
consist of representatives of all States and of the
Institutions and professions referred to above-. It will
NATIONAL ADVISORY GROUP :
CONSTITUTION
7.6.
In view of diverse and varying level of development
and health infrastructure in the country, ?. certain uegre
of flexibility will be essential in the imp1-mentation
of this programme.
The proposed plan needs to be
reviewed periodically for evaluation of goals, achieved.
In that aspect the present plan should be understo;.■■■<■ as a
initial statement Of intent rather than a rigid blu^Le-
print for all future programmes.
The National Advisory
-2?r-
Group would have the responsibility of regularly.monitoring
the progress •';£ the programme.
8
.
LEGISLATIVE REQUIREMENTS
Appropriate legislation for better implementation
of the National Mental- Health'would also have.to be locked
9.
RESE/-JRCH
.One basic feature-of the programme will have.to be
a c mtinuuus monitoring through evaluative research. Very
close links with the ICMR will thus be an integral part
ofthe programme activities. There is already a considerable
commitment on the part of the ICmR task forces in the field
of mental health, in general, and especially towards
issues related to service research. Such issues will
need considerable strengthening. Research like the
actually initiated study on determinants of the outcome
of mental diseases, or an illness behaviour, have a direct
bearing on service delivery. An additional focus will have
to be on evaluative research on the effectiveness of the
programme at its different levels of functioning, from the
training of the different levels of workers to the mode
of service delivery by those workers once trained.
In view of the severe scarcity of resources in India,
the equilibirium between research and service efforts
may have to be reconsidered.
Modern research requires
inputs from many sources. For a ma joy? national programme •
like this,'there would be need for bilateral and multi
lateral collaborative research’between national and inter
national groups.
Pursuing the rightful j-'licy of creating a’ network
of centres of excellence, and of research workers of
excellence in the country, due consideration may have to
be given to the orientation of such, research efforts in
the liciht. of th-, overall health policy of the country which
is directed towards health for all by the year 2000.
Every system of medicine-as practised in India should continue
to conduct research in the field of mental health and exchange-
views and research, data for the
benefit.
mutual enrichment &
RECOMMENDATION MADE BY THE CENTRAL' COUNCIL
OF HEALTH AND FAMILY WELFARE IN ITS MEETING
HELD ON -18-20TH AUGUST, 1982.
MENTAL HEALTH PROGRAMME
The Joint Conference considered the importance
of Mental Health in the total development of society
and appreciated that mental health is an integral
part of total health and it should'therefore be viewed
in that light. . The Joint Conference recommends that:
Mental Health must form: an integral part of
the total health programme and as such should
be included in all National policies and
programmes in the field of Health Education
and Social Welfare.
ii)
Realising the importance of mental health in
the course curriculae for various levels of
health professionals suitable action should
be taken in consultation with the appropriate
authorities to strengthen the Mental Health
Education components.
While appreciating the efforts of the Central
Government in pursuing legislative action, on Mental
Health Bill the Joint Conference expressed its earnestness
NATIONAL MENTAL HEALTH PROGRAMME (--9S2.)
SUMMARY
1.
.India is a signatory State to the Alma Ata
Declaration which envisages health for all by the
year 2000 as the goal and primary health care as an
approach.
Health has been defined not merely as
absence of disease but as a state of positive
well being, physical, mental and social. Mental
health, therefore forms an essential part of total
health and as such must form an integral part of
the national health rolicy.
2.
Contrary to the popularly, held belief, mental
illness is widely prevalent in India and the prevalence
is certainly not. less than what is reported, in the
Western countries. Further more, the figures in
India are as high in rural as in the urban areas.
The Indian research scientists have brought out
enough evidence that atleast 10-20 per thousand suffer
from severe mental illness at any given time and at
least three to five times that number suffer from other
forms of distressing and socio-economically incapaci
tating emotional disorders. It has also been- shown
that 15-20% of the peonla who visit general health
services such as a medical outpatient department or
of private practitioner or a primary health care
centre have in fact emotional problems appearing as
physical symptoms.
3.
With the help of th; Government of India and the
WHO, a series of meetings were arranged with specialists
in the field of mental health as well as experts in
education, social welfare, law, labour and leaders
engaged in various ^atio" -1 development programmes.
As ?. result of these, meetings, a proposal for national
mental health programme for the country has been
formulated. This programme has been designed keeping
in view the magnitude of mental health problem in the
country, existing resources, both human and material,
advances in the mental health technology particularly
in the field of delivery of health care to the people
in the rural and far flung areas and outcome of research
studies in various fields^
Under this programme,
it
is envisaged that atleast 200 million people,.particularly
belonging to the socially and economically backward
areas of the country are likely to benefit.
-2-
4.
The programme thus has been formulated with the
following objectives :
a)
to ensure availability and accessibility
of minimum mental health care for all
in the foreseeable future, particularly
to the most vulnerable and under-privileged
sections of population.,
b)
to encourage application of mental health
knowledge in general health care and in
social development.
c)
to promote community participation in the
mental health service development and to
stimulate efforts towards self help in
the communitv.
5.
In order to achieve the above objectives, the
programme has been designed to have the following
approaches s
a)
integration of the mental health care
services with the existing general health
services,
b)
tc utilise the existing infra-structure of
health services and also to deliver the
minimum mental health care service,
c)
to provide appropriate task oriented
training to the existing health staff,
d)
to link mental health services with the
existing community development programme.
6.1
.The programme ’’ill hlvs three components namely,
treatment, rehabilitation and prevention of illness
and promotion of positive mental health. The treatment
programme has been planned keeping the primary health
care approach as the sheet anchor. At the same time, it
consists '.>f the creation of an appropriate referral
system at various levels.. It is proposed that the
specialised psychiatric services should be made available
-3-
at th<- district level. The other major responsibilities
for the health personnel at the district level would be
to provide training and' supervision to theworkers at the
primary health centre level. The mental hospitals, medical
colleges, teaching institutions and mental institutes
shall also be linked together into the national grid
for the mental health care'particularly in the field of
education and research.
6.2
The rehabilitation sub programme will develop
services for the rehabilitation:of the chronically
.disabled both due to -mental illness as well asmental
retardation.
This programme envisages linkage with the
rehabilitation programme of other Ministries particularly
the Ministries of Labour and Social Welfare,
6.3.
In the field of prevention and promotion, the
sub programme ’visualises counselling services for common
manta! health problems like alcohol and drug abuse,
delinquency and'genetically inherited mental illness.
7.
An exercise has also been done in order to
identify the various targets that would have to be
attained in a time-bound frame.
It is proposed that a
small co-ordinating group at the Centre be formed
immediately which would $o into the phasing of the programme,
8.
The salient recommendations for further action are
as under ;
a)
Mental Health' must form an ijnt^graS part
of the total health programme and as such be
included in all national policies and programmes
in the fields of health, education & social
welfare.
b)
Considering the importance of mental health
in the total development of society, mental
heal th aspects should be kept in view in the
planning of activities for national development.
c)
ApfeagecinH'fig the importance of mental he l. \h
in the c'ourse curriculae for various levels
of health professionals, suitable agtion
should be taken with the appropriate
authorities to strengthen the mental health
educational component.
d)
The practitioners o.f Indian Systems of
Medicine should continue to play their
respective distinct roles in the field
of health inclusive of mental health.
9.
The above recommendations are commended for
consideration by the Central Council of Health. Keeping
in view the importance of mental health, as an integral
part of the total health, the Central Council of Health
may kindly lend its support for adoption of the programme.
A COMMUNITY MENTAL HEALTH PROGRAMME IN RURAL TAMILNADU
R.Thara*, R.Padmavathl
This is a brief report of a community
mental health rehabilitation programme
carried out in a rural area in Tamil
Nadu by the Schizophrenia Research
Foundation (SCARF). SCARF is a non
governmental. non-profit organisation
in Madras, working for people with
chronic mental illness, and has been
involved in community menial health
work in the past decade in urban slums
and rural areas. The community menial
health project is funded by a Canadian
donor (IRDC) and is carried out in Thiruporur.
Covering an arcaof 14,181 square miles
with over 100 villages, this area has a
total population of 1,10.758 persons.
most of whom live below the poverty
line. One Primary Health Centre (PHC),
a few sub-centres, and rural dispensa
34 Vol. 10 E No.l ■ 1999
ries cater to the health needs of the
population. Two major religious cen
tres in the area, a Dargah and a Hindu
Temple, arc prominent bealihg sites
for mental illness, and often arc the
first point of contact. Therapeutic mea
sures in these centres include special
prayers, offerings, special food and other
rituals, undertaken over varying peri
ods of lime.
mental health service system in the
area, planning and implementing an
intervention programme for the identi
fied mentally ill. integration of mental
health with primary health care infra
structure in the area, and conductin
periodic awareness programmes in the
community.
THE MENTAL HEALTH
PROGRAMME
The Community
Rchabilitatior
Workers(CRWs) were lay volunteer
identified from the community with it
help of village leaders. The trainin
consisted of five sessions each for te:
groups of CRWs. followed by periodic
reinforcing sessions. Medical office:
and multi-purpose workers ( number
ing 50 for the training ) from the PHC.
While the primary objective was to operate
a community mental health programme
in the defined catchment area, the other
programme components included training
lay volunteer workers to detect and
manage mental disorders, operating a
TRAINING
Asia Pacific Disability Rehabilitation Journal
were also trained during four sessions.'
The choice of CRWs from the local
population helped to facilitate easier
acceptance and accessibility to the homes
of the mentally ill. The training in
cluded detection of mental disorders in
the community such as psychoses, neu
roses, mental retardation, substance abuse
disorders and epilepsy, implementation
of simple intervention strategies, working
closely with families of the mentally
ill, and making appropriate referrals.
Manual and audio-visual training ma
terials were used for the sessions.
MENTAL HEALTH SERVICES
An active outpatient clinic was oper
ated twice a month in Thiruporur town.
Patients identified in the community
by the CRWs were treated by a psychia
trist, and reviewed periodically. A similar
procedure was followed in camps held
in remote villages, which were not ac
cessible to' the clinic. "Some simple
interventions offered by the CRWs in
cluded support to the client, educating
families on mental illness, management
of behaviour problems, ensuring drug
compliance, training patients in self
care and activities of daily living, job
placement, and initiating small busi
nesses as a measure of rehabilitation.
The.emphasis was on utilising local
resources and mobilising local support.
Over a period of five years. 637 pa
tients suffering from mental illness were
registered and offered treatment, and
at the end of the sixth year, 235 were
being followed-up.
INTEGRATION OF MENTAL
HEALTH INTO PRIMARY
HEALTH CARE
This was initiated by training health
care personnel in PIIC services to de
tect and manage mental illness. Active
liaison with the government health and
medical service departments, as well
as sustained efforts at ensuring a sup
ply of basic psycho-tropic medicines at
the PHCs have paid dividends. Il was
therefore possible to refer a number of
patients to the PHCs in that area.
AWARENESS PROGRAMMES
These were periodically held in differ
ent villages, using local folklore, dance
and music. The emphasis was on early
recognition of mental illness and prompt
treatment. Following the awareness
programmes, it was noticed that refer
rals to the clinic incrcasbd. mainly from
village leaders, traditional healers.community
workers and general medical practitio
ners
COMMUNITY INVOLVEMENT
AND EMPOWERMENT
The project has been community ori
ented in that over 80% of the staff were
drawn from the same community facili
tating easier acceptance and greater
involvement. Village leaders, teachers.
religious heads and others with influ
ence were involved in the programme
at various stages.
Most of rural India is devoid of formal
mental health services. It was evident
soon that communities by and large
favoured traditional and religious forms
of treatment, not only because it suited
their explanatory models of mental ill
nesses, but also because of the easier
availability of these services, in com
parison with formal medical facilities.
The project staff established good links
with traditional healers in that area
who gradually began referring cases to
35 Vol. 10 a No.l
iyyy
.the centre. No efforts were made to
thrust into the community a medical
model of illness or to persuade them to
give up the existing help they were
used to. Within a few months, it was
clear that this rural community was
ready to abandon its traditional treat
ments for some of the mental disorders,
while it continued to hold on to its view
points regarding others. This is not an
uncommon phenomenon, and it is prob
able that most stigmatising illnesses
are faced with this kind of “mixed loy
alties".
It is possible to train lay community
volunteers to identify various mental
disorders and implement simple psycho
social rehabilitation strategics. Involving
and training lay community workers
from the community facilitated easier
acceptance by the patients and their
families. The interventions offered as
part of this programme have facilitates^
community integration of the mcntal^^
ill. Interventions have been individu
ally tailored to the needs of the patients
and their families. Establishing rap
port with the family and the community
through the involvement of local vil
lage leaders has ensured the acceptance
of such a programme by the population.
The programme has shown that there •
arc some basic elements of psycho-so
cial intervention that arc essential in
any community mental health programme
in. a rural community, particularly in
developing countries. These should in
clude. besides provision of psycho-tropic
drugs, the involvement of the family
and the mobilisation of local.commu
nity resources. Structured and skilled
psycho-social rehabilitation programmes
may be too complex for implementa
tion and may not be necessary for the
rural population. Besides, these cann^H
be implemented by the lay communit^
volunteers.
Mental health care is undergoing a transition
the world over from institutionalisation
to community care. Understand! ng commit nity
perceptions, attitudes and coping styles
will increasingly become more crucial
in community based programmes. This
is even more relevant in developing
countries, where “stereotypes” about
the mentally ill have existed for centu
ries. Making a change in this without
antagonising or hurting the feelings of
the community would be a challenge.
In this respect, this project has been a
kind of forerunner and provided a model
which may be replicated in other parts
of the world.
’Schizophrenia Research Foundation
Plot R/7A. West Main Road
Annanagar. (West extension)
Chennai - 600 101, India
IMPLEMENTATION OF MENTAL HEALTH PROGRAMME IN YELANDUR TALUK
COLLABORATION WITH NON GOVERNMENTAL ORGANISATION
IN
2
3
Dr.K.V.KI SHORE KUMAR,
Dr. II.SUDHARSHAN,
4
5
Dr. SRIDHAR
& Dr. SHIVAKUMAR .
1
Dr.R.SRINIVASA MURTHY,
INTRODUCTION:
The myth
that mental illness is a phenomenon
of
the
de
veloped,
rich,
industrialised nations only, has
been
squarely
dismissed by consistent epidemiological investigative efforts
i»
our
country.
About
17 epidemiological studies
till
date
of
varied
research
sophistication have been conducted across
the
length
and breadth of the country covering both urban and
rural
population.
The
insight gained by such
investigations
reveals
that the mental morbidity is comparable to developed nations
and
that there are no rural and urban differences in determinants and
distribution of severe mental disorders.
While
epidemiological
studies
unequivocally suggests the presence of
such
disorders,
the
range has however varied due to differences
in methodology
and
case
identification methods.
The range
of
severe
mental
illness varies from a figure as low as 1.1/1000 (Sethi
et al.,
1972)
to
43.2/1000 (Nandi et al., 1975). Further
the
document
(WHO, 1975) 'Organisation of mental health services in developing
countries' points out
that at any given point
in
time
1Z
of
population
suffers from severe incapacitating mental
disorders
and
102
of the population have life time
risk of
developing
severe
mental
disorders.
Considering
this
evidence
and
extrapolating
these
figures,
nearly 9.3 million people
need
urgent
help for their incapacitating Miental disorders, while
93
million would potentially need help some time in their life.
Unfortunately the manpower and resource available to
tackle
this major public
health
problem
is
very meagre.
This
is
evidenced
by the fact that there are 3000 psychiatrists
in
our
country.
This
figure makes it upto 1
psychaitrist
for
about
300000
population.
The situation in United Kingdom is
about
1
psychiatrist for every
30000 population. There
are
42
mental
hospitals and 200 General hospital psychiatry units in India both
yielding
nearly
26,000
beds which is
comparable
to
that
of
Holland
which has
15 million population.
This
gross mismatch
between
the morbidity and resource (both in
terms
of
manpower
and
infrastructure) needs have to be addressed by
prophesising
the strategy of integration of mental health into general
health
services.
1. Professor & Head,
2. Psychiatrist
3. Secretary & Managing Trustee
4. Peadiatrician
5. Medical Officer
I
I
I
I
I
Department of Psychiatry,
NIMHANS, BANGALORE 560 029.
VGKK, BR Hills, Yellandur.
The
impetus for this approach has been possible due
to
the
following,
(a)
the commitment of the
country
to provide
health
care service to all, (b) the Alma Ata Recommendation
on
Primary Health Care, (c) the existence of a large
infrastructure
of
general
health
service (PHC system), (d)
the
approach
to
utilise multipurpose workers and to provide health care to
rural
people, (e) development of simple interventions to manage
mental
disorders.
Feasibility and effectiveness of mental
health
care
using
this strategy of integration has been demonstrated in
our
country in the last 2 decades.
They are (i) Raipur Rani
Project
(WHO
collaborative multicentred
international
study
titled
'Strategies
for
extending mental
health
care'
(1975-1981)
involving seven developing countries .(Harding et al., 1980,
Wig
et al., 1981). (ii) Sakalawara project initiated in the
villages
of
Karnataka, South India in order to develop models
of
mental
health
care, (Chandrasekhar et al. ,1981,
Isaac
et al.,
1981,
Isaac
et al., 1982), Parthasarathy et al., 1981).
(iii)
Jaipur
Project,
(Shiv Gautam, 1986).
(iv)
ICMR/DST
multicentred
collaborative study on severe mental morbidity (ICMR, 1987). (v)
Mental
Disorders in Primary health care (ICMR/CMH, 1985).
(vi)
Bellary project (1981-1990) (Isaac et al., 1986). The first
two
of the above mentioned studies resulted in the formulation of the
National Mental Health Programme for India, (GOI, 1982) with
the
following objectives:
1. To ensure availability and accessibility of minimum mental
health
care for all in the foreseeable future,
particularly
to
the
most vulnerable and under privileged section of the
popula
tion.
2. To encourage application of mental health knowledge in general
health care and social development.
3. To promote
community participation
in
the mental
health
services
development and to stimulate efforts towards self
help
in the community.
It is important to appreciate that all the major initiatives
towards integration has occurred in public sector, while collabo
ration with NGOs has been completely absent particularly in
this
area. Further continuation of
such work in the
long
term
in
public
sector has not been satisfactory for the reasons of
lack
of
essential
drugs, preceived over work of
the
staff,lack of
motivation, frequent transfers
etc. Therefore,
lately
such
an
effort has been given importance since the Governmental
agencies
alone may
not
be able to address the
needs
of
mentally
ill
population
in the country.
Work in this direction can
generate
useful
insights pertaining to feasibility and sustainability
of
mental health care through►integrated approach in NGO sector.
Current
report
focuses on such a debutant effort
area of integration of mental health in general health
through an NGO in our country.
in
the
services
DESCRIPTION OF THE STUDY AREA :
Yelandur Taluk
is part of Mysore
district
in
Karnataka,
South
India.
It is located 100 kms . from Bangalore and has
a
population of
seventy
thousand.
Health care
is
provided
by
Government
administered primary health centre and by
the
non
governmental voluntary agency 'Karuna Trust'. The medical service
provided
by
the MGO includes primary health
care
for
general
medical
problems, domiciliary care for leprosy and
tuberculosis
and care for persons with seizure disorders.
Agriculture is
the
main
occupation
of
the people which
largely
depends on
the
monsoon, a small proportion of the area is irrigated.
This taluk
is a reserved constituency politically since the majority of
the
population are
scheduled castes and scheduled tribes.
A part of
this
taluk is inhabited by 'Soliga Tribes' who are confined
to
the forests of BR Hills (Biligiri Ranganna Beta).
The quality of
life of the Soliga tribes have changed dramatically over the last
15
years
due
to strong commitment
and
sustained efforts
of
Vivekananda Girijana Kalyana Kendra headed by Dr. H.
Sudharshan.
The efforts have resulted in organization of primary health care,
development
of educational infrastructure,
vocational
training
facilities and social development for the tribal population.
METHODOLOGY:
AIM:
To
examine
the
feasibility
of
utilising
the
existing
personnel of an non governmental organisation in providing mental
health care as part of primary health care.
GENERAL OBJECTIVE: To orient the existing personnel in the NGO in
mental
health
care
by a short training programme
to
include
mental health care activities in their total health care.
SPECIFIC OPERATIONAL OBJECTIVES:
1.
To
enable them identify persons with severe mental
illness
among
those attending health facilities and those living in
the
communi ty.
2. To enable them to provide services to the persons with
mental illnesses in their institutions.
severe
3 . To provide skills for follow-up of persons with mental
and to ensure continuity of care.
illness
4. To incorporate mental health skills into specific
programmes
like,
ambulatory care of persons with tuberculosis and
Hansen's
disease.
5. To
facilitate their understanding and practice of
community
organisation,
principles
to ensure community
participation
in
mental health care.
6.
To understand the cost and sustainability of such initiatives.
7.
To understand the role of community based
rehabilitation
chronically mentally ill persons and its efficacy.
of
The initiation of mental health programme in Yelandur
taluk
was
started in October, 1994 . The catchment area has
Lwo
focal
points of service provision (Yelandur clinic in tarai
region
&
Jaya
Vijayam tribal hospital in BR Hills). The personnel of
NGO
consisted of three doctors and ten health workers. The first
two
day training programme was started by Dr. R. Srinivasa Murthy
on
sever
mental
morbidity
(psychosis,
depression
and
mental
retardation).
The
language of instruction was English
and
the
topics
covered were brain and behaviour,
signs
and symptoms,
aetiology and management of severe mental morbidity.
This was
suplemented by video-tapes "mental health in primary health care"
(WHO,
1993).
The
video materials
are
instruction
tapes
for
primary
care
physicians.
It has been produced
to understand
various
forms
of
presentation of severe mental
morbidity
in
primary care and to develop interviewing skills. Similar training
sessions were
held
for Doctors and Health
Workers
for
three
consecutive months. Apart from the video demonstration,
lectures
and
live
case
demonstration
in
field using
key
informant
technique were used. Following these inputs, persons with
severe
mental morbidity were identified by the health workers and
these
patients were
managed
by
doctors
under
the
supervision
of
resource persons from NIMHANS (Prof. R. Srinivasa Murthy and
Dr.
Kishore Kumar. The specialists visited the centre every month
on
the second Saturday and Sunday till date. The cases registered in
the
clinic
was used for on job training for
both
doctors
and
health
workers on a regular basis to increase their skills
in
evaluation
of patients, plan appropriate management,
monitoring
of
side
effects
and health education to
the
family
members.
In
addition
to inputs in the clinic, the
personnel
were
also
given training in case identification at the
level of
community
using
flip
charts
on
ten features
of
mental
disorders
and
administration
of
15 item questionnaire
Indian
Psychiatric
Survey Schedule (Kapur & Carstairs, 1974).
These techniques
are
important
measures to detect morbidity in the community who
arc
not availing mental health services.
RESULTS:
Following
implementation of mental health
programme
since
August
1994
nearly
196
patients with
severe mental
health
problems were registered who were availing services provided
by
doctors
and health workers.
Patients registered
are
evaluated
systematically on primary
care health record and
details
of
patients
are maintained in a central register.
Patient
details
are maintained on a computer data base out of which
103
cases
were analysed for the current report.
Table-1
shows
the background
characteristics
of
persons
using mental
health services in Yelandur taluk.
The
pool
of
patients analysed consisted of 64 males and 39 females,
majority
were illiterates and more than one half were single by virtue
of
being
separated,
widowed or never married, and
the
rest
were
married.
The person registered consisted
of
41.82
employed,
27.22
housewives, 15.52 were students, 6.82 were unemployed.
A
large majority of patients belong to nuclear families, less
than
one quarter were from joint families, and rest were living alone.
Most
of
the patient belonged to low socio-economic strata and
majority were Hindus.
The mean age of the sample was
32.7
♦ /1.49 years.
Illness characteristics of the persons uai.ig mental
health
services
is
shown in table 2.
Psychosis
related
complaints
formed more than one half of the sample, one third was depression
related and the rest consisted of mental retardation, anxiety and
a very
small
proportion formed alcohol
and dementia
related
complaints.
About 402 of patients presented with acute onset
of
symptoms and
an equal
proportion
with
insidious
onset
of
symptoms
respectively.
The
remaining patients
either
had
subacute
or unclear onset of symptoms.
The most
common mental
health problems diagnosed in the sample were schizophrenia 40.82,
depression
20.42, bipolar affective disorder
10.72
(depression
and
BPAD referred to as affective disorders form 31.12)
of
the
sample, mental retardation 9.72, acute psychosis 5.82 and others
12.72 in that order.
The mean age of the sample of patients
with
sch i zopli r e n i a
and
affective disorders (which forms the core of
severe
mental
morbidity
and
treatable
) was 36.9 + /- 13 and 31.8
+ /15.6
respectively (Table 3). The mean duration of illness was 72.4 + /65.1
months
and
20.6
+ /4.6
months
respectively
for
schizophrenia and affective disorders. Similarly the age at onset
was
31.4 +/- 14 and 28.4 + /- 13.5 years respectively.
Table
4
shows
the distribution of
dysfunction
affecting
biological,
personal, social and occupational spheres in major mental
health
problems. The most commonest was dysfunction in work performance
(91.32),
sleep (85.42), social norms (78.62),
appetite
(68.92)
personal
hygiene (54.42), sexual (23.32), and bowel
(18.42)
in
descending order.
Table
5 shows the service utilization pattern and distance
from residence to the clinic. The proportion of patients who
had
contacted mental
health
services
else
where
prior
to
the
development of such services in Yelandur were 35.92 i.e. only 3-4
out of 10 individuals who needed psychiatric intervention sought
help,
while the rest did not. Those who had availed help outside
stopped using that facility due to problems
like
distance, non
availability of
free
drugs,
inability
to afford drugs
due
economic
reasons and logistic difficulties involed
in shifting
the patient. On having access to psychiatric
services
locally
41.72
were
regular, 20.42 were irregular, while
first
contact
dropouts were only It).72.
The remaining patients were new cases
who
did not have enough follow up period to comment
upon
thier
utilization.
The mean distance from residence to clinic was
7.8
+ /- .75 kms.
5
Clinical
and social outcome of persons using mental
health
services
is shown in Table 6.
About 23.32 of patients
improved
symptomatically, 28.22 remitted completely, while the 13.62
were
status quo and rest were either first contact drop out or did not
have enough follow up care to comment upon the outcome.
However
when
time taken for improvement and, remission in
symptoms
were
considered
for major mental health problems it was found
to
be
1.6
+/- 1.7 months for schizophrenia, while it was 1.2
+/1.8
months for affective disorder, the figure for remission were
2.1
+/- 3.5 and 4.2 +/- 12.2 respectively.
Social functioning revealed that nearly one half of patient
were
functioning in expected roles, while nearly one quarter of
patient
had
impairment in this
sphere and for
the
rest
this
measure could not be assessed.
Subjective level of
satisfaction
of
significant
family members revealed that nearly
two
thirds
were satisfied with care they received from the centre.
DISCUSSION
The
implementation of mental health services
in
Yelandur
taluk
in
collaboration with
an
NGO using
the
strategy
of
integrating mental health care into general
health
services has
resulted
in
identification of nearly 196
persons with
severe
mental health problems till date. This figure represents about
a
third of the total cases of
severe mental morbidity excepted
in
Yelandur
taluk. These findings
clearly demonstrates
that
with
simple decentralised training inputs a liigh proportion of
severe
mental
morbidity
was identified by the
health
workers.
These
cases
were managed by the doctors in their weekly mental
health
clinics.
The
high
rate of identification
of
persons with
severe
mental
morbidity
and management by the
doctors
is
in
sharp
contrast to other similar studies using comparable methodology in
public
health
settings
like, 'co 11abarative
study
on
severe
mental morbidity'(ICMR/DST, 1982) and
study on 'mental health in
primary
health
care'
(ICMR/CMH,
1985-1987).
The
differences
observed between these studies could be related various
factors.
This could be due to the low image of the PI1C as a system among
the public;
low morale among the health
workers
and medical
officers
in
the
PHC; poor motivation on
the part
of
health
workers and medical
officers;
multiple
programmes;
need
to
acheive targets; emphasis on quantity than quality;
transferable
jobs
and frequent interpersonal problems between the
staff.
On
the
other hand personnel in NGO sector are better motivated
and
committed to work. As a team they are very cohessive;
frequently
meet’ to monitor
the progress of
work
in
an
atmopshere
of
friendship
and mutual respect. Lastly, the involvement
of
the
doctors and the supervisory staff in regular field work with
the
health workers goes a long way in boosting their morale.
till
Analysis
of the data of persons registered since
inception
May
1994
consisted of
103
cases.
The
sample
was
6
characterised
by predominantly males, belonging to middle
age
group
from
low socio economic strata and hailing
from nuclear
families.
It is
striking to note that nearly 40Z of
individual
were never married, while 45Z were married, the rest were single.
This
emerging
trend of nuclearisation
of
families
not
only
increases the burden
but also influences the
treatment
seeking
pattern, eg., underutilisation of services. Such issues have been
researched and reported by Murthy et al. , ( 1977) iWig et al. ,(1981)
and Jayaptakash et al.,( 1987 ).
The most
common presenting complaints were
related
to
psychosis,
depression, mental retardation, severe
neurosis
and
others like alcoholism and dementia.
This pattern suggests
that
if
services are
available persons with
severe mental
health
problems
would avail
sj*ch
services
without
any
reservation
arising
out
of
factors like stigma or
attempts
to
conceal
mental
illness etc.
Nearly 5-6 out of
every
10
persons who
visited
the clinic presented with acute onset of symptoms while
the
rest had insidious onset.
This demonstrates
the
potential
ability of such facilities to intervene at the very early
stages
of
illness
resulting
in
better outcome.
This
point
is
illustrated
with
the case examples elaborated below.
Ms.
P, a 20 year old married female was brought to
the
clinic with 15 days history of behaving abnormally.
She
was
subjectively
feeling very happy, often
she
would
sing and dance in public which would annoy her husband.
She
claimed
that god was talking to her
and
that
he
bestowed her with some special powers.
She
was
also
demanding
special food and had enormous
appetite.
Iler
sleep
was disturdbed, would wake up in the early
hours
of morning and start house hold chores and would
never
complete the task. She felt that all the family membe-rs
were
lazy and often quarelled with them.
This patient
was
treated by
the doctor
in
Yelandur
clinic with
C1orpromazine
100 mg., twice daily. Over the next
four
weeks all
the behavioral problems in the patient
had
disappeared and she resumed her normal functions at home
Mrs M,
a 28 year old married lady was brought
to
the
clinic with
2
years
history
of
being
suspicious,
sleepless,
refusing
food,
talking
and
arguing
with
imaginary
people.
At
times she
used
to abuse
the
neighbours
in foul language and claimed that they
were
doing black magic on her. Her personal hygeine was very
poor
and did not do any work at home. She did not
take
care of children and tend to wander away from aimlessly.
The f.'ini !y members I. hough I. I. lint she was possescd by evil
spirits
and took her to faith healers and priests with
no
benefit.
In the clinic she was very
irritable
and
aggresive. She was very suspious and argued that she did
not have any problem. She refused to take medication and
felt the doctors had joined her neighbours in
finishing
her.
The team had to admit this patient in their
small
primary health
centre and managed her with
Injection
7
Chlorpromazine
50mg IM twice daily. Over the
next
one
week patient
was
sleeping well, started
to eat
and
agreed
to take medication. With regular
treatment
all
her
symptoms
disappeared in two months time.
Mrs.
M.
continues to take medication and has reached normalcy.
The
diagnostic profile suggests that most common
severe
mental
health
problems
diagnosed
in
rural
settings
are
schizophrenia,
affective
disorder; mental retardation
in
that
order. The service utilisation pattern revealed very
interesting
results. One out of every ten patients with severe mental
health
problems registered in the clinic dropped out of treatment
after
first
contact,
about 6 continued I r e a I: me n I: regularly,
about
2
were
irregular but maintained contact with the team. This
trend
of
treatment utilisation pattern is better compared
to
earlier
studies.
This profile of follow-up reflects the skills the
teaig
has
developed over time to educate the family and
the
patient?
with regard
to the importance of regularity with medication
and
closely
monitoring
the
side
effects.
The
inputs
from
the
visiting
resource personnel further enhanced their skills.
This
occurs
in terms of the doctors requesting the problem cases
to
attend the clinic on the day of the visit of the resource persons
from NIMHANS to discuss and review diagnosis, management plan for
some
patients whom they felt difficult to manage.
For ex.,
a
patient with psychosis on conventional dose of chlorpromazine who
did
not respond to treatment, inability to
distinguish
between
depression
and residual schizophrenia or a patient
with
severe
side
effects
leading
to poor
compliance with
medication
or
difficulties in differentiating organic and functional psychosis.
Such
discussions
resulted
in
referring
such
patients
for
admission
to
a major mental health
facility.
These
reffered
patients were
suffering from a) space occupying
lesions
which
presented
as acute withdrawn behaviour, b) severe
side
effects
leading to stupor, c) episodic abnormal behaviour due to cerebral
mass
lesion.
It is important to appreciate that
with
periodic^
inputs
the doctors gained skills in managing
severe
neurotic
problems
through
non medical
mode
of
interventions
like,
counselling.
Further,
they were able to apply these
skills
in
their
regular management and improving compliance aihong
persons
with Hansen's disease and tuberculosis.
Since
the medication is dispensed free of cost and
concern
shown
to the patient is high , compliance with treatment on
the
part the patient and the family is definitely
better. About
one
half
to three fourth of the patients registered had
biological,
social and ocupational dysfuntion. The common form of
dysfuntion
was
impairment
in
work.
Using
simple
basic
drugs
like
(Chlorpromazine,
Imipraminc,
Injection
Fluphenazine
and
Trihexyphenidyl) to treat 'severe mental health problems,
nearly
5
out every 10 persons had clinically improved or remitted in
a
short period of time. Similarly 1-2 out every 10 persons
treated
remained clincally
symptomatic
and
functioned poorly.
CONCLUSION:
The
current
experience arising out of this work strongly
suggests
that with simple decentralised training,
provision
of
mental
health
care
to
the needy,
which
is
accessabile
and
affordable
in terms of minimal drugs would result in
remarkable
acheivement in rural India with respect to severe mental
health
problems.
Therefore what is needed is minimal
essential
drugs,
concern for the ill and commitment and continuity in care.
These
interventions
bring
in significant changes in the
patient
and
relcive
the enormous burden on the family by the simple
act
of
collaboration between the NGO and I he Professional.
REFERENCES
BB
Sethi,
SC Guptha,
Rajkumar,
Promila
psychiatric survey of 500 rural families . IJP
Kumar i
( 1972 ) . A
14 (183-196)
Nandi
D.N., Aginan S
Ganguli H, Bannerhee G, Boral G.C.,
Ghosh
G.G., Sarkar S (1975)
Psychiatric disorders in a rural community
in
West
Bengal - An epidemiological study,
Indian Journal
of
Psychiatry,
17, 87.
WHO
Organisation
of
mental
countries.
TRS- 564, 1975.
health
services
deve1 oping
T.W. Harding, M.V. De Alzango, J. Baltazar, C.E. Climent,
11. Il. A.
Ibrahim, L. Leidrido Ignacio, R. Srinivasa Murthy, N.N. Wig.
Mental
disorders in primary health care:
A study of their
fre
quency and diagnosis in four developing countries.
Psychological
Medicine (1980), 231-241.
Wig
N.N, Srinivasa Murthy, R., and Harding t.W. (1981)
for rural psychiatric services - Raipur Rani Experience.
Journal of Psychiatry
23, 275-290.
A
model
Indian
Chandrashekar C.R.,
Isaac M.K., Kapur
R.L.,
Parthasarathy
R.
(1981)
Management of priority mental disorders in the community.
Indian Journal of Psychiatry, 23, 174-178.
Isaac M.K.,
Kapur R.L., Chandrashekar C.R.,
Parthasarathy
R.
(1981)
Management of priority mental disorders in the community.
Indian Journal of Psychiatry, 23, 174-178.
9
Isaac M.K., Kapur R.L., Chandrasliekar C.R., Kapur M & Partliasarathy
R.
(1982)
Mental Health delivery in rural
primary
health
care - development and evaluation of a pilot training programme.
Indian Journal of Psychiatry, 24, 131-138.
Parthasarathy
R.,
Chandrasekhar C.R., Isaac
M.K.,
(1981)
A profile of the follow up of rural mentally
Journal of Psychiatry, 23, 139-141.
Prema T.P.
ill.
Indian
Shiv Gautam (1987)
Community psychiatry with limited
resources
in
developing
countries - experience from Jaipur.
Continuuing
Medical Education, vol. 5: pp. 59-69.
ICMR
DST Collaborative
study
ICMR/DST, New Delhi , 1987.
on
Severe
Mental
Morbidity.
ICMR Centre
for Advanced Research in Community
Mental
Health
project
'Mental Health in Primary Health care
(1985-1987)’. CMH
News, 2: 4-6, 1985.
Isaac, M.K. cL al.
Decentralised training for P11C medical
offi
cers of
a district - The Bellary
approach.
In:
Continuuing
Medical
Education vol. VI (ed)
A. Verghese. Indian
Psychiatric
Society, Calcutta, 1986.
GOI ( 1982 ).
Delhi.
National Mental Health Programme for India.
DGIIS,
New
Kapur R.L., Kapur Malavika, Carstairs G.M. (1974)
Indian Psychiatric Survey Schedule, Social Psychiatry, 9, 61-69
Srinivasa
Murthy,R.,Ghosh,A,.& Wig.N.N.(1977)Drop
outs
psychiatric
walk
in
c1inics.I ndian
Journal
Psychiatry.19(2).11-17.
f r om
of
Wig.N.N.,Srinivasa Murthy.R.,(1981)Reaching
the
unreachcd
11Experiments
in organsing
rural
psychiatric
services.Indian
Journal of Psychological Medicine, 47-52.
Jayaprakash.M.R.,
Sekar.K.,
Isaac.M.K.,
Srinivasa
Murthy.R.,
(1987) Problems of the mentally ill in rural areas.Indian Journal
of Social Psychiatry,3(4) 343-352.
10
1
TABLE
: BACKGROUND CHARACTERISTICS
No .
Var i nb 1 e
Vn 1
1 .
Ge nde r
Male
64
I'cm a 1 c
39
2.
I? du cat: i on
3.
4.
Marital
Status
Occupat i on
59
43
47
54
43
5.
Family type
6.
Socioeconomic
status
I 1 1 i teral on
Li terates
Married
Single
Workers
Nworkers
Living alone
Nuclear
Joint
Lower
Middle
Upper
TABLf3 2
:
Variable
1 .
Present ing
comp 1ai nt s
2.
4.
62.1
37. 9
57 . 3
42.7
45.6
52.4
4 1.8
58 . 2
4.9
72 . 8
22.3
79.6
17.5
2.9
60
5
75
23
82
18
3
Di str i but i on
Value
Psychosis
54
Depression
29
Mental Retardn . 10
Anxiei ty
7
Others
3
Type of onset
Acute
53
Gradua1
50
Course of
1st Episode
43
i11ness
Cont i nuous
59
Di agnosi s
Schizophrenia
42
Acute P s y c 11 o s i s
6
BPAD
11
Depression
21
Mental Retardn. 10
Others
13
TABLE
3 j. ILLNESS CHARACTERISTICS
No.
Variable
1 .
Age in Years
2.
Duration of illness
(months)
Age at OM»set in yrs.
Percentage
52.4
28.2
9.7
6.8
3.0
51.4
48.5
42.7
57.3
40 . 8
5.8
10 . 7
20 . 4
9.7
12.7
Diagnosis
Sch i z .
3.
1’ 0 r <: <• n 1. n g <•
ILLNESS CHARACTERISTICS
No.
3.
1) :1 nt r 1 b n 1. 1 on
36.9 ♦ /- 13
mi n= 1 8 ; max= 71
72.4 +/- 65.1
(5 - 6 years )
31.4 +/- 14
min=15; max=70
11
MDP
31.8 + /- 15.6
mi n= 1 2 ; max = 70
20.6 + /- 46
(2-4 years)
28.4 */- 13.5
min=l 2 ; max = 56
TABLE 4
PERSONAL AND SOCIAL DYSFUNTION
SL NO
1.
2.
3.
4.
5.
6.
7.
VARIABLE
DYSFUNTION PRESENT
TABLE 5
SERVICE UTILISATION PATTERN
:
Di st r i but i on
No.
Variable
Value
1 .
Past psych.
consultation
Type of
follow up
(current )
Present
Absent
Drop outact
Regular
Irregular
NA (New)
2.
TABLE
6
PERCENTAGE.
85.4
68.9
18.4
23.3
54.4
91.3
78 . 6
88
71
19
23
56
94
81
SLEEP
APPTITE
BOWEL
SEXUAL
PERSONAL HYGEINE
WORK PERFORMANCE
SOCIAL NORMS
:
37
66
11
43
21
28
Percentage
35.9
64.1
10 . 7
41.7
20 . 4
27 . 2
OUTCOME AND LEVEL OF FUNCTIONING
No.
Variable
Value
1 .
Out come
following
intervent ion..
Improved
Remit ted
Status quo
Others
Distribution
Improvement (months)
24
29
14
36
Percentage
23.3
28.2
13.6
35
1.6 + /- 1.7
1.2 +/- 1.8
2.1 +/- 3.5
4.2 + /- 12.2
2.
Social
Functioning well
functioning. Adequate
Poor
Status quo
Not known
27
20
13
15
28
26 . 2
19.4
12.6
14.6
27. 1
3.
Very pleased
Level of
satisfaction Sal. i n f i ed
Unhappy
NK
47
2. 1
8
27
45.6
2 0.4
7.8
26.2
Remission (months)
12
©-
COMMUNITY PSYCHIATRY IN INDIA •• THE ROAD AHEAD
R. SRINIVASA MURTHY
Associate Professor of Psychiatry
National Institute of Mental Heal Immunity health cell
and Neuro Sciences,
Bangalore-560029, India.
4//1. (First Floor)3t. Marks Road
BANGALORE-560 001
The recognition of integrating mental health with general health .
services, the more popularly called PRIMARY HEALTH CARE (PHC)
has been a very recent phenomenon. This is so, in spite of the
well recognised role of mental health.as part of the definition
of health by World Health Organisation. At this point it is
appropriate to refer to the recommendation of the WHO supported
international conference on Primary Health Care at Alma Ata in
1978. The recommendation includes Promotion of Mental Health
as one of the eight components of primary health care. With
this recognition and.,renewed emphasis, it can be hoped that in thcnext twenty years meaningful models of basic mental health care
v/ill emerge.
The development of the mental health services in India shows
interesting trends over the last forty years. The initial empha
sis was on mental -hospitals, which shifted to setting up of the
general hospital psychiatry units and then to community programmes.
This area of historical development’ has been reviewed recently
in detail (Srinivasa Murthy, 1982). For. a country like India,
■with’ vast area in which people live in.small relatively independent
units what is of greatest importance is the COMMUNITY PSYCHIATRY
MOVEMENT that has taken roots in the last ten years.
The Western concept of community psychiatry has been based on the
idea of community mental health centres (CMHC, USA) or linkages
with the universally available health service like the National
Health Services in Europe. Essentially the attempt has been on
prevention, to provide good and integrated services for catchment
areas or population, and by an extension -of the wide mental health
infrastructure’ already in existence. Thus, the reaching out is
not as important as it is to countries like India with nearly
non-existent mental health infrastructure in most parts of the
country. This point becomes very clear when we consider that
still a significant number of medical colleges do not have full
departments of psychiatry, there are states .with no mental health
facility and only about 10% of the district hospitals in the
country have psychiatric units, though they cater to the need? of
more than a million population!
In India, the community psychiatry has come to assume a different
role and importance. It is at present considered as a movement
or plan to provide basic mental health care to majority of.
the population in a reasonable time frame with minimum of inputs.
In other words, it can.be said that the attempt will be to extend
the services to the periphery simultaneously when the profess- .
ional infrastructure is being built up. This is a very interesting
innovation in that in the country the path for delivery of most
health programmes has been through PHC and by integration with
general health services This has its own limitations and needs
for support. Now we function and support this infant movement
will decide the face and fate c ” community-psychiatry movement in
India by the end of the Century.
♦Reprinted from CONTINUING MEDICAL EDUCATION Vol.1 (Eds) Ramachandran
V., Palaniappan V and Shah, L.P. (1983) Indian Psychiatric society
Madras.
/2/
This present paper deals essentially with the needs for future
action. The developments so far have been reviewed and published
in great detail (Srinivasa Murthy, 1982, Srinivasa Murthy and
Wig, 1982, Kapur, 1975, Kapur, 1977, Isaac et al, 1982).
The origins of the community psychiatry movement can be traced to
a number of meetings of the Indian Psychiatric Society. The notable
among these are the First Conference of Superintendents of Mental
Hospital at Agra in I960, the Madurai conference on Priorities in
Mental Health Care held in 1971, the WHO-SEARO workshop on commu
nity action for Mental Health care at Bangalore in 1973 and a number
of workshops at Uardha, Trivandrum in this area. All these deli
berations and committments for action in this area led to the
development of pilot programmes around the country. The notable
among these are the programmes to develop models of rural psychia
tric services at Chandigarh (Rappur Rani), Bangalore (Sakalawara).
and Vellore. These programmes are too well known to need
elaboration in this paper. What was achieved by these programmes
hase been to identify priorities for inclusion in the PHC set up,
development of training programmes including manuals, application
of epidemiological tools for evaluation of the effectiveness of
"ft
the interventions and training of postgraduates in mental health
in community psychiatry skills and philosophy. These initial
attempts have been taken up in a bigger way by the Severe Mental
Morbidity study of ICMR, since 1;979, where.the feasibility of
training health personnel is being examined at four centres, namely
Bangalore, Baroda, Calcutta and Patiala. There have been also
attempts in the direction of training of the general practitioners
and school teachers. (Shamasundar et al, 1978, 1980, Kapur et al
1978, 1979, 1980). All these studies and experiences have made
it possible to consider -launching community psychiatry programmed
on a bigger scale.
A recognition of this cominn of age of the community psychiatry
approach has been the formulation of the draft National Mental
Health Plan. The first meeting- of the group of more than 50
mental health professionals took place at Delhi in July 1981 (21-22)
where a draft document for the National level organisation of
mental health services was considered. The deliberations led
to the preparation of a new draft which v’as reconsidered in
September 1982 by a smaller group prior.to consideration by the
health administration and others like planners and administrators.
It is gratifying to note that the draft document was considered
by the Central Council of Ministers in October, 1982 and recor
mmended for further action. Thus the stage, in a way, is set
for future action and hence the title of the paper, THE ROAD
.-HEAD. Before considering the way 1 ahead, it is salient to
recall the important features of the past recommendations of
Indian Psychiatric Society and the proposed mental health plan,
namely (i) appointment of central mental health,a dviser,
(ii) appointment of state level mental health advisors
(iii) identification of 1 priorities’nfor different levels of
health care (iv) training of primary .health care personnel for
mental health tasks, (v) strengthening of the mental health
infrastructure like improving the mental hospitals-, enhancing
the training in psychiatry for undergraduates, setting up of'
district psychiatry units, organisation of peripheral units of
rehabilitation and strengthening the public involvement in
mental health care.
THE
ROAD
AHEAD
I have referred so far to the positive developments in the field
of mental health care and presented an optimistic picture.
However, as we look ahead, it is well to recognise that the ground
covered has not been very clean. The positive.and negative aspect
of mental health care in the country were poignantly highlighted
by a series of lay reports titled ’the sane approach', 'playing
on the gullible', and 'a moment of madness'. These reflect the
gullibility of the general’public to easy exploitation, the near
inhuman conditions of mental hospitals and a way out of the
situation by shifting the care to the door steps of the people.
There is no angle answer or approach.to reaching the goal of basic
mental health care as. part of PHC. The factors that will decide
the emergencie of meaningful services will depend on three factors?
(i)
(ii)
(iii)
General development of the community
Growth of general health services in.the country,
The organisation of mental healths ervices' on sound
principles.
The situation in the country is not only unsatisfactory in terms
of health and mental health but in regard to a number of basic
amenities. It is essential to remember that in the country nearly
50% live in villages of less than 500 population, and 75% in
units of less than 1000, that only 24% of the villages are conne
cted with all weather roads, th ;t more than 20% of the villages
e.
i.
50% of the population live below poverty line. The dramatic
changes in the range, quality of mental health services can occur
only along with changes in the development in these general areas
in the community.
■■■■.!.
The development of health services and the current status is one
of pluses and minuses. It is indeed creditable that we have such
a big infrastructure of PHC services in the country and there are
so many levels and categories of health personnel. However, it
is also relevant to note that' public health problems like
tuberculosis, malnutrition are only limited successes in spite of
the planning in the last 3 decades. The failures have been at
different levels like lack of longitudinal planning, non-specifications of priorities, limitations in training facilities, changes
personnel development and a very united amount of support in
terms of supplies like patrol for travel of PHC personnel, drugs
for treatment and equipment. Thus, the picture in regard
to most general health problems is one of lack of adequacy and
effectiveness. These problems of other National Programmes should
be a pointer and caution to us in our new enthusiasm for National
'■i.ntal Health Services.
/4/
FUTURE ORGANISATION OF MENTAL HEALTH SERVICES
There are four aspects that need.to be given importance:
(i) The political committment
(ii) The professional committment
The
(iii)
crystallisation of knowledge in mental health care
(iv) Public education and involvement.
No major programme in the country can take strong roots without
adequate committment at the political level and the public
acceptance and support. As mentioned earlier we have had too
many failures in the country because of the limitations in those
two areas, to be dealt ’•'ith in detail here. I will focus my
attention to the role of us, the professionals in the future
development of mental health care in the community.
PROFESSIONAL COMMITTMENT:
It is very gratifying and we can be proud to note that the senior
psychiatrists have consistently expressed their committment to
community psychiatry movement. At the' point of its implimentation, the following specific points come up for reconfirmaticn
of our willingness. The community psychiatry approach as outline'.'
in the National Mental Health plan calls for a number of actions
from the professional personnel. There is a necessity for the
role of the professional to be different in the process of
decentralisation and deprofessionalisation. To be more specific,
the role is different from the hospital-oriented one. The psy
chiatrist, for example, (this is-true for other professionals
like psychologists, social-workers and nurses) will have to devote
significant portion of the time for supervision rather than
direct patient care. Furthermore, because their work is carried
out in a field setting rather than in the protected environment
of a hospital or its clinic, they have to often accept different
standards of care more appropriate to the field situations in
which they are working. This calls for involvement in signifi- .
cation of the mental health work. Finally, they also need tg
"
acquire new skills, including managerial abilities and a
community orientation and capacity to coordinate, which are net
normally seen as being within the purview of a psychiatrist's
abilities in the more traditional settings. At an individual
level, it is not infrequent.for the supervising psychiatrist
to feel overwhelmed and inadequate for the multipurpose role
■in the community. It is' needless to add that perseverance, a
sense of openness and willingness to learn from the people is
very satisfying and comparable to the satisfqction from the
clinical responsibility in a hospital. (Srinivasa Murthy and
Wig-, 1983)
To support the planned mental health programmes in the community;
training of psychiatrists should include supervised experience
in the above area. This has been one of the important reco
mmendations of the WHO Export Committee on Mental Health
(WHO, 1975). At a practical level there is an urgent need to
have field practice areas attached to psychiatric training
centres in the different parts of the country.
»nere are other sensitive issues that need to bo taken cognisance
Of. The new approach will ive no results if the different
professionals (i) set up ’artificial' rigid 'boundaries between
the different mental health personnel(ii) do not devote enough
time in terms of research ?'tc., to enhance the know-how in this
area of work, (iii) lastly, one will also come up face to face
with issues like allowing for limited use of drugs by parapro
fessionals and non-professionals as it has happened in the .areas
of maternal and child welfare, tuberculosis, family welfare
leprosy and malaria.
To summarise the issues in thia area, it can be said that the
need is to accept, this approach as the REAL ALTERNATIVE rather
•than second rate method. This can result by a new generation
growing up with these ideas, wide discussion, sharing of ideas
and critical appraisal of the pilot schemes and inclusion of
skills in this area during the training period.
ADVANCES' IN MENTAL HEALTH KNOW-HOW:
Next I would like to focus our attention on an area of importance
to the professionals and the programme-. This refers to the needed
simplification of knowledte on sound scientific basis. It is
to be recalled that the' domiciliary care of tuberculosis was
demonstrated scientifically before care of tuberculosis moved out
of the confines of the sanatorium. Similar examples are there
in the area of public health. It is self-evident that decentra
lisation and deprofessionalisation can occur only when such .
knowledte is available and confidence levels in the day to day
clinical work is high. The research efforts need to be in the
areas of recognition'of mental disorders., their referral, the
initiation of treatments -and their effectiveness.
Is this an important need? I would say yes from two counts..
Firstly, professional colleagues have expressed doubts and reser
vations about the community psychiatry approach on the basis of
the complexity of the mental health care.
Opinions like treat
ment of psychiatric problems- are based on; experience, or the
dosage and the type of drug used is too individually dependent,
mistakes can.be very dangerbus etc. etc., are expressed. All
these speak for the need for professionals to be the final
arbitrors of the diagnosis and treatment. The second area of
greater concern has been lack of research into simple but very.
important issues like the treatment schedules and use of drugs,. .
A recent review of tho antidepressant drug studies published in
the country in the last two de-cades showed the lacunae clearly.
(Srinivasa Murthy and Ragh'avan, 1983) The review of more than
two dozen reports showed that (i) the diagnostic criteria was very
loose, (ii) the duration of use was four weeks in most of tho
studies, (iii) global evaluation of the improvement was the
cbmmon approach, (iv)' the relevance of age of the patient, sex
differences, the duration of illness, the presence of absence
of associated physical illnesses etc. have not been the subject
of study, and (v) the dosage variations and different treatment
regimens has not been studied to offer knowledge about the ideal
dosage and. duration schedules. . Thus, to-day, most of the
treatment of depressive- disorders is largely experience-based
and varies from clinician to clinician. The above point is made
as an example of the lacunae and the need for looking into areas
traditionally thought to be not relevant when trained professionals
are dealing with patients.
/6/
The needs in this area are protean and they should receive the
most stringent consideration at the earliest time possible. ,
There should not be decisions on an adhoc manner based on
; '
isolated pilot schemes but by research work in settings as
similar to the field setting as possible. I can outline, a few
more areas that need immediate answers, namely (i) the relativeeffectiveness and' safety of'-phenothia zincs and ECT for acute
psychoses ’arid depression, ?(ii) the differences in the rates of •
relapse when the initial treatment for psychoses or depression is
3 months by
as compared to 6 moriths to one year or more,
(iii) the relapse rates for epilepsy■when treatment is stoppedafter tone year of fit free interval versus 2,3,4, or 5 years'”(iv) the methods of public education and ,(v). the cost effectiveness
of rehabilitative measures with chronic patients.
It can be said' that knowledge alone is not enough a nd. quote the
many public health programmes that have not become successful in
spite of such knowledge being available (eg. tuberculosis, malari? )
However, none of us can doubt the heed for sound knowledge for
large scale planning. The recent introduction of the health* and
.
welfare programmes like community volunteer scheme, the
'
Integrated Child Development Scheme (ICDS) and the mid-day meal
scheme show how political will can initiate massive programme
touching the periphery, with or without a good technical base.
Should we be caught flat-footed in future?
The review so far has highlighted the direction in which the
community psychiatry movement in India is likely to move.
It has also outlined the needed action at all levels’ especially
focussing the'role of psychiatrists. There is a need for •
considering the National Mental Health Plan both by those who
work in the community as well'as those who are involved in
research and" training. We’can also support the movement and
projected programme by the various activities outlined
To conclude, mental health services -organisation has come a long
way in the last 40 years. The current situation raises hopes of
positive results in the noai- future. The time seems ripe for
changes and with the involvement of the public, professionals
(
and planners and by working out a long-term plan, meaningful bene
fits can reach the common man in the near future. Here lies the
road to’ 'REACH THE UNREACHED'.
REFERENCES;
1. Srinivasa Murthy,R (1982) Status paper on Delivery of mental
health services in India - The last 40 years. Indian Council
of Medical Research, Nev; Delhi.
2.
Srinivasa Murthy, R. and Wig, N.N. (1982 a) Community psychiatry
in India - Organisation, .training and service. In Readings in
Transcultural psychiatry. Eds. Kiev.A and Rao,A.V. Higginbothams.,
Madras, p. 85-100.
3.
Kapur, R.L. (1975) Brit. J. Psychiatry. 127? 286-293.
4.
Kapur, R.L. (1977) Community Psychiatry unit at NIMHANS
(Unpublished)' NIMHANS, Bangalore.
/7/
5.
Isaac, M. et al (1982)
6.
Wig, N.N. , Srinivasa Murthy, R. and Har.ding, T.W. (1981)
Indian J. Psychiat. 23; 275.
7.
Shamasundar et al (1978) J.I.M.A., 72: 310.
Indian J. Psychiat. 24: 131.
Indian J. Psychol. Med. 3.; 85.
8.
Shamasundar, C et al (1980)
9.
Kapur, M. and Cariappa? I (1978) Indian J. Psychiat. 20: 289.
10.
Kapur, M. and Cariappa,! (1979) Indian J. Clin. Psychol. 6:75
11.
Kapur, M. et'al (1980) Indian J. Clini. Psychol. 7: 103
Srinivasa Murthy, -R,. and Wig, N.N. (1983) A training approac
to enhancing the availability'of mental health manpower in a
. developing country (In press)
12.
worn he a nil
Si W IhI?3 N
1211 GENEVA27 SWITZERLAND-TELEPHONE: 791.21.11 - CABLES: UNISANTE-GENEVE-TELEX: 415 416-FAX: 791.07.46 -E-MAIL: lnf©who.lnt
Press Release WHO/1
10 January 2001
WHO LAUNCHES MENTAL HEALTH 2001 CAMPAIGN
The stigma is meaningless. The discrimination is unfair, if not unethical. Treatment is
possible. It has to be made available. In a bid to focus attention on the stigma and
discrimination surrounding mental health, the World Health Organization (WHO) is
launching a year-long campaign on mental health. WHO is daring governments, health
professionals and people from all walks of life to rise to the challenge posed by mental and
brain disorders.
“Stop Exclusion - Dare to Care" says WHO in a message that succinctly sums up the
year-long campaign that will culminate in a World Health Report on mental health
scheduled for release later this year.
;
An estimated 400 million people today suffer from mental or neurological disorders or from
psychosocial problems such as those related to alcohol or drug abuse. One out of four
people who turn to the health service for medical care suffer from such disorders. Yet, few
are diagnosed correctly, and fewer receive treatment. Most of their lives are characterized
by undue suffering, disability and, at times, premature death.
“By accident or design, we are all responsible for this situation today," said Dr Gro Harlem
Brundtland, Director-General of WHO. “Governments have been remiss in that they have
not provided adequate means of treatment to their people. And people have continued to
discriminate against those that suffer from these disorders,” she added.
Public health authorities say stigma and discrimination are the biggest obstacles facing
mentally ill people today. Rare is the family that is free from an encounter with mental
disorders, yet almost universal are the shame and fear that prevent people from seeking
care. The gross human rights violations in mental hospitals, insufficient provision of
community based mental health services, unfair insurance schemes and discriminatory
hiring practices are only some of the trials faced by people with mental health problems.
Individuals and institutions bear responsibility for perpetuating these practices.
WHO says mental and brain disorders such as depression or epilepsy can be treated
successfully, allowing people to function well in society. Important scientific advances have
been made in reducing suffering and the accompanying disability. Successful methods of"
involving the family and community to help in recovery have been identified.
Civpi y
• iV.'■ / ■
..
f WHO"-”~
Press Release WHO/1
Page 2
World Health Day 2001, with the slogan "Stop exclusion - Dare to care," aims not only to
raise awareness about barriers to mental health but also about solutions that exist to
tackle mental and brain disorders.
The issue will be put before the annual gathering of WHO's 191 Member States during the
World Health Assembly (WHA) in May 2001. Four ministerial round tables will discuss
poverty, discrimination, gender and human rights aspects of mental health. The winners of
WHO's global school contest on mental health will also be invited to read their winning
essays before the WHA.
World Health Report 2001 will cover topics such as the prevalence of mental health
disorders, the organization and financing of mental health programmes, the treatment gap,
prevention strategies and projected trends for the future.
“We must strive for parity in the way mental and physical disorders are regarded. We
know what is wrong, we know where solutions lie. We have a responsibility to push for
changes in both policy and attitude and we are determined to do just that,” said Dr
Benedetto Saraceno, Director of WHO's Mental Health programme. "'Stop Exclusion Dare to care’ will not be a theme that is highlighted in 2001 and then forgotten," he added.
For further information please contact Ms Reshma Prakash, Noncommunicable Diseases and Mental Health,
WHO, Geneva, Switzerland. Tel. (+41 22) 791 3443; Fax (+41 22) 791 4832; email - prakashr@who.int
Visit our web site at http://www.who.int/world-health-day Journalists may also wish to contact Mr Gregory
Hartl, WHO Spokesperson, WHO, Geneva, Switzerland. Tel. (+41 22) 791 4458; Fax:(+41 22) 791 4858.
Email: hartlg@who.int All WHO Press Releases, Fact Sheets and Features as well as other information on
this subject can be obtained on Internet on the WHO home page: http://www.who.int/
WORLD
HEALTH
DAY
World Health Organization
2001
FOREWORD
Address by Dr Gro Harlem Brundtland
Director-General of the
World Health Organization
On 7 April 2001, all peo-
' pies and governments
’’U9S around the world will
observe World Health
Day. This year is devoted
to mental health. We
focus on mental health in recognition
of the burden that mental and brain
disorders pose on people and families
Alt
affected by them, and with the aim to
highlight the important advances
made by researchers and clinicians in
reducing suffering and the accompa
nying disability. Our message is one of
concern and hope.
The road ahead is long. It is littered
with myths, secrecy and shame. Rare
is the family that will be free from an
encounter with mental disorders or
will not need assistance and care over
a difficult period. Yet, we feign igno
rance or actively ignore this fact. This
may be because we do not have suffi
cient data to begin addressing the
problem. In other words, we do not
know how many people are not get
ting the help they need - help that is
available, help that can be obtained at
no great cost. And, because we lack
this knowledge, we have not done well
to address mental and brain disorders.
As we fail to acknowledge this reality,
we perpetuate a vicious cycle of igno
rance, suffering, destitution and even
death. We have the capacity - within
us - to tackle the next frontier. Within
people, within societies, within gov
ernments. Together we have to work
to make the change.
An estimated 400 million people alive
today suffer from mental or neurologi
cal disorders or from psychosocial
problems such as those related to
alcohol and drug abuse. Many of
them suffer silently. Many of them
suffer alone. Beyond the suffering and
beyond the absence of care lie the
frontiers of stigma, shame, exclusion
and, more often than we care to
know, death.
The simple truth is that we have the
means to treat many disorders. We
have the means and the scientific
knowledge to help people with their
suffering. Governments have been
remiss in that they have not provided
adequate means of treatment to their
people. And people have continued to
discriminate against those that suffer
from these disorders. Human rights
violations in mental hospitals, insuffi
cient provision of community mental
health services, unfair insurance
schemes and discriminatory hiring
practices are only some of the exam
ples. By accident or by design, we are
all responsible for this situation today.
The time for reckoning is now. Let us
look at this day as an opportunity and
a challenge. A day to reflect upon
what remains to be done and how we
can do it. Let us use this day and the
weeks ahead to take stock and advo
cate for policy changes on the one
hand and attitude changes on the
other. Together with our Member
States, let us pledge to work towards
a day when good health will also
mean good mental health.
This past century has seen spectacular
changes in the way we live and think.
Human brilliance and technology have
come together to propose solutions
we dared not imagine fifty years ago.
We have conquered diseases that
once seemed insurmountable. We
have saved millions of people from
premature death and disability. And
our search for better solutions to
health is, as it should be, ceaseless.
The solutions to mental health prob
lems are not difficult to find; many of
them are already with us. What we
need is to focus on this as a basic
necessity. We must include solutions
and care for mental health in our
search for a better life for all in a sys
tematic way. Only then will our
successes be more meaningful. On
this day, we must commit to "Stop
exclusion - dare to care."
Myths hurt - face them
Facts help - use them
Mental health today
A vision for the future
Where to learn more
Introduction
Mental health is an integral compo
As mental health is a fundamental
nent of health through which a person
building block for human develop
realizes his or her own cognitive,
affective and relational abilities. With
ment, we must face the facts that
a balanced mental disposition, one is
more effective in coping with the
■.
of ■
-an work productively
life, that they can arise and that they
can be addressed.
nd
••
i, d is better able to
contribution to his or
Mental and brain distirig mental health,
< finish the possibility to
, nt of the above. Precud treating them clears the
road to achieving one's full potential.
mental health problems are a part of
Stop Exclusion
There is no justification in ethics, sci
ence or society to exclude persons
with a mental illness or a brain disor
der from our communities. There is
room for everyone.
The health care system can lead the
way. No rationale exists for excluding
mental health services from the gen
eral health care system. Parity
between physical and mental health
is vital.
Dare to Care
Don't fear those experiencing a men
tal illness. It can happen to anyone.
Don’t ignore early warning signs.
Dare to challenge the myths and the
misconceptions.
Provide better care; ensure access to
care, insist on equity in care. All this
must be done and all this is possible if
we dare to believe that mental health
care is a basic health concern for all.
MYTHS
HURT
FACE
THEM
Do mental and brain disorders only
affect adults in rich countries?
No. All are affected - children and adults,
rich and poor.
Number of persons world-wide with
epilepsy (yellow) and schizophrenia (blue)
(in millions)
Source: The International League
Against Epilepsy (ILAE) 1999
Developed Countries
Developing Countries
A study has shown that 10% of
Mental and brain disorders
affect adults, elderly,
children and adolescents
Approximately one in five of the
world's youth (15 years and younger)
suffer from mild to severe disorders. A
school children in Alexandria, Egypt
suffer from depression. Anxiety
among the secondary-level school
children in their final year of school
was found to reach 17% in this
study.
large number of these children remain
untreated as services simply do not
exist. The majority of treatments have
been traditionally geared to adult
patients, ignoring the need for early
intervention in childhood.
Some 17 million young persons in
the 5-17 age group in Latin Ameri
ca and the Caribbean are affected
by mental or brain disorders severe
enough to require treatment.
Mental and brain disorders
are a concern for both
developed and developing
countries
No nations and no peoples are spared:
In a landmark WHO study in 27
developing and developed coun
tries, no population has been found
to be free of schizophrenia.
Alcohol abuse is another common
disorder that knows no boundaries.
For example, in Russia, 35,000 peo
ple die every year from fatal alcohol
poisoning.
Epilepsy is universal and more
frequent in developing countries
A recent survey in a rural Pakistani
village concluded that 44% of the
adults were affected by depressive
disorders.
Are mental and brain disorders just
a figment of one's imagination ?
No. They are real illnesses that cause
suffering and disability.
"Pull yourself up - it's all in your
imagination." How often have we
heard that? It's not just friends and
family that fail to grasp the existence
of a mental disorder. Even govern
ments choose ignorance, as seen by
the fact that mental health is often
excluded from their health priorities
and plans.
• orders are real
Mental illnesses and brain disorders
provoke suffering, cause disability and
can even shorten life as we see from
episodes of depression after a heart
attack, numbers of liver disease result
ing from alcohol dependence or cases
of suicide. The existence of mental
and brain disorders often remains hid
den, voluntarily by the patient or sim
ply unrecognized as a real illness by
the person and their family. Yet the
underlying abnormal substructure of
many disorders has been identified by
images of the brain. Thus to ignore
their existence is akin to denying that
cancer exists because we are unable
to see the abnormal cells without a
microscope. Mental illnesses can be
diagnosed and treated before it is too
late.
The symptoms are a sign of
real illness
There are people who suffer from
overwhelming fears that are accompa
nied by a host of recognizable symp
toms. Others grapple with constant
negative or unpleasant thoughts and
turn to alcohol to escape. In some
cases, the patient’s pain can be so
excruciating that suicide is seen as a
relief. In the year 2000. there will
have been an estimated one suicide
death every 40 seconds.
It is easy to ignore or dismiss many
symptoms, yet the fact is that five out
of the ten most disabling disorders are
psychiatric in nature. Unipolar depres
sion, alcohol use, bipolar affective
disorder (manic-depression),
schizophrenia and obsessive-compul
sive disorder are among the 10 lead
ing causes of disability world-wide in
1990. The disability associated with
mental or brain disorders stops people
from working and engaging in other
creative activities, e.g., a mother may
cease caring for a baby, an adolescent
may stop socializing with peers, and
an elderly person may no longer take
care of himself or herself.
If someone has a broken arm, you feel sorry for them. But when
(the problem is) psychiatric, people don't know how to react because
they can't see anything. But just because you can't see someone's pain,
it doesn't mean they don't need your care and support.
Samoan woman, manic depressive. 29 years old. Auckland, New Zealand
I
FACE
THEM
Is it impossible to help someone with
a mental or brain disorder?
No. Treatments exist and caregivers
can be assisted.
Counselor meets with a mother and her
mentally impaired child during a
counseling session in a community health
center
Something can be done
for all mental and
neurological disorders
Some people recover completely. Oth
ers have a more difficult time. But in
all cases, there can be an alleviation of
suffering through different methods.
For example,
Schizophrenia, a severe disorder, is
treatable. People suffering from
schizophrenia can be helped with
medication to reduce the symp
toms. A relapse can be prevented
with psychosocial interventions
aimed at the family, for the benefit
of all.
Help can be found from the medical
profession on two levels.
It is not enough to assist
only the suffering person
The general health workers, such as
physicians and nurses, are the first
The family, which constitutes the main
professionals whom one could con
sult. Most communities have access to
them but in some parts of the world,
to preserve its functioning and well
being. Such help is seldom received;
more services for families need to be
they are not prepared to address the
emotional needs of their patients.
developed in all countries.
With proper training and supervision
these professionals could be better
equipped to identify and provide
effective treatment for mental and
brain disorders. A major stumbling
block is to lift the shame so that peo
ple will talk freely of their emotional
problems with their family doctor.
. Most recently diagnosed children
and adults with epilepsy could have
a complete control of seizures for
many years, provided they receive
appropriate medicines.
Rehabilitation measures, aimed at
enhancing social and personal skills,
assist persons with depression to
regain a normal life. Anti-depressant medication can also help in
many cases.
The specialized health workers,
including psychologists, psychiatrists
(for mental disorders) and neurologists
(for brain disorders), psychiatric and
neurological nurses, social workers
and occupational therapists provide
expert care where available.
support system, needs support as well
Are mental or brain disorders brought
on by a weakness in character?
No. They are caused by biological,
psychological and social factors.
"You could get over it if you really
tried." How often is this said? Yet, it is
not a question of willpower or effort
alone. In some cultures, people may
also consider that "immoral"
behaviour or bad fate are responsible
Ji problems. Let us not
he person or poor luck
. stand the complexities
.’ ain disorder.
in brain chemicals. Alcohol depen
Research is being
conducted to determine the
genetic origins or
biological factors of
various disorders
Genes have been shown to be associ
ated with the origin of schizophrenia
and Alzheimer's Disease. Depression is
known to be associated with changes
dence, often branded as a vice result
ing from poor moral character, is now
linked to both the social environment
and to genes. Mental retardation pro
vides another example. One biological
cause of this disorder is the lack of
iodine, vital for brain development, in
the diet of a growing child.
Social influences can
significantly contribute to
the development of various
disorders
For example, individuals react differ
ently to stressful situations. Loss of a
loved one can potentially lead to a
Extreme poverty,
war and
displacement can
influence the
onset, severity
and duration of
mental disorders.
depression. Loss of work is associated
with heavy alcohol use, suicide and
depression. Poor nurturing environ
ments, whether they are the result of
broken families or violence in the
home or community, can result in an
increased risk of mental illness.
In some places of the world, mental
illnesses are thought to be caused by
evil spirits. This is a difficult issue. It
pits faith against fact, faith healers
against doctors, cultural beliefs against
scientific knowledge. Perhaps to pre
vent a situation from taking a turn for
the worse, mental health professionals
can work with healers so that those
who cannot be helped by traditional
Mental illness is one of the major afflictions of mankind that has
medicine can receive conventional
treatments. Mental health profession
had little support in the past. During the last half century there has been
als serve the community better by
quite a revolution in the understanding and treatment of major mental
understanding the cultural and social
illness such as depression, schizophrenia, manic depression and anxiety.
context within which their work is to
be carried out.
Rather than a flaw in character or a consequence of a dysfunctional fam
ily, recent research has shown that mental illness has biological
roots.
Julius Axelrod, 1970 Nobel Prize for Medicine in a letter to
WHO Director-General on 30 June 2000
MYTHS
HURT
FACE
THEM
Should we just lock up persons with
mental illness ?
No. People with mental illness can
function and should not be isolated
or restricted.
We have seen there are many possible
treatments available; there are also
better and more appropriate condi
tions in which we can provide these
treatments.
Today, the picture in the world is far
from perfect, but care is now avail
able in a variety of environments.
People's own homes, clinics, emergen
cy rooms, psychiatric wards in general
hospitals and day care centers are all
viable options. Rehabilitation is carried
out in hostels, cooperatives, sheltered
workshops and through social support
groups.
Like physical disorders, mental and
brain disorders vary in severity. There
are those that are:
■ transient (like an acute stress disor
der);
• periodic (like bipolar disorder, char
acterized by periods of exaggerat
ed elation followed by periods of
depression);
Is this what we want ?
The treatment of mental illness is most
often associated with mental hospi
■ long lasting and progressive (like
Alzheimer's Disease).
tals. Institutions that violate basic
Treatment must be appropriate to the
human rights, stripping one's dignity
disorder, and take into account the
individual’s situation: is the person
through inhumane care still exist
today. Too often abandonment, con
alone at home? Does he/she have
finement, or isolation can be seen as
the only solution when confronted
with an ill person. Yet, the facts show
family who could provide care togeth
us that persons suffering from a men
tal illness or a brain disorder can
er with the doctor or a nurse? The
best alternative will depend on each
individual, and in any situation, the
human rights of people must be pre
improve and contribute to society.
served.
There are many other misconceptions
about mental illness and brain disor
ders. To address them all here would
be well beyond the scope of this
brochure. Take the time to explore
your own personal prejudices and
unfounded beliefs.
We should all recognize that persons
with mental illness suffer not only on
account of their illness. They are often
socially stigmatised, if not con
demned. In everyday life, this impedes
that people:
reintegrate fully into society, obtain
decent housing, a paying job or a
reasonable social life. For a person
who has been discharged from a
psychiatric hospital, such exclusion
may lead him back to the hospital;
I experienced homelessness at one stage coming out of the hospi
tal. I had nowhere to go. I had no other choice. My family at that point was
struggling with their own view of my condition and there was no place in
the family for me. If my family had been educated, taught how to help me,
supported and helped, then my story would be very different. Families need
to be involved - they are after all the ones we rely on the most.
Woman with a schizophrenic disorder, 43 years old. New Zealand
go for treatment when necessary,
for fear that the search for help be
known to others causing a loss of
social status to both the person or
the family. This is a serious problem
since suffering is not relieved and
functioning or quality of life may be
affected as the disorder continues.
The myths surrounding mental health
problems are responsible for terrible
shame and contribute to the low lev
els of treatment.
I am the main care-giver for my husband's brother, who is
schizophrenic. The families of the mentally ill... need to know that they are
not to blame for the illness that has torn their family apart. Shame and fear
build walls of silence. Now is the time to speak out so that families can
know that they are not alone, that they have nothing to be ashamed of. The
public must be educated to recognize symptoms, to know that mental illness
can strike anywhere and to understand that help is available.
Mrs. Kathy Esquivel.
wife of former Prime Minister of Belize. Central America
Schizophrenia
□
Africa
H
Americas
O
Eastern Mediterranean
□
Europe
■
South East Asia
□
Western Pacific
Number of people with schizophrenia world-wide (in millions)
MMBBMMMK
What is it?
Schizophrenia is characterized by pro
found disruption in thinking and feel
ings, affecting language, thought,
perception, and sense of self. It often
includes psychotic experiences such as
hearing voices or holding fixed abnor
mal beliefs, known as delusions.
How many suffer?
closed institutions have been giving
room to interventions at home, in
community services, general hospitals
and hostels. Psychosocial rehabilita
tion has made considerable strides and
has enabled patients to find a place in
the workforce, in their families and
communities. Early treatment is essen
tial for better recovery.
Around 45 million persons world-wide
above the age of 18 suffer from
schizophrenia at some point in their
My first-born son, today aged 39, was first hospitalized at age
lives. The disorder has been found in
all nations where studies have been
17 for about four months, some four years after his mother died of can
conducted. It begins at a young age
cer. The official diagnosis of schizophrenia was disclosed to me only five
and can impair functioning causing
years after its onset.
the loss of an acquired ability (i.e., not
being able to gain one's own liveli
hood or disruption of studies).
"For about ten years while at home, my son refused to take medication
due to adverse side effects, refused to see doctors leading to extreme
confrontations. For the last five years he is being treated with medica
What can be done?
Research has advanced the under
standing of the disorder and made
major contributions to the treatment.
tion and his condition has stabilized. He now lives in a very decent hos
tel [half way home] and works in supervised employment for few hours
every working day. His social life and personal relations are much
improved.
Treatments are both of a biological
"Beyond the personal saga, I gained extensive experience in the last
nature (e.g. medication) as well as
years. I am involved as member - and recently as chairman - of a family
psychosocial (e.g. psycho education of
the family and rehabilitation). The
helplessness of the past has been
replaced by considerable hope since
conditions that once were treated in
organization. I strongly believe that today most schizophrenia patients
and their families can avoid the via dolorosa we went through, if using
adequate combinations of medication and psycho-social rehabilitation with strong emphasis on the latter. This, however, requires drastic reform
— beyond lip service - by the medical establishment and the public
authorities - in the allocation and proper use of the public health funds
and manpower. Our families' organization is committed to struggle to
achieve this reform, but it is still a steep uphill struggle.
Father of a person with schizophrenia from Israel
/ am about fifty-seven years of age. I had never experienced any
odd or abnormal state of mind. Neither had I ever known any such thing
about any of my family members. By nature I am a very contented per
son, generally very helpful and cooperative, even to my casual acquain
tances. Holding a very senior position in a leading educational
institution, I have no problem with my job, status and family.
"In the month of April 2000 all of a sudden I observed certain changes
in my mental make-up. Though there was no personal provocation I
developed a kind of phobic anxiety, started attaching motives to hap
penings and persons around. There was a feeling of undue sadness, lack
of vigour and inability to concentrate on work and personal matters. I
started losing interest in all normal activities; loss in weight, appetite
and sleep was also experienced, thus causing so many simultaneously
What are they?
Depressed mood and loss of interest
and pleasure characterize these disor
ders. If they alternate with exaggerat
ed elation or irritability they are
known as bipolar disorders (one pole,
depressed; another pole, elation or
mania). Their severity, the symptoms
that often accompany the depressed
mood and the duration of the disorder
differentiate them from normal mood
changes that are part of life.
The causes of these disorders vary,
there are psychosocial risk factors that
influence the onset and persistence of
the depressive episodes as well as bio
logical factors of different kinds.
occurring complications, both physical and mental.
“I was diagnosed with depression and assured that it was curable. I reli
giously followed my doctor's instructions. I have visited him four times
and have the satisfaction that with the grace of the Almighty and with
the able handling by the esteemed Doctor, I have regained my confi
dence and have restarted taking interest in all normal activities
around.
Male patient from India
hl Depressive
/ji disorders
How many suffer?
Studies demonstrate that one out of
seven adult persons in the USA have a
mood disorder during a single year,
7% in Brazil, almost 10% in Germany
and 4.2% in Turkey. In the USA, 5%
of children aged 9-17 were found to
have depression, a disorder thought to
spare youth and adolescents. Ignoring
this reality can result in suicide.
Depressive disorders and schizophrenia
are responsible for 60% of all suicides.
What can be done?
Despite the existence of solutions, the
majority of people with depression do
not receive adequate treatment. This
implies that there are millions of peo
ple in the world currently affected by
about ones feelings or poorly trained
medical personnel can be at the root
of this. Fortunately, there are now
clear guidelines for the treatment of
mood disorders which include both
the disorder whose suffering and dis
antidepressant medications and psy
ability is prolonged because their con
chological interventions, such as cog
dition goes undetected or, often, is
not well treated. A reluctance to speak
nitive psychotherapy and social
support.
What can be done?
There is currently no cure for
Alzheimer's Disease. Over the last five
years there has been a growth in the
number of drugs being developed or
considered for use in people with
dementia, particularly Alzheimer's Dis
ease, which seem to provide symp
tomatic relief for some patients.
Interventions given by family care
givers can reduce the family's distress
and that of the person with
Alzheimer's Disease, as well as delaying
MMMMOI
What is it?
Alzheimer's Disease is a form of
dementia which destroys brain cells,
disrupting the transmitters which carry
messages in the brain, particularly
those responsible for storing memo
ries. It is one of the most common
types of dementia world-wide and
accounts for 50% to 60% of all cases.
Dementia is a progressive degenera
tive brain syndrome which affects
memory, thinking, behaviour and
emotion. Symptoms may include a
loss of memory, difficulty in finding
the right words or understanding
what people are saying, difficulty in
performing previously routine tasks,
personality and mood changes.
MWMM
the absenteeism of caregivers employees who take care of people
with the disease, with businesses con
tributing another US$7 billion toward
the total cost of care. There are no
global figures as yet for the financial
impact of Alzheimer's Disease.
nursing home placement where this is
available. Support for persons with
Alzheimer's Disease and their family
can come from different sources but is
often of limited availability. Voluntary
organizations such as Alzheimer's Dis
ease associations give practical and
emotional help as well as training for
caregivers and professionals.
Alzheimer's
Ati Disease
How many suffer?
There are currently estimated to be
about 11 million people world-wide
with Alzheimer's Disease. This figure is
projected to nearly double by the year
2025.
The late stage of Alzheimer's Disease
is one of total dependence and inac
/ now deeply regret that I was irritated by my husband's
behaviour instead of being considerate of him in such a situation, as I
did not understand what was wrong. Eventually at the age of 55, (my
husband was) diagnosed (with) Alzheimer's Disease. I attended the care
giving study class at the public health centre with my husband. On a
tivity. At this stage individuals are no
longer able to care for themselves and
do not recognize relatives, friends and
public health nurse's recommendation, my neighbours kindly attended
familiar objects. This represents an
be able to accept my husband's disease, I would like to thank him for
enormous burden on families and the
health care system.
giving me the opportunity for mental development.
A study by the American Alzheimer's
Association in 1998 has shown that
this disease costs US businesses US$ 33
billion a year; USS 26 billion related to
the centre to increase their knowledge of the disease. I was helped by
them enormously after his wandering started. Although I feel I will never
A woman's story from Japan
Epilepsy
What is it?
Epilepsy is a brain disease character
ized by repeated seizures ("fits")
which may take many forms, ranging
from the shortest lapse of attention to
severe and frequent convulsions. The
causes are multiple, e.g., trauma to
the brain, infections such as
encephalitis, parasites, alcohol or
other toxic substances. However, in
half of the cases, the causes remain
unknown. Epilepsy is treated by neu
rologists when available or by psychia
trists in many other places.
Bet-El School for children with epilepsy run by the
NCSK Church in Cape Town, South Africa
How many suffer?
It is estimated that about 45 million
people of all ages around the world
What can be done?
are affected by epilepsy, while 1 % of
the total burden of disease in the
world results from it. This calculation
of the burden of disease takes into
account premature deaths resulting
from the disease as well as the loss of
healthy life years due to disability. The
number of people with epilepsy is
over five times higher in developing
countries than in developed countries.
A vast majority of those suffering
remain untreated. Take the case in
Africa, for example, where up to 80%
of people suffering from epilepsy do
not receive any treatment at all.
failed to recognize or find those with
The solutions exist so that up to 70%
of newly diagnosed cases can be suc
cessfully treated with anti-epileptic
medication that is taken without inter
ruption. After 2-5 seizure free years,
epilepsy and in some cases, has failed
to provide the right treatment to
those it has recognized. The important
thing to note for a disorder so fre
quent is that there are medications
the anti-epileptic medication may be
gradually withdrawn in 60-70% of
which are both effective and cost effi
cient. Given their low price, they are
an affordable remedy in all countries.
the cases, provided the physician indi
cates such a course of action. Yet the
health care system in many places has
Ecuador
Ethiopia
~jjl
Z
Guatemala
India flBBBFTTT
Pakistan Rural
Pakistan Urban |
Philippines
. .
Sudan
0
20
40
60
80
. ,
100
Treatment gap in developing countries 1988 1996
% of ill persons not receiving treatment in yellow.
Source: The International League against Epilepsy 1999.
Mi Mental
/ai retardation
I
QOQQpr'
HHE]
□□□□□
EH3QD3
gang
BEDS
J
What is it?
The World Health Organization
defines mental retardation as a condi
tion of incomplete or halted develop
ment of the mind, which is
characterized by the impairment of
skills as manifested during the devel
opmental period that contributes to
the overall level of intelligence, e.g.,
cognitive, language, motor and social
abilities.
Q
"The Lonely Flower" painting by a severely mentally retarded adult
How many suffer?
What can be done?
It is estimated that the number of
The mental potential of all persons,
individuals with mental retardation
differs in relation to the level of coun
try development. The percentage of
young persons, aged 18 and below,
suffering from severe mental retarda
tion reaches 4.6% in the developing
nations and are estimated to be
including of those who are limited by
retardation, can either be developed
between 0.5%-2.5% for the estab
level. To achieve such goals, services
need to be provided and self help
groups, of both families and individu
lished economies. The difference
between both figures indicates that,
potentially, preventative efforts made
to reduce mental retardation, such as
better maternal and child health care
as well as specific social interventions,
could result in an overall decrease of
mental retardation worldwide.
or wasted. A positive attitude coupled
by appropriate educational and voca
tional programs can help those with
mental retardation to adjust and suc
ceed by performing at their highest
als, need to be fostered. The empow
erment of parents could accelerate the
formulation of healthy policies, pro
grams and services.
Alcohol
dependence
/ went to a party, Mom.
I went to a party,
and remembered what you said.
You told me not to drink, Mom
so I had a Sprite instead.
I felt proud of myself,
the way you said I would,
that I didn't drink and drive,
140 million alcohol dependents
What is it?
Alcohol dependence is a mental disor
der recognizable by symptoms which
can include a strong and persistent
desire to drink despite harmful conse
quences, inability to control drinking,
a higher priority given to alcohol con
sumption than to other activities and
obligations, tolerance to alcohol, and
a physical withdrawal reaction when
alcohol use is abruptly discontinued.
78% are not treated
Alcohol is responsible for 1.5% of
all deaths in the world
though some friends said I should.
I made a healthy choice,
and your advice to me was right
as the party finally ended,
and the kids drove out of sight.
I got into my car,
sure to get home in one piece,
What can be done?
It is very hard to determine exactly
when a person has become depen
I never knew what was coming, Mom
something I expected least.
Now I'm lying on the pavement.
And I hear the policeman say,
teeism, suicide and financial debt.
dent on alcohol and by that time a
range of problems may have already
occurred to the individual and others.
As a result, assessing levels of alcohol
consumption is the most effective way
to identify problem drinkers early. For
those at risk, brief interventions of
only five minutes can lead to a 25%
reduction in alcohol consumption,
preventing progress to more severe
problems, including alcohol depen
dence.
How many suffer?
Treatment of alcohol dependence and
withdraw! can be effectively carried out
Knowing that it ruins lives?
in community settings for most cases.
Voluntary mutual help organizations
can also play a large role in supporting
recovery from alcohol dependence.
like a hundred stabbing knives.
Alcohol can trigger health problems in
a large number of problem drinkers
(alcohol dependent or not), including
accidents and injuries, heart disease,
cancer, liver disease and alcohol psy
chosis. Alcohol is also related to social
problems including crime, violence,
marital breakdown, poor school per
formance, high rates of work absen
While there are an estimated 140 mil
lion alcohol dependents in the world,
there are over 400 million people who
drink excessively and can cause acci
dents, injuries, suffering and death.
There is no reason to blame only
"alcoholics". Excessive alcohol use is a
leading cause of PREVENTABLE death,
illness and injury. In 1992 the eco
nomic cost to society from alcohol in
the United States was an estimated
US$ 148 billion, while studies in other
countries have estimated that the cost
of alcohol related problems range
between 0.5% and 2.7% of the gross
domestic product.
However, measures aimed only at
treating those who are dependent are
not enough. Effective alcohol control
policies are also needed.
"The kid that caused this wreck was drunk,"
Mom, His voice seems far away.
My own blood's all around me,
as I try hard not to cry.
I can hear the paramedic say,
“This girl is going to die."
I'm sure the guy had no idea,
while he was flying high,
because he chose to drink and drive,
now I would have to die.
So why do people do it. Mom
And now the pain is cutting me,
Tell sister not to be afraid, Mom
tell daddy to be brave,
and when I go to heaven,
put ‘‘Daddy's Girl" on my grave.
Someone should have taught him,
that it's wrong to drink and drive.
Maybe if his parents had,
I'd still be alive.
My breath is getting shorter. Mom
I'm getting really scared.
These are my final moments,
and I'm so unprepared.
I wish that you could hold me Mom,
as I lie here and die.
I wish that I could say I love you, Mom
So I love you and good-bye.
Author unknown, circulating on Internet
Taking stock
"Great numbers of mentally ill still
live, shut away behind hopeless walls
by the prejudices and incomprehen
sion of society. The efforts of the most
advanced psychiatrists to have the
mentally ill treated as other sick peo
ple, who can be cured, are likely to
remain fruitless as long as irrational
fear of ‘madness' is not conquered, as
long as all the influential members of
the social hierarchy do not understand
that mental health is not only the
business of specialists but must con
cern the whole community."
This statement was written forty years
ago, in a special issue of World Health
commemorating World Health Day in
1959. What is remarkable is that this
statement is still reflected in the public
image of mental health today. As we
realize that the global perception and
practice in mental health remains
much as before, we can bring to light
the incredible accomplishments in
many corners of the world. Today we
have the opportunity to take one
giant step forward collectively- out of
the darkness - into the glimmering
rays of knowledge that many have
endeavored to bring forth. We know
many things: mental and brain disor
ders are real illnesses, they are diag
nosable, treatable and in some cases
we know how they occur and how to
prevent them. Anyone can be afflicted
but we pretend not to be concerned.
A change now needs to happen in our
hearts to accept the knowledge which
has been gained and to adopt a new
attitude about mental health. We are
the missing link - the minds of some
billion souls - that should come to
realize that one's mind and brain can
become sick but can also be healed,
just as the body.
We are on the path around the world
to improve the care of persons with
mental or brain disorders.
Croup health session in Venezuela
Reorienting
Mental Health services
The United Nations Commission of
Human Rights stated not only that
medical treatment should be consid
ered as a basic right for people suffer
ing from mental illness, but also that
those people have to be protected
from potential dangers. This was far
from the case for centuries of mentally
ill patients. While some countries have
been moved to change this situation,
still others have not. Violations of
human rights can be perpetrated both
by neglecting the patient through
carelessness and by forcing him/her
into restraining or even violent care
systems. Even under optimum circum
stances, persons with mental illness in
most countries are often powerless.
Yet, family members and patients
themselves can try to influence mental
health policy and service organiza
tions.
Latin America - an example
of the “consumer"
movement
In the early 1990's, throughout Latin
America care for persons with severe
mental disorders was mostly provided
in outmoded mental institutions that
often violated human rights. Out
raged by this situation, a group of
parliamentarians, mental health work
ers, media, consumers and advocates,
representing eleven countries gath
ered in Venezuela to analyse mental
health care and suggest ways to
upgrade it. The Caracas Declaration
which resulted from this historical
meeting has given further impetus to
a movement of reform in mental
health care that was on the making in
several countries of Latin America.
Brazil is one example where consider
able strides have been made. Active
participation of patients themselves
in the formulation of policies to over
come past inequities provides a
strong voice and vitality to a process
of change that is moving the care
from closed institutions into the com
munity. Change is resisted by some
quarters, often as a result of ill-con
ceived notions and traditions, yet
observers of the Brazil case note that
the patients keep the agenda moving
forward and force the pace of this
reform among both professionals and
society at large. The struggle has been
taken to the streets and into the
chambers of the parliaments. Brazil
has developed innovative pro
grammes, such as the one in the city
of Santos, State of Sab Paulo, where
mental hospitals of yesteryear have
given room to alternative settings of
care and where consumers are gain
fully employed by co-operatives.
Chile is another example of a country
resolutely moving forward to trans
form its services. Today, community
clinics are mushrooming all over its
territory although, admittedly, some
areas are yet to be covered. Moving
north, in Central America, Panama
and Belize, among other countries, are
innovating the type of services
offered. Belize, for instance, with just
a single psychiatrist working in the
country, has multiplied its resources by
training family nurses known as psy
chiatric nurse practitioners, entrusted
with the provision of mental health
care. A recently conducted evaluation
essary treatment of acute episodes. A
De-institutionalization
and human rights the case in Europe
De-institutionalization (providing care
to the mentally ill in community set
tings and not in harmful institutions) is
very closely related to human rights
concerns and represents a basic precon
dition of any serious mental health care
reform. De-institutionalization is not the
mere administrative discharge of
inmates’ populations leading to dra
matic patient neglect. On the contrary,
de-institutionalization is a complex pro
cess, where de-hospitalization must
lead to the implementation of a net
work of alternatives, outside of the
walls of the mental hospital. A more
positive notion of "non-institutionalization", with emphasis on community
alternatives should be the norm in all
countries.
In Italy, the 1978 Mental Health
Reform began a process of "human
ization" of the psychiatric hospitals
and led to the creation of community
based services capable of enabling
number of protected apartments pro
viding a "non-medical" and friendly
environment for the most severely
and chronically ill were created. Final
ly, work opportunities have allowed
many patients to secure a substantial
integration into the community life.
Many other European cities have wit
nessed a marked shift from hospital
based to community-based systems
leading to an important decrease of
mental hospital beds and, in some
cases, the closing of the whole institu
tion. The Siauliai mental hospital in
Lithuania, for example, is on the road
to providing rehabilitation services and
reintegration of psychiatric patients
into the society. With the purchase of
a residential building this year,
increased attention is given to psy
chosocial interventions aiming to
ensure that after treatment the
patients can independently function at
home and in society. Similar scenarios
of community mental health care are
being built in other regions of the
world, yet still not in the generalized
fashion that we hope for.
patients to live in normal environ
ments. The Italian city of Trieste has
created an impressive network of
community based services, protected
a
apartments and co-operatives
employing mentally ill persons. The
psychiatric hospital in Trieste was
closed down and replaced by commu
nity mental health services operating
24 hours a day. These centres provide
medical care, pyschosocial rehabilita
tion, social assistance and when nec
The Siauliai mental hospital in 1980
has shown that the public is satisfied
with their services, now offered all
over the country. Despite these
improvements, there is still a long way
to go to reach the aims that the
authors of the Caracas Declaration
had in mind. In Latin America, some
populations do not have mental
health coverage, many services remain
substandard and human rights viola
tions have not been banished.
The Siauliai mental hospital in 2000
Mental health
as part of general
health care services
Mental health care is a basic and
essential building block for ensuring
life-long good health. The family doc
tor and general practitioner need to
approach are the Health Houses in
become increasingly better able to
of around 2000 people. These small
units rely on human resources that are
recruited from the community and
trained. There is one community vol
unteer for every fifty families to assist
recognize any potential mental
impairment or brain disorder in order
to provide quality care. In many parts
of the world, different methods are
being utilized to address this concern.
One example from the
Middle East
An innovative approach for ensuring
that basic mental health services are
available to all people, even the most
vulnerable and deprived groups, was
conceived in Iran in 1985 as the
"National Mental Health Pro
gramme".
rural areas (and more recently Health
Units in urban areas); each one is
responsible for the basic health needs
ture started as a test case in central
Iran in 1987. Mental health responsi
bilities of each level were clearly
defined and appropriate training, fol
low-up and supervision provided. The
mental health system is supported by
a third specialized level composed of
together four or five health houses or
650 psychiatrists and about 10,000
psychiatric beds, although most of
them are still in large psychiatric hos
pitals. To gradually decrease the
reliance on mental institutions, there is
them in getting any necessary medical
attention. Health Centers group
units and provide the services of a
a standing decree from the Minister of
General Practitioner. Such a center is
in turn supervised by the District
Health and Medical Education that
10% of the beds in all new general
Health Center and has access to spe
cialist centers that are usually part of a
University of Medical Sciences and
Health Services. In each province of
the country (population of sixty mil
hospitals should be used for psychi
atric care.
lion), there is at least one such univer
sity which is in charge of health affairs
A unique feature of the Iranian health
system is the integration of health
delivery and medical education in one
The integration of mental health care
ministry. At the base of a pyramid
within this existing nationwide struc
of the province as well.
At present, the programme is active
throughout the country: almost 60%
of the rural Health Houses and 25%
of the Urban or Mixed Health Centers
comprising 5,500 general practitioners
are active in providing mental health
services.
This approach has been adapted by
other countries in the region, such as
Bahrain, Cyprus, Egypt, Jordan,
Tunisia, Saudi Arabia and Yemen.
There is more than one recipe for suc
cess but this approach to integrating
mental health care within a primary
health care system is a good testimo
ny to what may be accomplished in
other parts of the world.
Training of mental health professionals in Iran.
Woman with schizophrenia (holding child) in care at home with her family in India.
9 Cfl The empowerment
„»i of families
Family involvement in the care and
rehabilitation of persons with mental
or brain illness is being recognized
world-wide as a key factor in success
ful treatment.
The case in South Asia
The family has been an essential part
The focus of family interventions, to
date, has been to build a relationship
with caregivers based on understand
ing and empathy, and helping them
to:
identify ways to promote medica
tion compliance;
recognize early signs of relapse;
care programmes for elderly persons
with dementia initiated in Kerala,
India, is now spreading to other parts
of the country. Another initiative is
training for home care and support to
family members of mentally retarded
individuals. This has resulted in a
movement that has generated voca
tional rehabilitation for the adult men
tally retarded individuals. Families of a
person with schizophrenic illness in
many cities (such as Bangalore, Chen
nai, and Gauhati in India, Katmandu
of mental health care programmes in
South Asia for fifty years.
ensure swift resolution of crisis;
The first formal recognition of the
ty;
importance of the family as part of
organised mental health care can be
moderate the effect in the home
environment;
traced to the mid 1950's in Amritsar
in Nepal and Colombo in Sri Lanka)
have come together to form self-help
improve vocational functioning of
the patient;
groups and start day care centres,
develop self-help groups for mutual
pressure on the policy makers to
improve services for the mentally ill
Mental Hospital, India. Patients were
brought for hospital admission as a
form of abandonment once their men
tal illness was long-standing and their
relatives had no more hope. As an
experiment, the relatives were encour
aged to stay with the patient during
the treatment period by pitching tents
on the hospital grounds. The success
of this involvement led to other similar
experiments and the system of includ
ing a family member has become an
essential part of psychiatric in-patient
care in all countries of the Region.
reduce social and personal disabili
support and networking among
families.
half-way homes, hostels and to put
persons.
More than 500 persons who were
The successes of family care pro
long-stay patients in the mental hospi
tal have been rehabilitated in Sri
grammes have still not received the
full support of professionals and plan
Lanka, by community education and
ners to the extent that it becomes a
family involvement. In a number of
cities such as Jodhpur and Chennai in
routine part of psychiatric care. As we
enter the 21st century, this must
India, a camp approach to drug
detoxification has included the fami
lies as “partners in care". The ham.
become commonplace for everyone
around the world.
Mental health today
Mental health counselling after floods in Mozambique.
Ml Mental health care
Aii in countries in conflict
prevention and promotion activi
Many countries in Africa are engulfed
in conflict and civil strife resulting in
an adverse impact on the mental
health and well-being of the affected
Community Based
Psychosocial Interventions
- the story in Africa
ties such as peace education, con
populations. It is estimated that there
are between 40 to 50 million refugees
Community based approaches to
tackle mental health problems and
early detection and treatment of
physical, psychological and social
and displaced persons worldwide. Of
other consequences of war and social
disruption were recently the subject of
two important inter-country meetings
problems involving nutritional
rehabilitation, first aid for victims of
these, only 22.4 million receive
humanitarian protection and assis
tance and around 30% of these dis
placed persons are in Africa.
Increasing poverty and lack of interna
tional legal consensus are some of the
involving Angola, Burundi, Chad,
Congo, Democratic Republic of
Congo, Eritrea, Ethiopia, Lesotho,
flict resolution skills, prevention of
alcohol and drug abuse;
land mines and other forms of
injuries, psychological support
using school teachers and self-help
groups;
major factors preventing most of the
refugees from receiving support.
Liberia, Mozambique, Namibia, Rwan
da, Sierra Leone, South Africa, Ugan
da and Zimbabwe. These countries
Wars, other forms of violence and dis
asters contribute to the growth of
have embarked on different types of
community based interventions
The involvement of community and
psychological and socio-economic
despite the difficult conditions which
religious leaders, traditional medicine
burden. Family disruption with an
include;
practitioners, women and youth orga
rehabilitation through social reinte
gration, family reunification and
the promotion of human rights.
increase of abandoned children and
nizations and self-help groups is very
women headed families; increase of
effective to ensure culturally sensitive
street children; juvenile delinquency;
initiatives.
prostitution; and alcohol and drug
related problems are a common sce
nario in a number of countries of
Africa. All these stressful events con
tribute to anxiety, depression, differ
ent psychosomatic disorders, phobias
and post traumatic stress disorders.
Mental health
care in transition
economies
Innovating mental health one example from
Central Asia
Mongolia is a country which is chang
ing from socialism to one with a mar
ket economy following a democratic
Recent changes in the socio-political
development of many countries in the
Western Pacific Region have generat
ed considerable challenges which per
meate the lives of the people in these
communities. These changes affect
the structure of society, and are felt
especially in the mental health situa
tion of the population. Clearly, in situ
ations of transition economies,
concerns for job security and the eco
nomic survival of the household can
loosen social bonds and create enor
mous pressure on one's mental health
stability. The resulting need for mental
health programs at all levels, for
strengthening promotion, prevention
and care and for reorienting services
to address the psychosocial issues of a
changing society was addressed in
Mongolia.
political reform in 1990. This change
has been affecting all aspects of Mon
golian life: political, economic and
social life, especially impacting on the
family. In 1997, the National Health
Policy has articulated the shift from a
specialist to a generalist health care
delivery system. As a consequence,
general health services are being
strengthened, and hospital based care
has shifted to bring a greater empha
sis on community based health care.
home visits. Since 1999, the mental
health training has been expanded to
include the community health work
ers; many of whom attend to the
nomadic groups representing 40% of
Policy makers and government
authorities have recognized the
the Mongolian population.
importance of mental health by
specifically including mental health
Since 1998, a decrease in admission
services in the new national health
policy. As a consequence, appropriate
and in the length of hospital stay at
the State Mental Hospital has been
noted. An increase in the number of
training in mental health and psy
patients treated in the general health
chosocial skills is provided to all gener
al health personnel. In addition, health
promotion among youth to prevent
clinics as well as those referred to the
the adverse effects of social changes
(such as increased alcoholism, suicide,
Mental Health Law, passed in 1999,
violence and criminality) has been
undertaken. In the last two years at
reoriented programs in the country.
least 50% of general physicians in
Ulaanbaatar City as well as the
provinces in the eastern, western and
central parts of the country have not
only undergone mental health train
ing, but have started to manage
patients with mental health problems
in their clinics. These general physi
cians have also included mental health
topics in their health education activi
ties in the schools and during then
outpatient clinic and the Center for
Mental Health are also recorded. A
provides for the continuation of these
£4 We can do better
Stop exclusion
Ail Dare to care
Families
■ In a crisis, involve all family mem
bers to solve the issue and support
each other emotionally.
Recognize early symptoms and
encourage family members to seek
help if needed.
Support those suffering and do not
dismiss their symptoms. Integrate
them in the life of the family and
the community.
; Join with other families to support
each other and change common
misconceptions.
Mental health care is a collective and
continuous undertaking. It implies act
ing to preserve and recover that which
makes people human, alongside with
the spiritual life. It also requires a
healthy environment, one that is
peaceful, in which all people may
prosper, where tolerance is general
ized, and where violence is dimin
ished. Without this, we are all at a
greater risk for ill mental health.
Everyone
can help
Individuals
Encourage wholesome early
attachments and the acquiring of
age appropriate abilities in children.
Seek help if you have a mental
health problem or think you have
symptoms.
A vision for the future
■ Every individual will recognize the
importance of mental health.
■ Patients, families and communities
will be more empowered for taking
care of their mental health needs.
■ Health professionals will become
more skilled in prevention and
treatment of mental illnesses as
well as the promotion of mental
health.
Policy makers will be better
equipped to plan services more
rationally and ethically.
■ Join in efforts to dispel the myths
about mental illness and brain dis
orders.
Medical professionals
■
Consider your patients' emotional
state as well as their physical state.
■ Seek out training to recognize
symptoms and acquire skills to care
for those with a disorder.
Involve the families in caring for
the patient.
Mental Health
professional associations
Advocate for care to be provided
equitably and in the most optimal
conditions.
Media
Contribute to empowering com
Policy makers
(governments and insurers)
Mental health is influenced by
social factors; ensure that policies
extend beyond the mental health
care system to include education,
labor, criminal justice and general
munities by reporting pertinent
information and avoiding stereo
types and sensationalism.
Focus on human rights of mentally
ill persons.
health care systems.
Communities
■ Create educational opportunities
for citizens to learn the importance
of mental health.
■ Teach children tolerance to differ
ences in individuals and acceptance
I Provide coverage to assume the
costs of mental health care as a
basic guarantee.
Allot funds for mental health
research.
of disabilities.
■ Integrate those who have a mental
health problem by providing them
an opportunity to best contribute
to society.
Science
■ Study, in a comprehensive manner,
NGOs
Educate the public about mental
health and disorders.
all factors, including genes, envi
ronment and behaviour that con
tribute to the cause and duration of
mental and brain disorders.
Organize support groups for fami
lies of the ill individuals.
Mobilize public opinion about poli
cies, programmes and welfare ben
efits for the mentally ill.
For more
information
Copyright © 2000 World Health Organization
This document is not a formal publication of the World Health
Organization (WHO), and all rights are reserved by the Organization. The
document may, however, be freely reviewed, abstracted, reproduced or
translated, in part or in whole, but not for sale or for use in conjunction
with commercial purposes.The views expressed in the document by
named authors are solely the responsibility of those authors.
Concept and layout: Tushita Bosonet; logo: Marc Bizet
A product of NMH Communications
The WHO World Health Report which
is focusing on mental illness and some
brain disorders will be available in
June 2001. The Report will provide
more substance to the issues which
have been highlighted in this
brochure.
Eastern Mediterranean
WHO Post Office
Abdul Razzak Al Sanhouri Street,
(opposite Children's Library)
Nasr City
Cairo 11371
Egypt
Addresses of WHO
Regional Offices
Tel: (+202) 670 25 35
Fax: (+202) 670 24 92
Africa
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WHO
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India
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Fax: (+263) 479 01 46
Tel: (+91-11)331 78 04
Fax: (+91-11) 331 86 07
Americas
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USA
Tel: (+1-202) 974 30 00
Fax: (+1-202) 974 36 63
Europe
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Denmark
Tel: (+45-39) 17 17 17
Fax: (+45-39) 17 18 18
West Pacific
WHO
P.O. Box 2932
1000 Manila
Philippines
Tel: (+632) 528 80 01
Fax: (+632) 521 10 36
Many non-governmental organiza
tions are making a difference in
improving mental health care and
reducing exclusion. They are too
numerous to list in this brochure. Visit
the website www.who.int/worldhealth-day for links to many of these
organizations.
Bridge the gap
Health, as defined in the
WHO Constitution, is a state of
complete physical, mental and
social well-being and not
the absence of disease or ii
World Health Organization
Department of Mental Health and Substance Dependence
Avenue Appia 20
1211 Geneva 27
Switzerland
Tel:+41 22 791 21 11
Fax:+41 22 791 41 60
E-mail: WHD@who.int
Website: www.who.int/world-health-day
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