Five-year plans and once-in-a-decade interventions: Need to move from filling gaps to bridging chasms in mental health care in India

Mental Health Programme in India: Has the tide really turned?

Mental disorders in India form a major public health concern and the efforts to tackle these dates back to four decades, by way of the National Mental Health Programme (NMHP) and its operational arm, the District Mental Health Programme (DMHP). Although the progress of NMHP (and DMHP) was relatively slower till recently, the last 4-5 years have seen rapid strides with several initiatives, including (i) expansion of DMHPs to 90 per cent of the total districts of the country, (ii) the National Mental Health Policy and (iii) strengthening the Mental Health Legislation by way of providing explicit provisions for rights of persons with mental illnesses. Among others, factors responsible for this accelerated growth include the easily accessible digital technology as well as judicial activism. Federal and State cooperation is another notable feature of this expansion. In this review, the authors summarize the available information on the evolution of implementation and research aspects related to India's NMHP over the years and provide a case for the positive turn of events witnessed in the recent years. However, the authors caution that these are still baby steps and much more remains to be done.

The future of community psychiatry and community mental health services

PURPOSE OF REVIEW

The aim of this article is to provide a framework and analysis of a series of critical components to inform the future design, development, sustaining, and monitoring of community mental health services.

RECENT FINDINGS

Many mental health services remain too hospital-centric, often without adequate outreach services. On the basis of outcome evidence, we need to shift the balance of mental health services from hospital-centered with community outreach when convenient for staff, to community-centered and mobile, with in-reach to hospital only when necessary. Too few training programs those with emphasize the macroskills of public advocacy, working with service users, families, social movements, and the media to improve mental health and wellbeing of regional and local communities.

SUMMARY

We should adopt a health ecosystems approach to mental healthcare and training, encompassing nano to macrolevels of service in every region. Catchment mental health services should be rebuilt as community-centric mental health services, integrating all community and inpatient components, but led and integrated from community sites. Community psychiatrists and mental health professionals of the future will need to be well trained in the nano to macroskills required to take responsibility for the mental health and wellbeing of their catchment communities and to provide leadership in service-planning, management, and continuing revision on the basis of rigorous evaluation. These approaches should be the core of all training in psychiatry and all mental health professions prior to any subspecialization.

Inequity in Distribution of Psychiatry Trainee Seats and Institutes Across Indian States: A Critical Analysis

Background  The delivery of mental health services largely depends on the adequacy of human resources. In India, the deficit of psychiatrists is more than 90% and is one of the major challenges that needs to be tackled to address the huge burden of mental illness. Psychiatry trainee institutes play a vital role in reducing human resource deficit and inequality in delivering mental health care. However, the distribution pattern of psychiatry trainee seats and institutes across Indian states is unknown. Therefore, we estimated the number of psychiatry trainee seats and institutes in each Indian state and union territory (UT). Materials and Methods  In this cross-sectional study, psychiatry trainee seats and institutes were searched on the official web sites of Medical Council of India and National Board of Examinations. The data available on these web sites until December 2019 were included. State-wise data were compared using proportion and percentages. The psychiatry trainee index (PTI) was calculated and compared across Indian states and UTs. Results  Among 221 Indian psychiatry trainee institutes considered in the present study, 116 (52.48%) were private institutes and 105 (47.51%) were government institutes. Overall, more psychiatry trainee seats were reported in government institutes ( n = 565, 65.89%) than in private institutes. National PTI was considered fair (0.06), and based on their PTIs, Indian states and UTs were classified as follows: worst ( n = 9), poor ( n = 8), fair ( n = 9), average ( n = 7), good ( n = 1), and excellent ( n = 2). Conclusion  A huge deficit of psychiatry trainees and institutes exists in more than two-thirds of Indian states and UTs, along with a huge maldistribution of seats. PTI and its distribution across the states and UTs are a crucial indicator of the need to improve the access and equity of mental health care.

Rehabilitation of long-stay patients in state mental hospitals: Role for social welfare sector

Barriers to discharge long-stay patients with mental illness (PWMI) are complex and involve social factors. Recent legislations emphasize community living and creation of facilities by Government for PWMI without social support. The Honorable Supreme Court has dealt with the need for setting up rehabilitation homes for long-stay PWMI who do not require hospitalization. In such cases, nominated representative from social welfare sector needs to be involved in discharge planning. The social welfare sector needs to play a bigger role in the rehabilitation of long-stay PWMI.

Examining the initial usability, acceptability and feasibility of a digital mental health intervention for college students in India

Generalised anxiety disorder (GAD) is prevalent among college students in India; however, barriers like stigma, treatment accessibility and cost prevent engagement in treatment. Web- and mobile-based, or digital, mental health interventions have been proposed as a potential solution to increasing treatment access. With the ultimate goal of developing an engaging digital mental health intervention for university students in India, the current study sought to understand students' reactions to a culturally and digitally adapted evidence-based cognitive behavioural therapy (CBT) for GAD intervention. Specifically, through theatre testing and focus groups with a non-clinical sample of 15 college students in India, the present study examined initial usability, acceptability and feasibility of the "Mana Maali Digital Anxiety Program." Secondary objectives comprised identifying students' perceived barriers to using the program and eliciting recommendations. Results indicated high usability, with the average usability rating ranking in the top 10% of general usability scores. Participants offered actionable changes to improve usability and perceived acceptability among peers struggling with mental health issues. Findings highlight the benefits of offering digital resources that circumvent barriers associated with accessing traditional services. Results build on existing evidence that digital interventions can be a viable means of delivering mental healthcare to large, defined populations.

Concurrent Validity and Interrater Reliability of the "Clinical Schedules for Primary Care Psychiatry"

Background and Objectives  There is limited access to specialized mental health care in countries such as India with a wide treatment gap for psychiatric illnesses. Integrating mental health delivery with primary health-care services is vital. The clinical schedules for primary care psychiatry (CSP) was designed for training primary care doctors (PCDs) to identify and diagnose psychiatric illness in patients presenting to primary care settings. This study aims to study the validity and reliability of the CSP and its hypothesis is that the CSP would help PCDs to identify psychiatric caseness.

Methods  The study was conducted at three primary health centers of Karnataka. Consented PCDs were briefly trained in the use of CSP and screened patients who were later interviewed by a psychiatrist using a semistructured interview and confirmed by International Statistical Classification of Diseases and Related Health Problems 10th edition (ICD-10) symptom checklist. The appropriate statistical analysis was performed.

Results  A total of 180 patients were included. Agreement was found between diagnoses made by PCDs and psychiatrist for 142 (78. 9%) patients with a Cohen's kappsychiatry pa (K) = 0. 57. The sensitivity was 91. 1% and specificity was 68. 3%. The interrater reliability showed K = 0. 7.

Conclusion  The CSP helps PCDs to make psychiatric diagnoses. It has a relatively high sensitivity with reasonably high specificity but mayneed clinical training.

Responsive mental health systems to address the poverty, homelessness and mental illness nexus: The Banyan experience from India

Background

Mental health has gained prominence as a global public health priority. However, a substantial treatment gap persists in many low- and middle-income countries. Within this scenario, the nexus between homelessness, poverty and mental illness represents a particularly complex issue. This article presents the experience of The Banyan, a 25 years old non-profit organisation providing mental health care to people living in poverty in Tamil Nadu, India.

Case presentation

The case study describes the evolution of The Banyan using a timeline narrative. By applying an action learning framework, the organisation’s evolution through four lifecycles, strategy and the key elements underlying mental health system responses are identified and presented. ‘User centred’ and ‘service integration’ emerge as the main dimensions of The Banyan’s responsive health system. Relating to these two attributes, a typology of services is derived, indicating the responsiveness of mental health systems in addressing complex problems. The role of the organisational culture and the expressed values during the transition is considered.

Conclusions

The case study serves as an example of how responsive mental health systems may be constructed with both a user centred and a service integration focus.

National Mental Health Programme-Optimism and Caution: A Narrative Review

India was one of the major World Health Organization (WHO) member countries to launch its National Mental Health Programme (NMHP) in 1982 in accordance with WHO's recommendations to deliver mental health services to the people under the framework of general health care system in the community. NMHP underwent major strategic revisions over its course, starting from setting a district as the unit for program planning and implementation under the District Mental Health Program (DMHP) to incorporating it with the National Rural Health Mission (NRHM) for effectively scaling up the program. The program also underwent evaluations by government bodies and independent agencies and was reviewed by many researchers. The program has been partly successful in terms of enhancing its reach to community, improving service delivery, and getting increased budgetary allocation, but at the same time, its impact was limited by financial and human resource constraints, lack of community participation, ineffective training, poor NGO/private partnership, and lack of a robust monitoring and evaluation (M and E) system. The latest National Mental Health Policy and the incorporation of its objectives have given a new impetus to the ongoing NMHP, however, its implementation needs to be monitored and the impact is yet to be evaluated. We attempted to review the available literature pertaining to NMHP and DMHP to highlight the determinants of its outcome, with special emphasis on on-going programs and to provide some important future directions.

Mental health and the law: An overview and need to develop and strengthen the discipline of forensic psychiatry in India

Human rights and mental health care of vulnerable population need supportive legislations and policies. Both "hard" and "soft" laws relevant to mental health care have been devised internationally and locally. Amendments in laws and the formulation of new laws are often required and have been seen to occur in the area of mental health care in India. So far, reform in mental health care has largely been reactive, but newer legislations and policies carry the hope of proactive reform. The lack of trained human resources is one of the biggest problems in effective mental health care delivery in India. While postgraduate psychiatric guidelines recommend a 2-week training in forensic psychiatry, this is insufficient to develop the necessary competence in the area. There is, thus, a need to develop subspecialty of forensic psychiatry. Forensic psychiatric services also need to be developed, properly structured, and supported. There is a need to set up one or more centers of excellence in forensic psychiatry in India.