Detecting common mental problems in primary-care via promoting self-referral: A CMHP experiment of influencing pathways to care by solicitation with a symptom list.
One out of every five people who attend a primary health centre has one or the other mental health problem. The fact that it does not come to the clinician's attention is unfortunate. Many reasons can explain this -at the clinician's level (skill acquity), the setting (differentiation of symptomatology), the patient (presentational clarity) and so on.
How health-care services can become accessible or inaccessible is one question which public health researchers are particularly concerned about. Pathways to care with its associated filters at the various interfaces of the health-care system is one useful framework to understand how care reaches or eludes the needy. Such understanding can help inform, influence and improve the accessibly of our services.
Pathways to care analysis at Community Mental Health Program (CMHP, Kottayam district) informed us that 11.7% of patients (see chart) were self-referred to the clinic. It means they found out about the schedule of the monthly clinics by themselves. They got the information by reading -the notice board at each Community Health Center(CHC), the newspaper announcement about the clinics, the notice board at the nodal centre (near ward 4, Medical college hospital) about the clinics.
We thought of augmenting the self-referred pathway by directly influencing the treatment seeking of people who come to the OPD. A small slip (see picture) which listed common mental health problems was given to every patient at the OP registration counter at CHCs with a request to meet us at the "counseling room" (http://communitypsyindia.wordpress.com/2014/02/15/). We did it at CHCs where the CMHP had less than 20 patients for followup.
We found encouraging results as many patients came forward to meet us at the clinic after reading the slip. Sleeplessness and excessive worry were the common presenting symptom in people who came via this pathway.
It is therefore concluded that handing out a slip with symptom list of common mental health problems, at primary care OP is one way to improve detection of minor mental disorders and provide early intervention. Services and access to care can be improved by this simple approach.One barrier that was noted was - many of the older people found it difficult to read the fine print in the slip.
A TOT (Training Of Trainers) session for the palliative-care-program staff of Kottayam district, Kerala was organised by the DMHP (District Mental Health Program).The half day program was piggybacked on the schedule of their bimonthly district level meeting.
120 nurses and 5 medical officers who are part of the palliative care team of the district were the participants. As per felt-needs understanding of the CHMP team, home care of severe dementia and severe intellectual disability was decided as the focus area for training. Specific sub-areas focused for dementia care were management of behavioral problems in severe dementia and addressing caretaker issues. Training in self-care for adolescents and adults with severe mental retardation was the other sub-area selected. Validation of this need was sought by circulating a needs assessment performa among the pattiative care nurses (70 respondents) and the cumulative data is as follows.
|Needs Assessment Questions||Yes||No|
|Do you see people with mental health problems as part of your routine work?||90%|
|Are severe-mentally-ill patients who are home bound included as patients in the home care program?||90%|
|Have you received any training till yet in care of home bound patients with severe dementia and mental retardation?||31%||69%|
|Do you anticipate difficulties/challenges in care of above mentioned patients?||50%|
|What are those difficulties?||*See below|
|Have you received any training in counseling for caretakers in distress?||50%|
|Have you heard about the CHMP which is been running in the district since last one year?||50%|
|Have you referred any patients to CMHP clinics?||18.5%|
* Most responses were about the anticipated difficulties in communicating with the subset of this patients. There was apprehension that the patients may not cooperate because of their illness. They might resist everything….difficult to explain things to them….there will be no involvement from the patient’s side…the patients may refuse medications, how to deal with that….how to deal will issues of care takers.
All questions and responses were collected originally in Malayalam.
See below our team psychologist taking session on selp help training.
Nobody will say that the medical and social needs of the elderly patient with severe dementia and children with severe intellectual disability will be justifiably met by attending a once monthly outpatient clinic. But that is all the community based care that is available for mental health in Kerala now. The District Mental Health Program (DMHP) in all 14 districts of Kerala work in a montlhy outreach clinic mode. This is beside the fact that Kerala as a state is far ahead in India in having a functional DMHP in all its 14 districts as against most other states where the program is still a non-starter.
The care for the chronically ill, who will not be able to come to the clinic, will be a nagging problem for all field-psychiatrists who are part of the program in most districts in Kerala. We at Kottayam district, did a database search of our patients (270 patients out of the ~725 who have registered with the program since its inception one year back). 12 patients with Dementia and about 35 children with Intellectual disability were found.
Some form of home based care is the only option for this subset of population. But where are the personnel for doing that?
We had knowledge that the palliative care program has a strong field presence in the state. This fact was also evident in the analysis of the referral pattern to our clinic. We get 10.60% of our referral from the field staff of which many are from the palliative program (see below). Horizontal integration with the palliative care program is a potential solution for homecare of the severe mentally ill.
The palliative program has its visible presence in all districts of Kerala with amble support from the local self governments. Working with palliative team for delivering mental health services was successfully demonstrated in the Malapuram district of Kerala and often it is hailed as the “Malapuram Model” (see my previous blog post where it gets a mention).
Some concluding comments:
1. I was surprised by the large human resource capital of the palliative program available for a district (120 nurses for Kottayam district and about 7 medical officers of health department who are incharge as nodal officers). The DMHP with 3 support staff for the field-psychiatrist for an entire district pales in comparison!
2. While interacting with the District Program Manager (DPM) of Kottayam it was suggested that whatever field work that is felt as requirement for the DMHP, it could be carried out through the palliative care nurses. Potential areas like home based monitoring of drug compliance or enlisting service of the palliative care nurse as the first contact personnel when symptoms in patients worsen were discussed.
3. The field nurses of the palliative care had knowledge of many patients in the community who were not taking psychiatric treatment or discontinued medications. This interaction is sure going to benefit these patients as they will soon be referred to the outreach clinics of CMHP. Previously only 50% of the palliative staff in Kottayam had knowledge about CHMP program, now that everybody in the palliative team has come to know about it, opportunities for working together is sure to increase :-)
Kerala has bent the curve on hard liquor consumption. Figures from the annual sale figures of alcohol from the state speaks for itself. As the data has been collated from many sources based on BEVCO (BEVerages COrporation of Gov. of Kerala, which has monopoly over sales) figures, it is fairly accurate. (Graph created using http://www.chartgo.com/)
Many reasons have been put across for this change. Increasing awareness programs from government , reducing availability of liquor etc. However incremental taxes on alcohol could be the primary reason as shown by increase in tax revenue for the government (see chart below). Alcohol has become increasingly costly. Increase in beer consumption if viewed a gateway phenomenon can indicate more use among young people, however if it is viewed as behavioral change among seasoned drinkers it can indicate how punitive tax structures are helpful in harm reduction.
Recent government decision to shut down bars because of poor quality of service has resulted in mixed reactions. Sociologists have commented that …. that neither prohibition nor cutting down of availability is going to bring down Kerala’s liquor menace which is causing serious social and family problems. According to them, the problem in Kerala is not liquor as such but it is the underlying social and psychological factors that are forcing Keralites to hook to booze.
It is indeed a multidimensional problem. Will need more analysis in coming years.
Sales figures from 2010-14.
Gross sales value
|Revenue for Gov.(Tax etc)|
|2010-11||217.41lakh cases (15.6% increase from previous year)||85.61 (0.4%)||6730.30 crores(21.52%)||5232.53 crores|
|2011-12||241.78 (11.06%)||97.82 (14.2%)||7861.74 (16.8%)||6292.48|
|2012-13||244.33 (1.2%)||101.64 ( 3.8%)||8818.81 (12.17%)||7240.89|
|2013-14||240.67 (-1.5%)||108 .00 ( 6.26%)||?9353||?7511|
CSR of BEVCO http://m.newindianexpress.com/kerala/335246
Today’s report in the Hindu gives a reality check on the NCD (noncommuicable diseases) program in Kerala. With the central plan to integrate the 5 central health schemes (see earlier post here) under the rubric of the NCD, it makes sense to make a situation appraisal so as to plan ahead. Kerala may be the first state to take the baby steps in this direction as it already has active Mental health, palliative, geriatric and NCD programs.
Some excerpts and comments:
NCD drugs are in short supply across the State and in many districts, there are no stocks available anymore. Even the basic drug for diabetes, metformin, and glucometer test strips for blood glucose monitoring are totally out of stock in many places. Apart from NCD drugs, some 150 commonly used drugs are also totally out of stock in most districts.
The inability of the State to provide uninterrupted supply of the drugs defeats the very objective of the NCD control programme because strict and uninterrupted adherence to prescription medications and regular follow-ups are crucial for keeping all NCD-related complications under check.
As far as the mental health program is concerned it also has its share of adversarial news coverage. It has been mainly for the unavailability of mental health doctor (at-least a trained medical officer in mental health) in certain districts like Iddukki to continuously run the program. Uninterrupted drug availability has also been a problem as in the report on the NCD program. However mental health program also has the additional problem of drug excess approaching the expiry date. This has been because of the centralised drug intending which is quite out of sync with the dynamic need on the filed.
The decision to provide NCD drugs for free to all those detected with diabetes or hypertension had been ill-conceived and several senior Health officials had warned the government that this was a huge commitment which will be difficult to sustain,” a senior Health official said. The National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke (NPCDCS) is being carried out in five districts in the State since 2012. There is no free drug distribution under NPCDCS. But the State took a decision to extend the scheme across the State and to use State’s funds to screen the entire population and provide drugs free of cost.
The decision has proved to be a huge drain on the exchequer because all the funds allocated for the programme – both Central and State funds – are now being spent on purchasing drugs while the other components of the programme, like activities to promote primary prevention of the disease in the community, have not taken off at all.
The uni-modal biomedical model for public health is something which all have to be forewarned on, not just for its medicalisation of programmic architecture but also for the perverse diversion of funds for irrational and financially nonviable pharmacotherapy.
Hence, a directive was issued to all PHCs/CHCs to calculate their individual requirement of NCD drugs, so that it can be included in the general indent for drugs being sent to KMSCL by every hospital.
“In the long-term, the focus should be on encouraging people to adopt risk reduction strategies and adopting policies that encourage healthy living. Apart from a few basic drugs, no government can afford to offer statins or expensive insulins free to the people for a lifetime. This was a populist measure which has gone horribly wrong,” the Health official added.
Drug intending at the point of care is definitely the way ahead. It is at the core of integration of care of chronic illnesses into the health system architecture.
See below a collated list of emerging intersectoral health (physical+ mental) and social care programs in Kerala. This list is complied based on newspaper reports of last three months.
Name of program/ Initiative
|Lifestyle Education and Awareness Programme (LEAP)
|National Rural Health Mission (NRHM), The State Health Department, and the Education Dept.
Children (? School going)
|District Early Intervention Centres (DEICs)
|RBSK (Rashtriya Bal Swasthya Karyakram),Departments of Health and Social Justice, ‘State-wide Initiative on Disabilities’
All Children with disabilities 0-18 yrs
|Dial A doctor (1056)
|DISHA (Direct Intervention System for Health Awareness), NRHM,The State Health Dept.
Health care and counseling over telephone
|State-wide joint survey to prepare a database on disabilities
|Departments of Health, Education, and Social Welfare, State social security mission,‘State-wide Initiative on Disabilities’
All age group, Prevention of disabilities, early detection and intervention, education, and rehabilitation.
|NUHM (National Urban health mission)
|The Health Dept, Depts of Urban Affairs, Social Justice, and Local Self Government with expanded District Health Societies.
Health care in urban areas.
|NCD (Centrally sponsored Scheme)
|NMHP, Cancer control, Diabetes, CVD, Stroke,Elderly care and Trauma
All non communicable diseases.
|Clean campus/ Save campus.
(This list is not exhaustive)
|Home Dept+ Edu Dept.||
Substance use in schools.
This post is based on this report in TheHindu which is based on analysis of data from the India Human Development Survey (IHDS) of 2004-05 and 2011-12. It is a comparative analysis of the The Right to Education Act (RTE) , the National Rural Health Mission (NRHM), and the Janani Suraksha Yojana (JSY) across the said time frame. An excerpt on the NRHM is below
The NRHM is supposed to strengthen preventive and curative care, particularly in rural areas and in States with poor health infrastructure such as Uttar Pradesh, Bihar, Rajasthan, Madhya Pradesh. However, a very small proportion of the Indian population relies on public facilities. About 70 per cent of patients visit private providers — either as their first choice or once they are frustrated with public services.
Between 2005 and 2012, years when the NRHM was implemented, instead of increased usage of government services, we see a modest growth in the use of private services for minor illnesses such as cough, cold and fever (from 69 per cent to 73 per cent) as well as for treatment of major illnesses like diabetes, cancer and heart problems (from 67 per cent to 72 per cent). Ironically the greatest increase in the use of private services is in high-focus large States like U.P., Bihar, Rajasthan, M.P. and Orissa. Here the proportion of patients going to private providers increased by nearly 5 percentage points.
The disenchantment of parents and patients with government services is widespread. When asked in 2012 about their confidence in government and private schools and medical facilities, 53 per cent of the respondents expressed confidence in government schools compared to 72 per cent for private schools. Similar differences are observed for confidence in government doctors vis-à-vis private doctors. What explains this? There is no reason to believe that private doctors and teachers are more qualified than government doctors and teachers. Typically government recruitment standards are more stringent about training and qualifications while there is little control over the private sector. It is hard to imagine that anyone would prefer a self-styled private “doctor” in a distant village to an MBBS doctor in a Primary Health Centre (PHC). Yet, this is exactly what we see around us.
The reasons for these preferences are myriad. Parents and patients feel disrespected by government service providers and may find they get better service if they pay. For example, about 6 per cent of the patients see a government doctor or nurse in their private practice rather than in the government dispensary where the same services could be practically free. Government facilities are often irregular in their opening times and teacher and doctor absenteeism adds to the disenchantment.
My current vocation is as Filed Psychiatrist under the community Mental Health Program (CMHP), Kottayam District Kerala. The funds for the program are channelized through the NRHM. This mechanism made it possible for the DMHP/CMHP to establish in districts were the district hospitals are understaffed to to take up the program.
The CMHP is a hybrid venture of the regional medical college, and staff and vehicle provided by the NRHM. The potentials/pitfalls of this arrangement needs to be explored in due course. Early indications is that the program will suffer in terms of quality as all people involved in this arrangement have no long term stakes in the program. The program can at best drift along as it is nobody’s child.
One positive that I have noted is that infrastructure in all Commnity Health Centres (CHC) have improved thanks to NRHM funding. I also meet a lot of primary care doctors who have been appointed by NRHM. Other programs like the palliative care program and many other social care programs have nurses and counsellors appointed under NRHM.
Staff in the program which includes me are in contract employment. Salary and perks are less compared to those in permanent employment. Phenomenon called “service break” is built into the arrangement i.e every first day of the academic year (April 1) all staff contracts expire and we are reappointed on April 2. The staff has been resisting this for a while, see below.
NRHM staff in Allahabad has also been demanding regularisation of tenure. See here. This post ends here.
Other recent connected news:
4. lack of capacity at state level to absord nrhm funds http://www.thehindu.com/todays-paper/tp-national/theres-will-but-limited-way/article5194658.ece
The Kerala High Court intervenes in the issue of Anganwadi worker’s pay dispute. The details are summarised below based data in the Newindianexpress report.
Blog Comment: It is unfortunate that valuable time of our courts have to be drawn into these issues which should have been sorted out at policy level. It is the government’s non committal to raise the percentage public spending on health from a meager less than 1% to at least 2 to 3%, the underlying reason for this situation. There has been a constant demand from health workers at the cutting edge of delivery of various governmental schemes for fair remuneration. The issue is complex as one can immediately see by going thorough the various arguments that came before the court and as also discussed elsewhere in various other forums.
All photographs are only representative and downloaded from the web (no explicit permission has been sought).
With the cabinet decision today to prune centrally sponsored schemes, NMHP becomes part of NCD. The noncommunicable diseases program (NCD) will include the following programs as per Planning Commissions draft document.
1. Cancer control program.
3. National program for Diabetes, Cardiovascular diseases and Stroke
4. Health care of elderly.
5. Assistance for states in capacity building in Trauma.
6. 8 pilot projects.
(Official communication awaited)
The following intent for research activity at CMHP-kottayam was submitted to the state-level Nodal officer. Suggestions and comments are welcome.
Ramkumar G S
Community Mental Health Program.
State-level Nodal Officer.
Sub: Submission of a proposal for research study in Kottayam district under the Community Mental Health program.
It is heartening to understand that conducting research activities is also very much a part of the DMHP/CMHP programmic architecture. The monthly reports which are being furnished from the district have explicit instructions to furnish details of the research activities done during the month. As you are aware research activities cannot be planned on a monthly basis as it involves discussion on research design, ethical approval and funding support. Therefore I submit the following research proposal as an abridged statement of interest for conducting research in my district.
Kindly advice me on the specifics of moving forward with this proposal with respect to
- Procedure for getting ethics approval for conducting research as part of DMHP/CMHP activities.
- The funding head of account for research based activities.
- What other procedures need to be followed.
Ramkumar G S
As per draft policy document for the DMHP 12th plan, regarding research activities it is explicitly mentioned that
The primary role of research in the context of DMHP is to….reduce the treatment gap. As the ICMR already supports clinical and epidemiological research and the DBT supports aetiology and basic sciences research, it is recommended that the DMHP (or NMHP) conduct health policy and systems research in order to provide guidance about how to increase access to cost-effective treatments. In particular, the emphasis in these priorities is to better understand how to deliver what we know works in an affordable manner, which has been referred to as ‘implementation’ science.
Research questions include……To develop and evaluate mental health interventions for delivery by non-specialist health workers, a strategy referred to as ‘task shifting’
Research-Proposal-Proper as an abridged statement of interest.
In keeping with the mandate of NMHP I have selected an operational research question which aims to test the implementation of primary care integration of mental health care by trained GPs in the health department via an incentive augmented task-shifting paradigm.
General Practitioner run outpatient clinic for mental health: Exploring the feasibility and role of monetary incentive as a motivational factor.
Idea put forward by Ramkumar G. S. MD, Field Psychiatrist, Community Mental Health Program, Kottayam District.
Duration of Study
With many years of experience with the training of General Practitioners (GPs) in Mental Health service delivery ever since the conceptualization of the National Mental Health Program (NMHP) in 1983, it has become clear that training is not correlated to service roll out in the periphery. The ICMR –DST study on severe mental morbidity (1987 Report) had forewarned that even though General practitioners gained knowledge after training their actual performance over a one year period was not good.
Based on certain anecdotal reports it is possible to believe that DMHP Thiruvananthapuram may have had some success in GP delivered mental health care, however we have report from northern Kerala and other parts of India that training alone does not translate to practice. The reasons may be due to include lack of motivation and not being adequately incentivised for taking up this work, rather than just skill or confidence deficit.
Incentives have a major role in motivating health care professionals in running various public health programs. In a Cochrane systematic review (1) it was noted that financial incentives are being increasingly utilized for bettering health care delivery, though convincing research evidence is not available to support it unequivocally. In the review which evaluated seven studies it was found that there were positive outcomes of modest sizes in some, if not all, outcome measures like quality of care.
In the Indian context GPs working in facilities designated as rural areas are awarded rural service incentives (Rs 3000 per month), those working in difficult rural areas with special health packages are awarded (Rs 20,000 per month in addition to regular salary), those enhancing IP and lab facilities in their facility under the RSBYN scheme are awarded patient care allowances. Health workers involved in facilitating hospital delivery in Janani Suraksha Yojana (JSY) is another example of performance based financial incentive practice.
AIM of this study:
1. To explore whether a modest financial incentive will motivate a trained GP in running a mental health OP in a peripheral health centre and thus increase access to care to patients in the periphery.
2. To quantify the financial burden of this initiative for purpose of policy prescription.
Comparison of study group with the control group.
Status quo situation which is that no GP have come forward for delivering mental health care in the periphery even after providing training for some of them about six months back.
Primary Outcome measure
Groups compared based on
1. No of mental health clinics in the periphery managed independently by trained GPs.
2. No of patients who received mental health care in GP run clinics as a reflection of increased access to care.
Secondary Outcome measures
1. Percentage of response to request for participation in this research work as a measure of interest in financial incentive based care.
2. Number of GPs who completes one year of running mental health clinics.
3. Assess GP comfort level in running mental health clinic and willingness to continue it if it becomes a policy decision.
4. Patient satisfaction levels with GP run mental health clinics.
Ethical clearance by the appropriate review committee as research participants are
(1) The Field Psychiatrist who is employed on contract under NRHM,
(2) Trained GPs working under the Health Department and
(3) The Nodal office which handles the finances is attached to the medical education department.
|Postage and paper work||Rs 6000|
|Incentive money for research participants||Rs 30000|
|Writing and publication costs||Rs 4000|
|Total expenses||Rs 45,000.00|
If a performance based financial incentive is found to work, the financial implication to the exchequer may be duly ascertained for a possible scale up of primary care integration of mental health care in the NMHP via a sustainable performance based financial incentive model.
1. Scott A, Sivey P, Ait Ouakrim D, et al. The effect of financial incentives on the quality of health care provided by primary care physicians. Cochrane database Syst. Rev. 2011;(9):CD008451. Available at: http://www.ncbi.nlm.nih.gov/pubmed/21901722. Accessed January 27, 2014.
Post by Dr Anoop, Medical officer in charge of CHMP Palakkad district.
The progressive rise in number of patients attending CMHP clinics leads to a concern as to where are we heading towards and what is the limit??? (for in Palakkad within one year of functioning a few clinics have as high as 100+ patients every month with 5-6 new cases/month adding on…..So a natural question is, it being a government program can we restrict the patients attending the clinic??? and if not will it be possible to give quality care to such large number of patients within a limited time span???
Even if we advise once in 2 or 3 months visit for few patients, we have a limitation to administer them medicine for total 2 or 3 months in one go (because of drug shortage) and hence the patients invariably turn up every month at the clinic……
It is high time to train and shift the clinical load to trained medical officers…………………….else NMHP outreach clinics may well turn out to be nothing more than a glorified pharmacy service!!