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An excerpted tweet-summary from Health Systems Asia Conference 2013 on theme of vertical health program integration in India. Click here
The following are some random interactions (during open discussion) between delegates at the state level workshop on DMHP (Nov 6, 2013, Ernakulum) on the issue of primary care integration of mental health care.
1. While talking about the many projects (Santhwanam, Snehasparsham and Prateksha (pain and palliative program- it was called the “Malapuram model” when mental health component gets integrated into it)) which he is stewarding, Dr Krishnakumar (Director, IMHANS, Kozhikode) shared his views on the grander project of “mental health integration into primary care” as follows…
…now what are the problems in achieving primary care integration?… as a former health secretary has said (candidly) “what you are doing (in the name of integration) may be harmful, because previously in Malapuram, the PHC doctor was at least seeing a few mentally ill patients, now that you are going there, they are no longer seeing any! So you are actually not integrating care (mental health) in primary care but taking care away from the mentally ill”, and that is a fact,…Kiran was successful (integrated mental health care)..we don’t know how he has achieved it ..we have tried our best in Waynad, Malapuram and Kasargode to give training for PHC doctors (for mental health integration) but we failed.
2. Earlier in his presentation, Dr Raju, Secretary, Mental health Authority, while talking about the future directions for DMHP said
…about full integration of mental health care into primary care…Dr Kiran (Nodal officer) has said that Trivandrum has achieved this goal!
3. After his presentation on the Trivandrum DMHP, Dr Kiran answered the following questions that were put to him.
(A selected few as transcribed below from audio recording)
Did you provide any incentives for the doctors (at PHC)? (by Dr Gururaj, Public health expert and resource person, NIMHANS, Bangalore)
No incentives were given for doctors, ..but for a project undertaken under Cherupur Grama panchayat, ASHA workers were remunerated for home visits during a household survey (Rs 100 per day during project period).
So Dr Kiran you say you have trained all medical officers in PHC and CHC in Trivandrum district? (By Dr Ramkumar, Field Psychiatrist, Kottayam)
Almost all, except some 10-15 doctors who did not come after repeated calls.
Okay, it is a tremendous achievement, I want to know, among all the trained medical officers, did all of them take up mental health care? (Dr Ramkumar)
…(having) interest is a big factor in it, some of them however viewed this new responsibility (even the various other general health care routine responsibilities) as additional work burden. There fore we got an order passed by the district medical officer (DMO) that they have to run a separate clinic for mental health on every Thursday from 11AM to 1 PM and a monthly report has to be sent to the DMO, and a copy of the same has to be sent to the DHS.
So do you think if a similar order is issued by DMOs in other districts the same could happen there? (Dr Ramkumar)
It is possible. There has to be some pressure at the initial level before it takes off on its own. The NMHP guidelines say mental health care has to be part of the routine OP work of the PHC doctor, however the MOs said that screening for mental illness is not possible during their routine OP hours because of time and logistic constrains. Another reason was that due to stigma patients did not prefer treatment during general OP hours. In fact the MOs themselves had suggested the separate OP for the mentally ill as it will also be easier to maintain a register if OP is separate like that in the NCD clinics.
Dr Prabhachandran (Health Dept.) added that the training was also sometimes on a one-to-one basis in a liaison-attachment pattern and many of the trained medical officers who developed interest in the subject has also opted for post graduate training later.
(Dr Ramkumar) It might be a good idea to compare the attributes of the trained MOs who later take up mental health care as part of their work and those who do not. This might inform other DMHPs to decide on whom to train based on such profile instead of training everybody.
Dr Kiran concluded by saying that the most important determinant which could predict if the learned psychiatric skills gets applied in the OPD by a trained MO was his/her personal interest in delivering psychiatric care. For the others who do not get motivated, a small nudge from the DMO in the form of an official order to run separate OPD for the mentally ill was found to work in Thiruvananthapuram DMHP.
This post contains audio and written excerpts from the workshop on Community Care: Prospects and Challenges during the IPS-South Zone conference, Oct 2013 at Kumarakom, Kottayam, Kerala. The expert panelists were (1)Dr Ramasubramanian, (2) Dr Praveen Lal and (3) Dr D Raju. The Session was chaired by Dr N S Jinen.
1. Audio excerpt from talk by Dr Ramasubramanian (M.S Chellamuthu Trust & Research Foundation, Madurai, Tamilnadu) on the Madhurai-DMHP experience of community based rehabilitation.
2. Excerpts from talk by Dr Praveen Lal (Dean, Kerala University of HealthSciences)
Grass root health workers are a demoralised group as their work is not recognised as the health system bypasses them, said Dr Praveen Lal in his talk, which mainly touched on the conceptual framework, policy aspects and deficiencies in mental health training and services programs and the efforts for improvement.
More people take care from private sector than from the government sector. Therefore it remains to be seen as to how to include private sector in community based services.
Continuity of care between hospital and community is a lacunae. He asked whether we could have hospitals without outpatient care so that outpatient care could be entirely outsourced to Community mental health teams.
Outreach services by specialists as it exists now, disincentive the GP from initiating mental health services directly as case detection is immediately clubbed with referral. Lack of political will, is one reason for NMHP/DMHP being a non starter as appraised by official authorities. Professional elitism is another reason. Bringing in democratization and demystifying professional demeanour without jeopardizing the professional standing should be the sure way of moving ahead.
3. Audio excerpt from talk by Dr D Raju (State Nodal Officer and Secretary, Mental Health Authority, Kerala State) on Kerala- DMHP scenario.
4. And finally excerpts from the interactive session.
- A suggestion for thinking about innovations in community pharmacy, roping in qualified pharmacists on pro rata basis to ensure better dispensing of psychotropic medications was put forward.
Blog comment: Current practice of nursing staff disbursing psychotropics in DMHP outreach clinics have come under criticism. Role of pharmacists need to be roped in as suggested, not only for efficient dispensing of medications but also for optimal role utilization of mental health skills of nursing staff.
- A fundamental question about whether it was time to move away from the primary care integration of mental health services model was raised. Reasons being that -times have changed, psychiatrists are more in number (Kerala produces about 40-50 psychiatrists in a year) and patients can travel easily as better and quicker facilities for travel have come into being at least in the southern parts of the country. It could be argued that having three psychiatric centers in each district will solve the problem of accessibility as people in a district will not need to travel more than 50 kms for mental health care. With good turn over of psychiatrists, within five years time all vacancies for psychiatrists could be filled including those in the DMHP which have been difficult to fill as young professionals are attracted by better pay packages in the private sector and overseas. The counter point raised was whether the psychiatrists were indeed applying themselves to the true role of a consultant and seeing patients referred to them rather than being the doctor of first contact for people with mental health needs. The intention of primary care integration is to ensure that basic mental health services are available to all and not to negate specialist care. The psychiatric specialists need not feel professionally threatened nor should they consider the trained primary care doctor as a competitor in delivering mental health services.
- It was also mentioned that no psychiatrist who has passed his DPM or MD will find the job designation of the DMHP psychiatrist (traveling 20 days a week to different part of district) as a good career choice.
Blog comment: Regarding the issue of job profile of the DMHP psychiatrist, the issue of traveling 20 days a week is probably only secondary in the mind of the young professional who is contemplating about it as a career choice; what is primary is the pay and service package and how it compares with the alternatives. Whether incentives are inbuilt in, to cover the drudgery of travel would be the consideration as one could observe that specialists in the private sector are not particularly bothered about the travel they have to make to multiple centers to earn their pay. The fact being that services are actually turning mobile internationally, makes it imperative that the inertia of the current incentive structures which implicitly favors the static, are actively reversed.
- Tamilnadu model of assessment and certification and bringing mentally ill to receive benefits of the PWD Act was lauded. The fact that it is not happening in Kerala was noted and it was commented that the reason was because of absence of awareness among mental health processionals themselves and the existing cumbersome processes involved in securing these benefits. In Kerala, the disability certification camps conducted by social welfare department did not make much headway compared to those conducted for other disabilities because of lack of coordinated activities between health and social welfare dept.
Blog comment: Poor rates of disability certification is only partly because of lack of awareness. The already aware doctors shy away from certification because other counterproductive awareness! These is fear of the legal overlay and bureaucratic overlay. Undue fear of excessive demands from patient family side for frivolous certification, fear of certification misuse by relatives for property dispute issues and the doctor being drawn to court are present. Recent issue of Learning disability certifications being rejected because of frivolous inclusion has brought a bad name to certifications of all kinds, rendering doctors not enthused about certification in general. The issues of simplifying the procedure has been contemplated two years ago by the social welfare dept however it has not been given sanction yet. The bureaucratic tyranny of the medical boards continue to rule. Lack of awareness about allowance for carers of mentally ill and the mentally retarded is palpable among mental health professionals.
- Rehabilitation should be at PHC level and community based and it was warned that if district headquarter rehab centres are built (as is being planned in Kerala) it can degenerate to institutionalization.
Blog comment: Collaborating with community based rehab programs like those already being organised by the palliative programs which are running well in Kerala is definitely one way of going ahead. Day care centers are a need of the hour in Kerala as most homeless people in long stay home (almost all in the private sector) are people with family members who are unable to take care of them. Having a day-care home could be one way of sharing care of these people between the state and the family members.
- It was said that the pattern of the specialist-run outreach DMHP clinics has to change if fidelity to Bellary model is to be achieved. Specialist in outreach clinic has to do IEC and training rather than see patients which is what is happening now. It was added that psychiatrists as a group did not work for DMHP, it was always some individuals who had contributed. The DMHP in a nutshell had just worked as prescribes of psychotropic medications in a decentralized manner. This has to change.
Blog comment: (warning-long read :)) Inability for fidelity with the Bellary model need not be considered as a limitation because…….. The story (as told by the late Prof. R L Kapur in Chapter 8, Mental Health Indian Perspective 1946-2003, Edited by S. P Agarwal, DGHS) is that the ICMR-DST study of severe mental morbidity (1987 Report) which was done before the NMHP and DMHP days had evaluated prospectively, the ability of doctors and health workers to recognise and manage psychotics and epileptics at the PHC level in four different centres ( Bangalore, Vadodara, Patiala and Kolkata). The findings were not very encouraging at that time itself. The report reads so..
It was discovered that while the knowledge gained after training for both doctors and MPWs was extremely good, their actual performance over the year was not. Only 20% of the actual cases were picked up by a few MPWs who were motivated; there were many who did not refer even a single case to the PHC doctors. Hardly any patient detected was followed up by the MPWs in the community. Most of those who went to the PHC doctor for follow-up treatment, came on their own. Many patients preferred to consult the specialist staff in the research teams. When asked why the job was poorly done, many excuses were given. Some complained about family planning targets they had to meet, which prevented them from doing this work. Others feared that if they did a good job, this would also become a national programme with targets to be met. Some also wanted to be paid for their extra efforts. There were also some MPWs who said that they knew of more cases, but could not persuade the patient’s relatives to take them to the PHCs. In general, the influence of the PHC personnel in the community was very poor. Neither the doctor nor the health workers were able to organise any programme to impart mental health education, which was one of the objectives of the research project. Record keeping was extremely poor in all the four centres. In short, there was a lack of motivation and leadership. It is intriguing why this particular study has never been referred to by the enthusiasts of the PHC-based mental health programmes.
Without taking into account the findings of this study, first, the NMHP and then the DMHP was launched. Dr R L Kapur goes on to say that the NMHP at its inception was more a wish list than a serious exercise and about the Bellary DMHP-model he says
NIMHANS launched a pilot model programme in the Bellary district to implement the NMHP, at a district level. In some ways,this was a more rational exercise compared to the ambitious aims of the NMHP, as the scope was limited to just one district. Here also, the personnel of the PHCs in the district were trained to recognise and manage mental patients in the community. A specially trained programme officer was appointed to conduct a regular mental health clinic and also to monitor the progress in PHCs all over the district. Good results were described, but on close-examination, the picture did not appear to be as rosy as claimed. In a paper read at the 23rd Annual Conference of IPS-South Zone on 14 October 1990, the programme officer in charge of the Bellary model, talked of the difficulties in correct diagnosis, the choice of appropriate medication, as well as dosage and difficulty in handling side effects of medicines. He also talked of administrative problems like the transfer of personnel who became acquainted with the programme, poor motivation on the part of personnel and the erratic supply of drugs. Being an optimistic person, he gave suggestions regarding measures which could be taken to make the model programme more effective, but was transferred himself, before he could carry out these measures, An informal enquiry by the author to people working in the Bellary district revealed that the model actually fizzled away in the very district where it was first tried out. Unfortunately, the documents from NIMHANS or the Karnataka Health Ministry continue to paint a glowing picture of the Bellary model. Perhaps, if the programme had been evaluated by a research team, whose members were not involved in administering the programme, one would have learnt many things which would have been useful for future programmes
Incidentally the problems with the Bellary model was read out as a paper in the 23rd annual conference of the IPS- South Zone in Oct 1990 (marked as red in the excerpt above) and it is heartening that we are discussing the same issues in a workshop in the 46th version of the annual IPS-south Zone conference today in Oct 2013, 23 years later!
Acknowledgement : I thank Prof V Sathesh, Dr Bobby Thomas and Dr CR Radhakrishnan for the warm hospitality offered at Kumarakom.
1.Introductory remarks by Prof. Mathew Varghese, HOD Psychiatry (NIMHANS) for the program on public mental health.
2. Talks by Dr C R Chandrasekhar (CRC) and Dr K V Kishorekumar (KVKK) as slidecasts (slides+synchronized audio).
Reflections by CRC [Please click the play button and wait for audio to begin] (slidecasts were discontinued by slideshare from april 2014, so no audio available)
Talk by KVKK [Please click the play button and wait for audio to begin]
Courtesy: Digitography dept. NIMHANS for the digital data.
[added on 15.09.2013- see draft of bill here http://mohfw.nic.in/index1.php?lang=1&level=1&sublinkid=1385&lid=1319]
Highlights from this news article:
..services should be affordable, of good quality and available without discrimination
Under the provisions of the Bill, government has an obligation to provide half way homes, community caring centres and other shelters for mentally ill people. This has been planned under the District Mental Health Programme in the 12th Plan.
In 2005, the National Commission on Macroeconomics and Health reported that 10-12 million or one to two per cent of the population suffered from severe mental disorders such as schizophrenia and bipolar disorder, and nearly 50 million or five per cent from common mental disorders such as depression and anxiety, yielding an overall estimate of 6.5 per cent of the population. The prevalence of mental disorders was higher among women, those who were homeless, poor and living in urban areas, Union Health and Family Welfare Minister Ghulam Nabi Azad told The Hindu.
He said the Bill tries to address the needs of the families and caregivers, and the needs of the homeless mentally ill. It provides for setting up Central and State Mental Health Authorities, which would act as administrative bodies, while the Mental Health Review Commission would be a quasi-judicial body to oversee the functioning of mental health facilities and protect the rights of persons with mental illness in mental health facilities.
The new Bill, once approved by Parliament, will repeal the Mental Health Act, 1987.
added on 05.07.2013
Released at the United Nations: “A NEW GLOBAL PARTNERSHIP: ERADICATE POVERTY AND TRANSFORM ECONOMIES THROUGH SUSTAINABLE DEVELOPMENT”. Report by the High-Level Panel on the Post-2015 Development Agenda. Link to the report: http://www.post2015hlp.org/featured/high-level-panel-releases-recommendations-for-worlds-next-development-agenda/
comment on it: ” Surprisingly, mental health does not feature in the report even though WHO says that more than 450 million people encounter this issue.”http://www.thehindu.com/opinion/op-ed/on-disability-missing-the-bigger-picture/article4885638.ece
The Lions club has been closely associated with the monthly extension clinic run by NIMHANS at Kanakapura ever since its inception about three decades ago.
In a meeting organised by Lions club on the evening of 19.04.2013, the long association that Dr Kishore Kumar had with the extension clinic was appreciated.
See below an excerpt from Dr Kishore’s address to the audience at the Lions club meeting.(audio in Kannada language)
Has the Thiruvananthapuram (TVM) District Mental Health Program (DMHP) cracked that vexing and long persisting problem with specialist outreach? -a workable, dynamic and sustaining link with the primary care doctor to provide integrated psychiatric services at the periphery.
Let us see what Dr Kiran, Consultant Psychiatrist and Nodal officer of DMHP at TVM District of Kerala State has to say..
As per Dr. Kiran organising a specialty psychiatry clinic once in a week at the peripheral center has worked well for TVM for the past one year. The visiting psychiatry specialist runs this clinic once in a month and the primary care doctor runs it for the rest of the three weeks.
The advantage of this arrangement is that patients can move back and forth between the specialist and the primary care doctor based on their clinical needs. New cases and patients needing intensive clinical attention are sent to the specialist whereas patients on routine follow up and maintenance treatment are nudged to attend the clinic with the primary care doctor. Another advantage is that the psychiatric clinical load remains separate from the routine clinical load in the peripheral center and it gets evenly distributed between the specialist and primary care doctor. The timing of the clinic is fixed at 12.00 pm to 1:00 pm after the regular OP timings. As of now, it is working well for the primary care doctor, the patients and the visiting specialist doctor.
DMHP Clinic Structure
A possible integration of the specialty psychiatric clinic with the NCD (Non communicable Diseases) clinics which are currently functioning in the peripheral centers is also being considered.
Other aspects of DMHP at Thiruvananthapuram
1. School Program and Community Based Rehabilitation.
4. Plans for the coming years.
5. And finally the street play used by TVM DMHP for public education activity.
Disclosure: Thiruvananthapuram is the author’s (Ramkumar) home town.
Professor Mitchell G Weiss talked about “Researching Explanatory Models in Mental Illness: Integrating Mixed Research Methods” at Department of Mental Health Education @NIMHANS on 7.2.2013.
The talk focused on integrating qualitative and quantitative methods in investigating explanatory models in illness in the framework of cultural epidemiology.Principles of the EMIC (The Explanatory Model Interview Catalogue) interviewing was explained along with using tablet-computer aided data entry, integrated quantitative and quantitative data management and data analysis. The features of MAXQDA software was demonstrated.
1. An overview of conceptual framework of cultural epidemiology (mixed) as a combination of Anthropology/ethnography (qualitative) and epidemiology (quantitative) was provided in a research methodology orientation with emphasis on tools and software.See audio excerpt below.
2. In the earlier part of the talk, the integrated qualitative and quantitative methods used in explanatory models in Illness was focused with detailing of the EMIC interview method and questionnaire.See excerpt below.
added on 08.07.2013
3. EMIC 1992
4. SEMI 1998
The first Indo-European Symposium on Coercion hosted by Mysore Medical College brought to limelight the often ignored aspects of various forms of coercion in psychiatric practice. The Session on Community Treatment Order (CTO) featured talks by two eminent speakers- the audio excerpts of which can be accessed below.
1. Talk by Prof. Mohan Issac (The University of Western Australia, Formerly Professor & HOD Dept of Psychiatry, NIMHANS) covers What is CTO, How It came to being, What are the benefits, shortcomings and controversies associated with CTO and Whether CTO are relevant and useful in India.
2. Talk by Prof. Peter Lepping (Medical Director BCULHB, North Wales Visiting Professor Glyndw^r University Wrexham. UK) covers general guidelines for clinicians on CTO.
During the interactive part of the session it was discussed that the law in general infact permits use of moderated and supervised coercion like that in the order for inpatient commitment for patients who are in danger to themselves and to others (Reception order MHA India 1987) -similarly the CTO is one innovative use of the same for outpatient treatment for certain subset of patients who might benefit from it. One discussant drew a parallel between the DOTS therapy for tuberculosis and CTO. CTO can be a clinically useful tool if skillfully and judiciously used by the clinician.And finally here is also an independent select textual overview and criticism of CTO curated from the web.
More recent data on CTOs.
From the theme session @ANCIPS2013 –Psycosocial Adversity and Mental health. The speakers were
1.P Sainath who is a journalist and rural affairs editor at The Hindu and visiting professor at University of California.One of the few Indians to win the the Ramon Magsaysay award in the category of journalism and literature. Sainath speaks mainly on agrarian distress, financial inequity and misguided fiscal policies (man-made “policy driven disaster”) as root cause of farmer suicide (“collapse of the farmer’s universe”).
2. R Srinivasamurthy who is retired Professor of Psychiatry (NIMHANS) talks about mental health impact of disasters by tracing through the Bhopal tragedy, Maratwada earthquake, Orissa tragedy, Gujarat earthquake, riots and Tsunami. RSM draws on literature which correlates economic inequity and mental distress/illness and says a public health approach via community and family based psychosocial interventions (facilitating community support) for distress responses/behaviors/illness is effective and can mitigate suffering from disaster.”..the implication is that we really have to think of mental health of the population rather than the patients who come to us -in terms of prevention, in terms of preparedness”. Interventions at national level to reduce economic inequality and interventions at international level to maintain peace.