Community Psychiatry in India

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Horizontal interaction with palliative care program: TOT session @Kottayam.

 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).IMG_0007The 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 🙂

added 0n 03/03/2016

lancet-psychiatry article on “palliative psychiatry”



Kerala bends the curve on hard liquor consumption.

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


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.


Hard liquor


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



alcohol consumption reduce after bar closure alc

NCD program in Kerala, a reality check.

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.