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”




  1. Anju Miriam John says:

    Sir.. Hope the interaction between palliative care and mental health programme does become a reality really soon..

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