Community Psychiatry in India

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DMHP: from the state-level workshop for nodal officers


Thanks to the invite from the state nodal-officer for mental health, Directorate of Health Services, Kerala; Dr Kiran PS, I got the opportunity to participate in the Workshop on District Mental Health Program.

Among the various program related topics, the group-discussion on inter-sectoral/ inter-program-ic coordination was the main activity which I involved with. Over the span of the two day workshop, I got the opportunity to participate in the discussions which the Secretary of Health, GoK and the Director of health services had with the nodal-officers of the programs from all the districts to sort out the implementation issues of the program.

(The specific context in which the workshop was convened was with the objective to facilitate familiarization of the program to the many nodal officers who were newly taking charge. This came about as nodal charges which were till now rested with the medical-college psychiatry departments in many of the districts are being shifted to the health services department because of increasing availability of psychiatrists in the services-arm and also for easier implementation and integration efficiency. I could understand from the concluding session that hosting of the program was taken up by the SHSRC (State Health Systems Resource Centre) as strengthening community based mental health programs was keeping with its mission of attaining the sustainable development health goals set for the state – mental health is part and parcel of the comprehensive primary health approach being strengthened through Family-Health-Centers in the state.)

Brief detailing about the inter-sectoral  discussion:

The inter-sectoral familiarization was facilitated by brief summary of program activities by invited  key members of other vertical programs.

  • The Dial a doctor (DISHA -tele contact) by Ms Gopika,
  • Mahila Samakhya programme– KMSS by Ms Boby
  • NCD(non commicable diseases) – palliative care (absentia)
  • Adolesent health(ARSH) (presented in absentia in another sesssion)
  • RBSK -DEIC (DR Arun in another session)

Incidentally I had looked at this area in a blog  in 2014: Emerging intersectoral health/social programs in Kerala in which I listed a few programs with inter-sectoral scope. The Dial a doctor (DISHA -tele contact), NCD and RBSK (DIET) were listed there, horizontal integration into palliative program was dealt in another blog, while ARSH was listed in my article in Kerala journal of psychiatry on school mental health. So it was familiar area for me except for the new knowledge acquired from the workshop about the KMSS program.

Program with which intersection was discussed Benefit for DMHP Benefit for the program
KMSS – works with women in socioeconomically disadvantaged areas. Was a CSS now under general education department, also has overlap with SJD. Works with nirbhaya centers (nirbhava centres have services of clinical psychologist) The program has workers who have field presence which dmhp does have  drop out cases can be traced by using field workers of program. Case management and such psychosocial care at doorstep could be done through them. In areas they work there are no provisions for mental health care  these could be arranged by DMHP by camp approach.
DISHA1056 program under NHM. Provide telephonic services Could utilize the tele counselors under disha (20-25 MSW trained counselors ) for crisis intervention in distress calls. Many of the calls now are information seeking, Disha will benefit if dmhp can provide database of services /personnel at district level.
RBSK –DEIC CSS with multidisciplinary facility based team and filed level school-health-nurses 50-100 per district. DEIC has services of  clinical psychologist, educator , pediatrician The school-health-nurses have field presence with district spread. Can be utilized for school-mental-health-program. ?LD cetification could be more streamlined by liason with DEIC DEIC could benefit by including psychiatrist services in view of the neurodevelopment and behavioral issues in children that they handle.
Adolescent health program- district facility level councilor (MSW trained ) under RKSK  it is a CSS ? ?
NCD Not discussed Not discussed
Palliative program Not discussed Not discussed

Now moving on the general discussion that happened and some observations:

The health secretary observed that to  keep with the vision of the program the psychiatrist conducting the clinics in DMHP should be the nodal officer of the program too. Wherever this was not the case, it should be rectified.

A second team to be considered in Mallapuram district in view of the case loads. I brought in the idea of evolution to TMHP (further decentalization to thaluk level) citing its early indications in kottayam district. Cost  of it was  discussed. Nevertheless awareness about other programs (eg  the RBSK) with staff pattern 10-25 times more than DMHP (staff of 5/district only ) and more than one mobile unit, should embolden DMHP to expand its staff base to evolve to TMHP.  Current working pattern of thaluk hospitals may not be facilitatory for a specialist from there being freed for community outreach was raised. Thus the idea of TMHP resonated as  premature as many of the districts were yet to have functional IP facilities at district level even. TMHP will have to wait a few more years before it will come to policy attention.  Related ideas were discussed in one of my earlier blog too in 2014: Some health-policy trends worth emulating for DMHP-Kerala.



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