26/12/2021

Integrating Mental Health in Primary Healthcare: Recommendations for Telangana State’s Proposed ‘District Mental Health Programme’

By Rhea Thakkal

Abstract:The National Mental Health Program in India provides recommendations for state governments to tackle mental health along with primary healthcare. This is especially relevant in the context of increasing reports of mental disorders amongIndians during the COVID-19 era. This research paper will analyse strategies from other Indian states (with special focus on Andhra Pradesh and Kerala) around successfully integrating mental health within primary healthcare. The analysis aims at informing Telangana state policy for integrating mental health in the framework of the public health system, executed through the proposed DistrictMental Health Program of Telangana State.

I. Introduction

Worldwide, there are now reports of increasing numbers of people suffering from mental health disorders as a consequence of the COVID-19 pandemic.[1]The Indian central government defines mental health as a state of well-being in which individuals realize their own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and are able to make a positive contribution to their community.[2]According to the World Health Organization, even before the onset of theCOVID-19 pandemic, 56 million Indians suffered from depression and another 38million Indians had anxiety disorders.[3]Mental health is therefore an urgent crisis in India, and measures are required from the part of the Indian government for acknowledging and resolving the crisis on a systemic level.

As a response to the urgent crisis of mental health among Indians, the National Mental Health Programme (NMHP) was formulated by the Indian central government to provide recommendations for state governments on prioritizing mental healthcare within the framework of public health systems. The COVID-19 pandemic has now increased the necessity of incorporating mental healthcare facilities as an essential and routine component of primary health care.

The NMHP’s guidelines and recommendations have been interpreted and executed in different ways by different states across India. South Indian states including Tamil Nadu, Karnataka among others have already progressed in incorporating the NMHP’s guidelines around mental healthcare within their public health systems, primarily through District Mental Health Programmes (DMHPs). Now, the government of Telangana state in South India is also proposing designing a DMHPas an extension of the National Mental Health Programme.

This research paper is an analysis of the integration of mental health services within the public health systems of SouthIndian states, with specific focus on Andhra Pradesh and Kerala. The analysis aims at informing Telangana state’s public policy on resolving existing barriers for integrating mental healthcare within its public health system, primarily in the form of recommendations for its proposed DMHP. The findings of this research will also inform policies across South Indian states for cost-effective, scalable solutions that facilitate the treatment of common mental disorders (such as depression and anxiety) through existing primary healthcare systems of state governments.

II. The National Mental Health Programme (NMHP)

In 1982, India was one of the majorWorld Health Organization (WHO) members to launch its National Mental HealthProgram (NMHP) in accordance with the WHO’s recommendations to deliver mental health services under the framework of general health care.[4] The NMHP was thus the result of the Indian government’s objective of developing non-institutional models of mental healthcare through general health and welfare activities that already exist within India’s governance framework.

Both the central and state governments are enabled in drafting policies and initiatives around public health in India.According to the World Health Organization’s assessment of the status of public healthcare in India, roughly 4000 rural dispensaries, 900 health posts, 140,000 sub-centres and 24,000 primary care centres exist to provide primary and preventive care across different governance levels. Approximately 4000 community health centres also provide health care for around 150,000 people. There are approximately 3000 rural hospitals that provide public healthcare, while municipal hospitals are found in urban areas. Particularly in urban India, public healthcare services are supplemented by private and non-governmental infrastructure.[5]

In April 2011, the Ministry of Health and Family Welfare, Government of India formulated the first National Mental Health Policy as a part of the National Mental Health Program. The goals included promoting mental health, preventing mental illnesses, enabling recovery from mental illnesses, ensuring the socio-economic inclusion of people affected by mental illness,[6] among others. In response to this new Mental Health Policy, in Telangana State the NMHP was initiated in 9 districts with limited Primary Health Centres. The measures implemented in Telangana so far include screening for those who need mental healthcare (the individuals who were thus found at risk are referred toPrimary Health Centres or PHCs), recruitment of a psychiatrist who is required to visit all PHCs at least once a month for treatment on a minor scale, drug procurement and supply of the IMH’s list of commonly prescribed antipsychotic and antidepressant drugs, and capacity building (all medical officers are trained by the IMH and from the National Institute of Mental Health and Neurosciences).[7]

Ever since the NMHP was established in 1982, there have been promising developments across states in South India. There has been increased emphasis on training of personnel at Primary Health Centres (PHC) to enhance the quality of support given to patients with regard to mental healthcare. Most importantly, District Mental Health Programs (DMHP) have been implemented across states, bringing a larger scale of mental health support to citizens.[8]From the very beginning of designing and implementing the NMHP, the central government recommends focusing integrating mental health care into general health services that exist within each state’s healthcare systems. This objective hasn’t been achieved on a consistent basis in most states in India. Telangana state is also lagging behind with regard to implementing this guideline of the NMHP.

In 2014, the central government assessed the situation once again to arrive at the conclusion that “owing to the enormity of the problem, it is prudent to have a strategic, integrated and holistic policy that will guide future course of action including a pan-Indian scaling up of the existing Mental Health Program.”

In response to this assessment, and in direct response to the dire need for mental healthcare in the time of the COVID-19 pandemic, the government of Telangana state has proposed implementing a District Mental Health Program (DMHP). This paper examines the ways in which District Mental Health Programs have been implemented successfully in other South Indian states wherein mental healthcare has been integrated in public health systems. In particular, the South Indian states of Kerala and Andhra Pradesh provide useful insights into how this can potentially be achieved within Telangana state also.

III. Integrating Mental Health in Public HealthcareFrameworks: Successful Strategies of Andhra Pradesh and Kerala

Telangana need only examine its neighbouring states to design a DMHP that will successfully integrate mental healthcare within the larger primary healthcare framework of the state. Such a design would ensure inclusivity and accessibility of mental healthcare to even socio-economically disadvantaged citizens, a major goal of the NMHP as a whole since its inception.

The South Indian state of Andhra Pradesh is one such excellent instance, where barriers and facilitators for tackling mental illnesses within the primary healthcare system has been successful with the help of unique interventions. For example, the Systematic Medical Appraisal, Referral and Treatment (SMART) Mental Health Project that was implemented across 12 villages in the West Godavari district of Andhra Pradesh was designed specifically to address challenges within this state. This intervention “focused on a mental health services delivery model to screen, diagnose and manage common mental disorders (CMDs)”, which included adequate training and supervision of field staff, ASHA workers and doctors, use of electronic decision support, door-to-door campaigns, culturally tailored dramas and videos to raise awareness about CMDs within the community and organizing health camps in villages to facilitate intervention.[9]The SMART project also included the successful “development of a multifaceted intervention using training, task shifting and mobile-based decision support to increase the screening and referral of individuals with CMD”.[10]

Under the National Mental Health Programme, Andhra Pradesh also established the Government Hospital for Mental Care (GHMC) in 2018 as a Centre of Excellence, with the state allocating a total budget of 38 crore Indian rupees towards this project. The main objective is to “address the manpower deficit in the psychiatry department throughout the country and upgrade the hospitals with more departments and academic blocks such as psychiatric nursing, psychiatric social work and clinic psychology, paediatric and geriatric wards, equipment and rehabilitation centres”.[11]It has been reported that since the GHMC is the only government mental care centre in the entire region, “the 300-bed hospital gets 60,000 – 65,000 patients annually, not just from Andhra Pradesh but also from neighbouring states”.[12]

The government of Kerala state opted for equally unique interventions within their District Mental Health Programme. The beginning of integration of mental health with general healthcare in Kerala state “began in earnest with the introduction of the District Mental HealthProgramme in two Kerala districts in 1999 and 2000”.[13]Yet, Kerala state’s interventions were grounded in community engagement and development, as compared to Andhra Pradesh’s DHMP interventions. It has been argued that Kerala had circumstances conducive to successful integration of mental healthcare within its public health system, including the relatively high number of mental health professionals per population in the state, the higher number of medical colleges with psychiatry departments, strong private mental health provisions, high distribution and access to mental healthcare for the general population within the state and high literacy rates, among other factors.[14]

In 2018, it was reported through the Kerala State Mental Health Survey (SMHS) that approximately 14.4% of citizens older than 18 has suffered a psychiatric disorder at least once in their lifetime, and that 11.3% of the state’s total population is affected by mental illnesses. Alarmed at these revelations, the Kerala state government intervened through their “comprehensive mental health programme”, which focused on roping in “ASHA workers for identifying those suffering from mental illness in their locality and provide treatment via family health centres (FHCs)”.[15]The Kerala government has reported the integration of tertiary care institutions for tackling mental disorders as part of the successful implementation of its DMHP, chiefly through ASHA workers. Along with the regular clinics in PHCs, mental health awareness classes were given to ASHA workers which alleviated misconceptions and stigmas around mental disorders and imparted knowledge on primary care integration and the role of ASHA workers within it.[16]

Kerala state has pioneered mental health interventions within schools for many years now, with UNARV being implemented in 2007 (where high school students with behavioural and academic problems received counselling from teachers trained in adolescent developmental psychology and mental health disorders).[17]These students were thus identified and treated with care in time, rather than being suspended or expelled from their school. The government’s school interventions were revitalized under the DMHP through a project titled ‘Thaliru’, which included preventative programs, awareness classes, counselling and psychiatric services for students. The interventions at the school level are also achieved through the integration of mental health within the primary healthcare systems of these schools.

Another, more recent notable intervention of the Kerala government since the emergence of COVID-19 is the formation of the Psychological Support Team at the state level, which devised strategies to manage stress and other mental health concerns resulting from the new lifestyle created by onset of the pandemic.[18]Kerala’s DHMP team revised their plan of action to provide targeted counselling and psychological support for citizens undergoing isolation or quarantine due to the virus, coordinating with panchayat officials for efficient, community-level interventions through public healthcare systems.[19]

IV. DMHP: Recommendations for Telangana State

As a government initiative, the District Mental Health Programme was envisioned to ensure access to mental healthcare services for the general public by integrating it with existing public health facilities. It is an important step towards making the guidelines and recommendations of the National Mental Health Programme concrete realities in the states where it is implemented.

Considering the effects of the COVID-19 pandemic on the mental health of Indian citizens, it is high time that Telangana state also brought the provisions of the NMHP to its citizens through a strategic, effective and informed DMHP. The core building blocks of Telangana state’s DMHP, including its governance structure, overall goals, service delivery strategies and context-specific innovations must be informed by, among other factors, examining how other South Indian states have successfully implemented their DMHPs over the last few years.

After conducting such an analysis through this research paper, it is recommended that Telangana state policy closely consider the following guidelines while finalizing its proposed DMHP for execution:

·      Since mental health is a crisis shared across all sections and classes of society, it is recommended that an integrated system comprising of the public and private sectors, with mixed financial models (that include tax-based funding, social/community insurance and private insurance) be designed by the state. Social insurance models, where the state offers subsidies for citizens from lower income households, should be used for funding additional mental healthcare offered within the larger public health system.[20]

·      Drawing inspiration from the current model in Kerala state, basic mental healthcare needs to be provided by existing local healthcare services that promote community participation and social integration. This would in turn help to reduce the stigma associated around patients suffering from mental disorders or illnesses.

·      In order to truly integrate mental healthcare within the general framework of public health, Telangana state requires effective coordination between different government agencies, pertaining to not only public healthcare but also social services, law and order and local governance bodies such as village panchayats. Patients who receive treatment for their mental ailments from secondary or tertiary service providers should be required to consult the local public health provider as well.

·      Confidential datasets that compile citizens’ data around their mental health via the public health system should be created within Telangana state, and such data collection should be made mandatory for patients benefiting from the public health system. The data collected through the public health system should comprise the framework of the state’s policies and intervention programs.

·      As with the example of the GHMC Centre of Excellence in Andhra Pradesh state, concrete initiatives backed by sufficient allocation of funding from the Telangana state government around enhancing research and training capacities for improving mental healthcare should be an important provision within Telangana’s DMHP.

·      Liaising with psychology and social work departments of colleges and universities by the Telangana state government is recommended, following Kerala state government’s model.[21]

·      A mobile application called the GoK Direct app, launched by a collaboration between Kerala government’s Startup Mission and Information and Public Relations Department could also mean effective intervention for the citizens of Telangana state. The app sends SMS alerts to basic mobile phones for spreading information and decreasing uncertainty regarding crisis situations like the pandemic, thereby helping ease the fears and anxieties that ordinary citizens may experience during such unusual and uncertain times.[22] It is recommended that Telangana also develop an app of a similar nature to help its citizens tide through the extreme circumstances created by theCOVID-19 pandemic in an informed manner.

V. Conclusion

It is not easy to tackle mental health in India at the policy level. There are diverse barriers towards formulating effective and translatable policy actions around integrating mental health within primary health care, including low awareness around mental health, stigmas associated with people suffering mental ailments, socio-economic obstacles in relation to accessibility of citizens for healthcare in general and lack of social support for citizens recovering from mental disorders.[23]

Even though the performance of states like Kerala and Andhra Pradesh in South India have been stellar with regard to the integration of mental health in public healthcare frameworks, their District Mental Health Programmes have faced obstacles in the initial stages of implementation that range from funding shortages to ineffective coordination between varied government departments. It is therefore important that Telangana state design its DMHP with careful attention to detail around strategy and execution.

The World Health Organization states that mental healthcare is most efficiently delivered in the context of developing countries like India when “primary care for mental health works with, rather than against, existing mental health facilities”.[24]This is the principle upon which all directives, policies, recommendations and initiatives around mental healthcare should be formulated by Telangana state government.

VI. Bibliography

·     “Andhra Pradesh Mental Hospital to Become Centre of Excellence” in The Times of India, 4 July 2018. Accessed on October 30, 2021. https://timesofindia.indiatimes.com/city/visakhapatnam/andhra-mental-hospital-to-become-centre-of-excellence/articleshow/64856188.cms

·      “Annual Activity Report: 2011-2012”, District Mental Health Programme: Kerala Government, 2012. Accessed on October 13, 2021. http://dhs.kerala.gov.in/docs/ar040912.pdf

·       “COVID-19 has led to a sharp increase in depression and anxiety”. The Economist, 11 Oct 2021. Accessed November 4, 2021. https://www.economist.com/graphic-detail/2021/10/11/covid-19-has-led-to-a-sharp-increase-in-depression-and-anxiety

·      “COVID-19: Taking Heed from Kerala’s Mental Health Interventions” in The Wire, 27 March 2020. Accessed on October 13, 2021. https://science.thewire.in/health/covid-19-kerala-mental-health/

·      “Depression and Other Common Mental Disorders: Global Health Estimates”. Geneva: World Health Organization, 2017.Accessed November 3, 2021. https://apps.who.int/iris/bitstream/handle/10665/254610/WHO-MSD-MER-2017.2-eng.pdf

·      “Government Unveils Mental Health Programme” in The New Indian Express, 17 July 2018. Accessed on 3 October, 2021. https://www.newindianexpress.com/states/kerala/2018/jul/17/government-unveils-mental-health-programme-1844364.htm

·      “Improving India’s Mental Healthcare: A Case Study of Kerala” in the Observer Research Foundation, 23 July 2020. Accessed on October 13, 2021. https://www.orfonline.org/expert-speak/improving-indias-mental-healthcare-a-case-study-of-kerala/

·      “India: Integrated Primary Care for Mental Health in the Thiruvananthapuram District, Kerala State” in World Health Organization, pp. 111. Accessed on October 23, 2021. https://www.who.int/mental_health/policy/services/India.pdf

·      “Initiative to Address the Mental Health Problems in Telangana” in Health, Medical and Family Welfare: Government of Telangana, 2021.

·      Kumar Therayil, Manoj. “Mental Health Care: Can We Create a New Kerala Model?”. Kerala Journal of Psychiatry 28(1):100-108, 2015. https://kjponline.com/index.php/kjp/article/view/10.

·      Maulik, Pallab K et al, “Increasing Use of Mental Health Services in Remote Areas Using Mobile Technology: a Pre-post Evaluation of the SMART Mental Health Project in Rural India” in Journal of Global Health vol. 7,1(2017): 010408. Accessed on October 13, 2021. 10.7189/jogh.07.010408

·      “New Pathways, New Hope: National Mental Health Policy of India”. Ministry of Health & Family Welfare: Government of India, October 2014. Accessed November 1, 2021. https://nhm.gov.in/images/pdf/National_Health_Mental_Policy.pdf

·      Reddy, G. N., Channabasavanna,S. M., & Murthy, R. S.“Implementation of National Mental Health Programme for India”. NIMHANS Journal, 4(2), 77–84.

·      Snehil Gupta and Rajesh Sagar, “National Mental Health Programme-Optimism and Caution: A Narrative Review”. Indian Journal of Psychological Medicine 40 (6): 509–16, 2018. Accessed on October 16, 2021. https://doi.org/10.4103/ijpsym.ijpsym_191_18

·     Tewari, Abha et al, “SMART Mental Health Project:process evaluation to understand the barriers and facilitators for implementation of multifaceted intervention in rural India” in International Journal of Mental Health Systems vol. 15,1 15, 8 Feb. 2021. Accessed on October 13, 2021.10.1186/s13033-021-00438-2

Endnotes

[1] Tewari,Abha et al. “SMART Mental Health Project: process evaluation to understand the barriers and facilitators for implementation of multifaceted intervention in rural India” in International Journal of Mental Health Systems vol. 15, pp. 11-15., 8 Feb. 2021. Accessed on October 13,2021. 10.1186/s13033-021-00438-2

[2] “India:Integrated Primary Care for Mental Health in the Thiruvananthapuram District,Kerala State” in World Health Organization, pp. 111. Accessed on October 23, 2021. https://www.who.int/mental_health/policy/services/India.pdf

[3]Manoj Therayil Kumar, “Mental Health Care: Can We Create a New Kerala Model?” in Kerala Journal of Psychiatry 28(1):100-108, 2015. Accessed on 12 October, 2021. https://kjponline.com/index.php/kjp/article/view/10.

[4] “Annual Activity Report: 2011-2012”, DistrictMental Health Programme: Kerala Government, 2012. Accessed on October 13,2021. http://dhs.kerala.gov.in/docs/ar040912.pdf

[5] “COVID-19:Taking Heed from Kerala’s Mental Health Interventions” in The Wire, 27 March 2020. Accessed on October 13, 2021. https://science.thewire.in/health/covid-19-kerala-mental-health/

[6] Tewari,Abha et al, “SMART Mental Health Project: process evaluation to understand the barriers and facilitators for implementation of multifaceted intervention in rural India” in International Journal of Mental Health Systems vol. 15,1 15, 8 Feb. 2021. Accessed on October 13, 2021. 10.1186/s13033-021-00438-2

[7] Maulik, Pallab K et al, “Increasing Use of Mental Health Services in Remote Areas Using Mobile Technology: a Pre-post Evaluation of the SMART Mental Health Project in Rural India” in Journal of Global Health vol. 7,1 (2017): 010408. Accessed on October 13, 2021. 10.7189/jogh.07.010408

[8] “Andhra Pradesh Mental Hospital to Become Centre of Excellence” in The Times of India, 4 July 2018. Accessed on October 30, 2021. https://timesofindia.indiatimes.com/city/visakhapatnam/andhra-mental-hospital-to-become-centre-of-excellence/articleshow/64856188.cms

[9] See note above.

[10] “India:Integrated Primary Care for Mental Health in the Thiruvananthapuram District, Kerala State” in World Health Organization, pp. 111. Accessed on October 23, 2021. https://www.who.int/mental_health/policy/services/India.pdf

[11] Manoj Therayil Kumar, “Mental Health Care: Can We Create a New Kerala Model?” in Kerala Journal of Psychiatry 28(1):100-108, 2015. Accessed on 12 October, 2021. https://kjponline.com/index.php/kjp/article/view/10.

[12] “Government Unveils Mental Health Programme” in The New Indian Express, 17 July 2018. Accessed on 3 October, 2021. https://www.newindianexpress.com/states/kerala/2018/jul/17/government-unveils-mental-health-programme-1844364.html

[13] “Annual Activity Report: 2011-2012”, District Mental Health Programme: Kerala Government, 2012. Accessed on October 13,2021. http://dhs.kerala.gov.in/docs/ar040912.pdf

[14] “Improving India’s Mental Healthcare: A Case Study of Kerala” in the Observer Research Foundation, 23 July 2020. Accessed on October 13,2021. https://www.orfonline.org/expert-speak/improving-indias-mental-healthcare-a-case-study-of-kerala/

[15] “COVID-19:Taking Heed from Kerala’s Mental Health Interventions” in The Wire, 27 March 2020. Accessed on October 13, 2021. https://science.thewire.in/health/covid-19-kerala-mental-health/

[16] See note 18above.

[17] Snehil Gupta and Rajesh Sagar, “National Mental Health Programme-Optimism and Caution: A Narrative Review” in the Indian Journal of Psychological Medicine 40 (6): 509–16, 2018. Accessedon October 16, 2021. https://doi.org/10.4103/ijpsym.ijpsym_191_18.

[18] “India:Integrated Primary Care for Mental Health in the Thiruvananthapuram District,Kerala State” in World Health Organization, pp. 111. Accessed on October 23, 2021. https://www.who.int/mental_health/policy/services/India.pdf

[19] “New Pathways, New Hope: National Mental Health Policy of India” in Ministry of Health & Family Welfare:Government of India, 2014. Accessed on October 21, 2021. https://nhm.gov.in/images/pdf/National_Health_Mental_Policy.pdf

[20] “Initiative to Address the Mental Health Problems in Telangana” in Health, Medical and Family Welfare:Government of Telangana, 2021.

[21] Reddy, G. N et al, “Implementation of National Mental Health Programme for India” in the NIMHANS Journal 4 (2): 77–84, 1986.

[22] “COVID-19 has led to a sharp increase in depression and anxiety” in The Economist, 11 Oct 2021. Accessed November 4, 2021. https://www.economist.com/graphic-detail/2021/10/11/covid-19-has-led-to-a-sharp-increase-in-depression-and-anxiety

[23] “New Pathways, New Hope: National Mental Health Policy of India” in Ministry of Health & Family Welfare:Government of India, October 2014. Accessed November 1, 2021. https://nhm.gov.in/images/pdf/National_Health_Mental_Policy.pdf

[24] “Depression and Other Common Mental Disorders: Global Health Estimates” in Geneva: World Health Organization, 2017. Accessed November 3, 2021. https://apps.who.int/iris/bitstream/handle/10665/254610/WHO-MSD-MER-2017.2-eng.pdf