National Mental Health Programme

Introduction
Psychiatric symptoms are common in
general population in both sides of
the globe. These symptoms are
worry, tiredness, and sleepless nights
affect more than half of the adults at
some time, while as many as one
person in seven experiences some
form of diagnosable neurotic
disorder.
The Government of India decided to
launch the National Mental Health
Programme (NMHP) during the
Seventh Plan period to ensure avail-
ability and accessibility of minimum
mental health care for all in the
1
foreseeable future, particularly to the
most vulnerable and underprivileged
sections of population; to encourage
application of mental health knowl-
edge in general health care and in
social development; to promote
community participation in the mental
health service development.

What is mental health?

Health is important for development
of the country. World health
Organization (WHO ) defines health
as a state of physical, mental, social
and spiritual well-being and not
merely the absence of disease or
infirmity. WHO defines mental health
as mental well-being in which an
2
individual realizes his or her own
abilities, can cope with the normal
stresses of life, can work productively
and is able to make a contribution to
his or her community. In this positive
sense, mental health is the
foundation for individual well-being
and the effective functioning of a
community.
Mental health has impact on:

1. Educational out come.

2. Productivity at work.
3. Development of Positive
personal relationships
4. Crime rate.
5. Alcohol & drug abuse.

3
 WHO response to Mental Health

WHO supports governments in the

goal of strengthening and promoting
mental health. WHO has evaluated
evidence for promoting mental health
and is working with governments to
disseminate this information and to
integrate the effective strategies into
policies and plans. Early childhood
interventions (e.g. home visits for
pregnant women, pre-school psycho-
social activities, combined nutritional
and psycho-social help for
disadvantaged populations).
Mental health has impact on:

4
 1. support to children (e.g. skills
building programmes, child and
youth development programmes)
2. socio-economic empowerment
of women (e.g. improving access
to education and micro credit
schemes)
3. social support for elderly
populations (e.g. befriending
initiatives, community and day
centres for the aged)
4. programmes targeted at
vulnerable groups, including
minorities, indigenous people,
migrants and people affected by
conflicts and disasters (e.g.
psycho-social interventions after
disasters)
5. mental health promotional
activities in schools (e.g.
5
 programmes supporting ecological
changes in schools and child-
friendly schools)
6. mental health interventions at
work (e.g. stress prevention
programmes)
7. housing policies (e.g. housing
improvement)
8. Violence prevention
programmes (e.g. community
policing initiatives); and
community development
programmes (e.g. 'Communities
That Care' initiatives, integrated
rural development)

6
 Why is mental health important?
More than 450 million people suffer
from mental disorders. According to
WHO, by the year 2020, depression
will constitute the second largest
disease burden worldwide (Murray &
Lopez, 1996). Global burden of
mental health will be well beyond the
treatment capacities of developed
and developing countries. The social
and economic costs associated with
growing burden of mental ill health
focused the possibilities for
promoting mental health as well as
preventing and treating mental
illness. Thus the Mental Health is
linked to behaviour and seen as
fundamental to physical health and
quality of life.
7
 1. Physical health and mental
health are closely associated and
it is proved beyond doubt that
depression leads to heart and
vascular diseases.
2. Mental disorders also affect
persons health behaviour like
eating sensibly, regular exercise,
adequate sleep, engaging in safe
sexual practices, alcohol and
tobacco use, adhering to medical
therapies thus increasing the risk
of physical illness.
3. Mental ill health also leads to
social problems like
unemployment, broken families,
poverty, drug abuse and related
crime.

8
 4. Poor mental health plays a
significant role in diminished
immune functioning.
5. Medically ill patients with
depression have worse outcome
than those without.
6. Chronic illnesses like diabetes,
cancer, heart disease increases
the risk of depression.

Burden of Disease
The World Bank report (1993)
revealed that the Disability Adjusted
Life Year (DALY) loss due to neuro-
psychiatric disorder is much higher
than diarrhea, malaria, worm
infestations and tuberculosis if taken
9
individually. According to the
estimates daily loss due to mental
disorders are expected to represent
15% of the global burden of diseases
by 2020. During the last two
decades, many epidemiological
studies have been conducted in
India, which show that the prevalence
of major psychiatric disorder is about
the same all over the world. The
prevalence reported from these
studies range from the population of
18 to 207 per 1000 with the median
65.4 per 1000 and at any given time,
about 2 to 3 % of the population,
suffer from seriously, incapacitating
mental disorders or epilepsy. Most of
these patients live in rural areas
remote from any modern mental
health facilities. A large number of
10
adult patients (10.4 to 53%) coming
to the general OPD are diagnosed
mentally ill. However, these patients
are usually missed because either
medical officer or general practitioner
at the primary health care unit does
not ask detailed mental health
history. Due to the under-diagnosis of
these patients, unnecessary
investigations and treatments are
offered which heavily cost to the
health providers.

Mental Health Care

1. The mental morbidity requires
priority in mental health treatment.
2. Primary health care at village
and sub center level.
11
 3. At Primary Health Center level.
4. At the District Hospital level.
5. Mental Hospital and teaching
Psychiatric Units.

Programme
The Government of India has
launched the National Mental Health
Programme (NMHP) in 1982,
keeping in view the heavy burden of
mental illness in the community, and
the absolute inadequacy of mental
health care infrastructure in the
country to deal with it.
NMHP has 3 components:
1. Treatment of Mentally ill.
2. Rehabilitation.
12
 3. Prevention and promotion of
positive mental health.

Aims
1. Prevention and treatment of
mental and neurological disorders
and their associated disabilities.
2. Use of mental health
technology to improve general
health services.
3. Application of mental health
principles in total national
development to improve quality of
life.
Objectives
1. To ensure availability and
accessibility of minimum mental
13
 health care for all in the forseeable
future, particularly to the most
vulnerable and underprivileged
sections of population.
2. To encourage application of
mental health knowledge in
general health care and in social
development.
3. To promote community
participation in the mental health
services development and to
stimulate efforts towards self-help
in the community.
Strategies
1. Integration mental health with
primary health care through the
NMHP.

14
 2. Provision of tertiary care
institutions for treatment of mental
disorders.
3. Eradicating stigmatization of
mentally ill patients and protecting
their rights through regulatory
institutions like the Central Mental
Health Authority, and State Mental
health Authority.

Mental illness has been included as

one of the disabilities under f the
“Persons with Disabilities (Equal
Opportunities, Protection of Rights
and Full Participation)” Act of 1995,
which came into force on February 7,
1996.
15
The Government of India has
constituted CMHA to oversee the
implementation of the Mental Health
Act 1987. The Act provides
safeguards for protecting patients
suffering from mental illness from
stigmatisation and discrimination. It
provides for creation of State Mental
Health Authority also to carry out the
said functions.
The National Human Rights
Commission (NHRC), along with the
Government of India, also monitors
the conditions in the mental health
hospitals. States are currently acting
on the recommendations of the joint
studies conducted to ensure quality
in delivery of mental care.

16
During the Tenth Five Year Plan
(2002-07), NMHP was restrategised
from a single pronged programme to
a multi-pronged programme for
effective reach and impact on mental
illness. The strategies included the
following:
i. Expansion of District Mental Health
Programme (DMHP) to 100 districts
all over the country;
ii. Modernisation of mental hospitals;
iii. Upgradation of psychiatry wings of
Government Medical Colleges and
general hospitals; and
iv. Research and training in mental
health for improving service.

17
v. Information education and
communication ( IEC)
At the end of the Tenth Plan, the
DMHP was under implementation in
123 districts throughout India. Grants
were also released for upgradation of
psychiatric wings of 75 government
medical colleges and general
hospitals and for the modernisation of
26 mental hospitals.
In 11th five year plan the national
Mental Health Programme has the
following components or schemes
 District Mental Health Programme
 Manpower development schemes
like centres of excellence and
setting up or strengthening post
18
 graduate training departments of
Mental Health specialities
 Modernization of state run mental
hospitals
 upgradation of psychiatric wings of
medical colleges for general
hospitals
 Information education and
communication
 Training and research
 Monitoring and evaluation
During the eleventh five year plan
and allocation of rupees thousand
crore has been made for National
Mental Health Programme. A sum of
70 crore has been provided in 2008
to 2009 for implementation of
national Mental Health Programme.
19
For the Eleventh Five Year Plan
period (2008-2013), the government
has proposed to decentralise the
programme and synchronise with
National Rural Health Mission for
optimising the results. the main
components of national Mental
Health Programme has been
proposed are under,

20
21
 District Mental Health Programme

A district mental health programme

with a community-based approach
was launched under the NMHP in
1996-97 on a pilot basis in four
districts, one each in the states of
Andhra Pradesh, Assam, Rajasthan,
and Tamil Nadu. The programme has
been extended to some other
districts/states in the country.

Objective-
To provide community mental
health services and integration of
Mental Health with general
services through decentralization
22
of treatment from specialised
mental hospital based care to
primary Health care services

Components:
1. Training programmes of all
workers in the mental health team
at the identified Nodal Institute in
the State.
2. Public education in the mental
health to increase awareness and
reduce stigma.
3. For early detection and
treatment, the OPD and indoor
services are provided.
4. Providing valuable data and
experience at the level of
23
 community to the state and Centre
for future planning, improvement
in service and research.

Activities
The approach to the treatment of
mental disorders is based upon the
following strategy:
i. Integrating mental health with
primary health care through
the NMHP.
ii. Early identification and
treatment for mental illnesses
in the community bioactive
case identification by health
workers by conducting
24
 periodic mental mental health
camps in each taluk of district
iii. Referring all persons with
mental problems to their
respective primary Health unit
or to the taluk hospital after
initial evaluation and initiation
of treatment in the camps
iv. intensive education to the
community about availability
of treatment for mental
disorders universal nature of
mental illness and regarding
the need for regular follow up
in the primary Health centre.
These efforts will bring in
large number of persons with
mental disorders into care and
consequent reduction in
stigma and discrimination.
25
 v. Facilitate adequate
psychosocial care of the
recovered mentally ill person
in the community by making
appropriate linkages with non
government of organisations
in the local area
vi. Promotive and preventive
activities for positive mental
health for example school
Mental Health services life
skill education College
counselling services
workplaces stress
management and suicide
preventions
vii.Linking psychosocial care and
public education with social
welfare department which

26
 comes under public private
partnership
viii. The district Mental Health
Programme in urban location
will address the mental health
needs show existing public
healthcare infrastructure such
as municipality hospitals or
corporation hospitals orada
speciality hospitals mental
hospitals and medical
colleges and hospitals
ix. Under district Mental Health
Programme a small amount of
rupees 50000 will be available
for research purpose. Non
governmental agencies in
district Medical College
department of psychiatry can

27
 be encouraged to take up
research work
ii. Provision of tertiary care
institutions for treatment of mental
disorders.
iii. Eradicating stigmatisation of
mentally ill patients and protecting
their rights through regulatory
institutions, such as the Central
mental health authority (CMHA) and
state mental health authority (SHMA).

At the end of 2002 28 districts in

25 states are having district
Mental Health Programme and
during next five year plan about
hundred districts are expected to
have the program. At the end of 5
28
 years state governments are
required to continue the program
with their own resources.
In October 2002 Government of
India launched a program with
rupees 190 crores which includes
implementation of district Mental
Health Programme in 100 districts.
Rupees 50 lacs is to improve the
department of psychiatry in all
government medical colleges and
rupees 3 crores is to improve
every mental hospital.
Agencies like World Bank and
WHO have been contacted to
support various components of the
programme. Funds are provided
by the Govt. of India to the state
29
 governments and the nodal
institutes to meet the expenditure
on staff, equipments, vehicles,
medicine, stationary,
contingencies, training, etc. for
initial 5 years and thereafter they
should manage themselves. Govt.
of India has constituted central
Mental Health Authority to oversee
the implementation of the Mental
Health Act 1986. It provides for
creation of state Mental Health
Authority also to carry out the said
functions.
The National Human Rights
Commission also monitors the
conditions in the mental hospitals
along with the government of India
30
 and the states are currently acting
on the recommendation of the joint
studies conducted to ensure
quality in delivery of mental care.

Nurse’s Role
 National Mental Health Programme
for India 1982 recommended the
formation of district mental health
team in order to decentralize mental
health care at district level with to
qualified psychiatric nurses and one
psychiatrist.

31
  the role of psychiatric nurse in the
district Mental Health Programme is
to provide care to the in patients.
 The care includes meeting their basic
needs conducting occupational
therapy recreational therapy and
individual and group therapy Along
with mental health education two
families and the public in general
 In addition to the above qualified
psychiatric nurses will actively
participate in decentralized training
of professionals and non
professionals working at taluk and
primary Health centres

32
  they will also supervise the task of
multipurpose workers in Mental
Health care delivery
 They will assist psychiatrist in
research activities in monitoring
mental health care and district and
primary Health care levels
 There are active participation in
Mental Health education to the
public will go a long way in creating
public awareness in the care of
individuals with various mental
disorders

33
 What are the difficulties in
implementation of mental health
programmes?

1. Stigma is associated with

mental illness and patients are
discriminated in the society in all
aspects like education,
employment, marriage etc, which
leads to delay in seeking medical
advice.
2. Vagueness in concepts of
mental health and illness, with lack
of definitive signs and symptoms
which result in diagnostic
confusion.

34
 3. People feel that mental
illnesses occur in those who are
mentally weak or due to spirits.
4. Many people are in the opinion
that mental illness is irreversible
that lead to therapeutic nihilism.
5. Many people believe that
preventive measures are unlikely
to succeed.
6. Many people believe that drugs
used to treat mental illness may
cause many side effects and leads
to addiction. They feel that these
drugs merely induce sleeping.
7. Data collected by WHO
demonstrated that there is large
gap between burden caused by
mental health problems and the
resources available in countries to
prevent and treat them.
35
 8. In most parts of the world, the
treatment of mental illness was
alienated from rest of medicine
and health care until recently.
9. Psychiatric patients and their
families fail to act like pressure
groups as they are reluctant to
come together because of severe
social stigma and lack of
knowledge about their rights.
10. Even Non Governmental
Organizations (NGOs) consider
this as a difficult field as it needs
long term commitment and they
are scared to deal with mentally
handicapped.

36